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Emergency department nurse-initiated protocols for paediatric febrile neutropenia: A scoping review. Collegian 2022. [DOI: 10.1016/j.colegn.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Dessie AS, Lanning M, Nichols T, Delgado EM, Hart LS, Agrawal AK. Patient Outcomes With Febrile Neutropenia Based on Time to Antibiotics in the Emergency Department. Pediatr Emerg Care 2022; 38:e259-e263. [PMID: 32941363 DOI: 10.1097/pec.0000000000002241] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although bacteremia in pediatric oncology patients with febrile neutropenia (FN) is not uncommon, sepsis and mortality are rare. Because of the lack of clinically meaningful decision tools to identify high-risk patients with bacteremia, time to antibiotic administration (TTA) is increasingly considered an important quality and safety measure in the emergency department. Because little evidence exists suggesting that this benchmark is beneficial, we sought to determine whether TTA of 60 minutes or less is associated with improved outcomes. METHODS We retrospectively reviewed patients presenting to a pediatric emergency department with FN from November 2013 to June 2016. Clinical outcomes including mortality, pediatric intensive care unit admission, imaging, fluid resuscitation of 40 mL/kg or greater in the first 24 hours, and length of stay were compared between TTA of 60 minutes or less and more than 60 minutes. RESULTS One hundred seventy-nine episodes of FN were analyzed. The median TTA was 76 minutes (interquartile range, 58-105). The incidence of bacteremia was higher in patients with TTA of more than 60 minutes (12% vs 2%, P = 0.04), but without impact on mortality, pediatric intensive care unit admission, fluid resuscitation, or median length of stay. The median TTA was not different for those who were and were not bacteremic (91 vs 73 minutes, P = 0.11). CONCLUSIONS Time to antibiotic administration of more than 60 minutes did not increase mortality in pediatric oncology patients with FN. Our study adds to the existing literature that TTA of 60 minutes or less does not seem to improve outcomes in pediatric FN. Further larger studies are required to confirm these findings and determine which features predispose pediatric FN patients to morbidity and mortality.
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Affiliation(s)
| | - Miranda Lanning
- New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Tristan Nichols
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | | | | | - Anurag K Agrawal
- Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA
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Ockfen S, Egle L, Sauter K, Haber M, Becker SL, Wagenpfeil G, Graf N, Simon A. Meropenem Use in Pediatric Oncology - Audit on Indication, Appropriateness and Consumption Comparing Patient Derived and Pharmacy Dispensing Data. KLINISCHE PADIATRIE 2021; 233:278-285. [PMID: 34261135 DOI: 10.1055/a-1481-8905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Meropenem is an important second- or third-line antibiotic in pediatric cancer patients with febrile neutropenia (FN). Concise utilization data of meropenem in this setting is limited. It remains unclear how drug dispensing data from the hospital pharmacy correlate with data derived from patients' files. METHODS Retrospective audit of meropenem-consumption in a University-affiliated pediatric oncology center in days of therapy (DOT)/100 inpatient days. The individual indication for meropenem was critically reviewed. The real consumption (in g/100 inpatient days) was compared with the drug amounts dispensed by the hospital pharmacy (in gram and in defined daily doses (DDD)/100 inpatient days). All patients receiving at least one dose of meropenem from 1st of April 2016 until the 30th of June 2018 were included. RESULT Of 235 consecutive patients, 45 (19%) received meropenem, comprising 57 FN events. The probability of receiving at least one dose of meropenem was significantly higher in patients with ALL, AML, NHL and certain CNS tumors. Preceding the use of meropenem, only 5% of patients were known to be colonized with multidrug-resistant Gram-negative pathogens. Meropenem was administered as first-line treatment in 26% of all meropenem cycles, in 74% of all FN events with meropenem, Piperacillin-Tazobactam was used for initial treatment. In 5 of 57 FN events (8.8%), initial blood cultures yielded a Gram-negative pathogen. Concerning definite treatment, appropriate alternatives to meropenem with a smaller spectrum of activity would have been available in 4 cases, but a de-escalation was not performed. The median length of therapy in the meropenem group was 6 days, the corresponding median for days of therapy (DOT) was 12 days. This corresponds with combination therapy in 56% of all meropenem treatments, mostly with teicoplanin. On average, drug dispensing data from the hospital pharmacy were 1.53 times higher than real use (relying on patients' data) without a significant correlation. A higher Case-mix Index positively correlated with meropenem-consumption. CONCLUSION The use of meropenem should become a target of antibiotic stewardship programs in order to restrict its use to certain indications and preserve its outstanding role as second- or third-line antibiotic in this vulnerable population. Irrespective of the metrics used (g or DDD/100 inpatient days), pharmacy dispensing data do not accurately depict real patient-derived data concerning meropenem use in pediatric cancer patients.
