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Outpatient Management of Fever and Neutropenia in Low-risk Children with Solid Tumors: A Quality Improvement
Wallace Bourgeois1, Jonathan Paolino1, Riley Garland1
1From the Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Department of Pediatric Oncology, Boston, Mass.
Insights
A quality improvement project successfully increased outpatient management for pediatric cancer patients with fever and neutropenia. This approach is safe for low-risk patients, with most preferring home care.
Area of Science:
- Pediatric Oncology
- Quality Improvement
- Infectious Disease Management
Background:
- Febrile neutropenia in pediatric oncology typically requires inpatient antibiotics.
- Lower-risk patients may be candidates for safe outpatient management.
- A quality improvement project aimed to increase outpatient fever and neutropenia management.
Purpose of the Study:
- To implement and evaluate a standardized algorithm for outpatient management of fever and neutropenia in children with solid tumors.
- To achieve at least 80% outpatient management for eligible patients within 20 months.
Main Methods:
- A standardized algorithm was developed for low-risk pediatric patients with solid tumors.
- Plan-do-study-act cycles were used to improve algorithm compliance.
- Patient and caregiver surveys assessed satisfaction and impact of outpatient management.
Main Results:
- 71% of eligible patients were managed as outpatients.
- Only 6% of outpatient cases resulted in bacteremia and subsequent admission.
- Most patients (83%) preferred home management, while caregiver preference varied.
Conclusions:
- Outpatient management of febrile neutropenia is safe for select pediatric solid tumor patients.
- Engaging parents and caregivers is crucial for the success of this practice change.
Background:
Management of febrile neutropenia in pediatric oncology usually requires inpatient parenteral antibiotics after initial evaluation, but some patients at lower risk of sepsis could be safely managed outpatient. We describe a quality improvement project to increase outpatient management of fever and neutropenia.
Methods:
We designed a standardized algorithm for children with a solid tumor diagnosis and low risk for bacteremia. The aim was to achieve outpatient management for at least 80% of eligible patients within 20 months of project initiation. We used plan-do-study-act cycles to improve algorithm compliance, including optimizing medical record decision support, developing targeted educational materials and outreach, and restructuring outpatient processes to allow for close follow-up. We surveyed patients (age ≥12 y) and parents/caregivers to assess the impact of outpatient management.
Results:
The initiative led to 71% (n = 34) of eligible patients being managed as outpatients. Six percent (n = 2) of patients developed bacteremia, resulting in hospital admission. Fifteen of 26 parents/caregivers and five of 11 patients approached completed the survey. For the preferred setting of febrile neutropenia management, 83% of patients preferred to be home versus 40% of parents/caregivers. No patient expressed any of the three highest ratings in the question exploring fear regarding outpatient febrile neutropenia management versus 67% of parents/caregivers.
Conclusions:
Some children with a solid tumor diagnosis at low risk for bacteremia are safely managed for febrile neutropenia as outpatients. Targeted efforts to engage parents/caregivers early in this practice change are necessary for success.
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