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Comprehensive Care Improvement for Oncologic Fever and Neutropenia from a Pediatric Emergency Department
Nicholas A Kuehnel1, Erin McCreary2, Sheryl L Henderson3
1From the Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
Insights
Rapid antibiotic administration for pediatric fever and neutropenia significantly improves outcomes. This study enhanced time to antibiotics (TTA) and developed outpatient management for low-risk cases, demonstrating successful process improvements.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Disease Management
- Healthcare Quality Improvement
Background:
- Rapid time to antibiotics (TTA) is crucial for pediatric patients with fever and neutropenia, reducing in-hospital mortality.
- National guidelines advocate for outpatient antibiotic management for low-risk fever and neutropenia (LRFN) patients.
- Current TTA rates for suspected fever and neutropenia in emergency departments require significant improvement.
Purpose of the Study:
- To increase the percentage of pediatric patients with suspected fever and neutropenia receiving antibiotics within 60 minutes of arrival from 55% to 90%.
- To develop and implement an effective outpatient management process for low-risk fever and neutropenia (LRFN) patients by October 2018.
Main Methods:
- Implementation of Lean methodologies, including Plan-Do-Check-Act cycles.
- Focus on guideline development, electronic medical record (EMR) reminders, and order-set creation.
- Utilized statistical process control charts (G-chart, Xbar-chart, P-chart) to monitor and assess improvements.
Main Results:
- Achieved a significant improvement in TTA, reducing average time from 68.5 to 42.5 minutes.
- Increased the proportion of patients receiving antibiotics within 60 minutes from 55% to 86.4%.
- Successfully developed and implemented a LRFN guideline and workflow in October 2017.
Conclusions:
- Guidelines, EMR reminders, and order sets are effective tools for improving TTA in suspected fever and neutropenia.
- Sensitive statistical process control charts aid in early recognition and guidance of process improvements.
- Outpatient management workflows for LRFN are feasible but warrant further investigation.
Introduction:
Rapid time to antibiotics (TTA) for pediatric patients with fever and neutropenia in an emergency department decreases in-hospital mortality. Additionally, national guidelines recommend outpatient antibiotic management strategies for low-risk fever and neutropenia (LRFN). This study had two specific aims: (1) improve the percent of patients with suspected fever and neutropenia who receive antibiotics within 60 minutes of arrival from 55% to 90%, and (2) develop and operationalize a process for outpatient management of LRFN patients by October 2018.
Methods:
Using Lean methodologies, we implemented Plan-Do-Check-Act cycles focused on guideline development, electronic medical record reminders, order-set development, and a LRFN pathway as root causes for improvements. We used statistical process control charts to assess results.
Results:
The project conducted from July 2016 to October 2018 showed special cause improvement in December 2016 on a G-chart. Monthly Xbar-chart showed improvement in average TTA from 68.5 minutes to 42.5 minutes. A P-chart showed improvement in patients receiving antibiotics within 60 minutes, from 55% to 86.4%. A LRFN guideline and workflow was developed and implemented in October 2017.
Conclusions:
Implementation of guidelines, electronic medical record reminders, and order sets are useful tools to improve TTA for suspected fever and neutropenia. Utilizing more sensitive statistical process control charts early in projects with fewer patients can help recognize and guide process improvement. The development of workflows for outpatient management of LRFN may be possible, though it requires further study.
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