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Affiliation(s)
- Svenja Ockfen
- Pediatric Hematology and Oncology, Children's Hospital Medical Center, Children's Hospital Medical Center, Saarland University Hospital, Homburg, Germany
| | - Leonie Egle
- Pediatric Hematology and Oncology, Children's Hospital Medical Center, Children's Hospital Medical Center, Saarland University Hospital, Homburg, Germany
| | - Katharina Sauter
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
| | - Manfred Haber
- Director Hospital Pharmacy, Saarland University Hospital, Homburg/Saar, Homburg, Germany
| | - Sören L Becker
- Medical Microbiology and Hygiene, Saarland University Medical Center, Homburg, Germany
| | - Gudrun Wagenpfeil
- Saarland University, Campus Homburg, Institutes for Medical Biometry, Epidemiology and Medical Informatics (IMBEI), Homburg, Germany
| | - Norbert Graf
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
| | - Arne Simon
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
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Northcott KMT, Gibson K, Peters MDJ. Nurse-initiated protocols in the emergency department management of pediatric oncology patients with fever and suspected neutropenia: a scoping review protocol. JBI Evid Synth 2021; 19:1243-1250. [PMID: 33156131 DOI: 10.11124/jbies-20-00149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The objective of this review is to provide an overview of the existing evidence regarding nurse-initiated protocols in the emergency department management of pediatric oncology patients with fever and suspected neutropenia. INTRODUCTION Febrile neutropenia in pediatric oncology patients poses a significant burden of increased morbidity and mortality. Prompt, efficient emergency care and rapid antibiotic administration within 60 minutes of presentation to hospital is required to prevent clinical deterioration and reduce rates of intensive care admission and mortality. Efficient emergency department care delivery is impacted by modern day challenges, such as increasing user-demand, limited resources, and lack of flow. In response to this, to expedite care provision, practice guidelines have been developed to include nurse-initiated protocols that guide nurses to initiate specific predetermined investigations and interventions for patients meeting certain criteria. Febrile neutropenic pediatric patients may be a specific group that can benefit from nurse-initiated protocols due to the time-critical nature of required care. INCLUSION CRITERIA The scoping review will consider literature that reports on nurse-initiated protocols in the management of pediatric febrile oncology patients with suspected neutropenia in the emergency department setting. METHODS JBI methodology for scoping reviews will guide the review process. English-language literature from 2000 to present will be searched in Embase, MEDLINE, Scopus, Emcare, CINAHL Plus, and gray literature in Google Scholar, Open Grey, and Theses Global. Critical appraisal will not be performed. A tabular and accompanying narrative summary of the information will present extracted evidence aligned to the review's objective and questions.
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Affiliation(s)
- Katie M T Northcott
- University of South Australia, Clinical & Health Sciences, Rosemary Bryant AO Research Centre, Adelaide, SA, Australia.,The Women's and Children's Hospital, Adelaide, SA, Australia
| | - Kim Gibson
- University of South Australia, UniSA Clinical & Health Sciences, Adelaide, SA, Australia
| | - Micah D J Peters
- University of South Australia, Clinical & Health Sciences, Rosemary Bryant AO Research Centre, Adelaide, SA, Australia.,Adelaide Nursing School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.,The Centre for Evidence-based Practice South Australia (CEPSA): A JBI Centre of Excellence, Adelaide, SA, Australia
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Anderson K, Bradford N, Edwards R, Nicholson J, Lockwood L, Clark JE. Improving management of fever in neutropenic children with cancer across multiple sites. Eur J Cancer Care (Engl) 2021; 30:e13413. [PMID: 33511731 DOI: 10.1111/ecc.13413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/28/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60 minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. METHODS Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16 months. A follow-up audit was conducted after 12 months. RESULTS We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60 minutes (RR 0.69, 95% CI 0.56-0.85, p = <0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57 minutes) and sustained at follow-up (60 minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. CONCLUSION Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.
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Affiliation(s)
- Katrina Anderson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Natalie Bradford
- Cancer and Palliative Care Outcomes Centre and Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Qld, Australia
| | - Rachel Edwards
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Jessica Nicholson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Liane Lockwood
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Julia E Clark
- Infection Management and Prevention Service, Queensland Children's Hospital, South Brisbane, Qld, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Australia
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Improving Time to Antibiotics for Pediatric Oncology Patients With Fever and Suspected Neutropenia by Applying Lean Principles. Pediatr Emerg Care 2020; 36:509-514. [PMID: 33125202 DOI: 10.1097/pec.0000000000001557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fever in the setting of neutropenia is a potentially life-threatening complication of cancer treatment. A time of less than 60 minutes from presentation to antibiotic administration is therefore recommended. OBJECTIVE To use Lean Six Sigma methodology, a quality improvement initiative, to improve time to antibiotics (TTA) for children with chemotherapy-induced febrile neutropenia presenting to the emergency department. METHODS Lean Six Sigma is a quality improvement method that engages all impacted stakeholders and focuses on streamlining the process by removing process wastes. Stakeholders identified multiple process wastes in an in-depth study of 49 fever episodes in patients attending a tertiary care pediatric hospital, including patients waiting to be registered, waiting for laboratory technicians, delay in accessing central venous access device, waiting for absolute neutrophil count, and delayed antibiotics orders. We implemented multiple solutions: engaging patients in the process through predischarge tours of the emergency department, home application of topical anesthetic, nurse-initiated pathway, early access of central venous access device for all blood work, and planned antibiotic administration no later than 45 minutes after triage. We prospectively determined the impact of these interventions on TTA. RESULTS The TTA significantly improved to a median of 59 minutes (interquartile range, 38.5-77.5 minutes) compared with the baseline of 99 minutes (interquartile range, 72.0-132.0 minutes; P < 0.0001). CONCLUSIONS Lean methodology effectively identifies barriers and provides solutions to remove barriers and improve administration of antibiotics in febrile oncology patients. These can be widely applied, including in smaller institutions with minimal increased utilization of resources.
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Koenig C, Schneider C, Morgan JE, Ammann RA, Sung L, Phillips B. Interventions aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN), a systematic review. Support Care Cancer 2019; 28:2369-2380. [PMID: 31486984 PMCID: PMC7083808 DOI: 10.1007/s00520-019-05056-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/22/2019] [Indexed: 11/18/2022]
Abstract
Purpose Multiple interventions have been developed aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia (FN) following chemotherapy for cancer. We evaluated their effect to reduce TTA and their impact on important clinical outcomes in a systematic review. Methods The search covered seven databases. Biases and quality of studies were assessed with the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. Interventions could be implemented in any setting and performed by any person included in the FN management. Absolute change of TTA was the primary outcome. Registration: PROSPERO (CRD42018092948). Results Six thousand two hundred ninety-six titles and abstracts were screened, 177 studies were retrieved and 30 studies were included. Risk of bias was moderate to serious in 28 studies and low in two studies. All but one study reported a reduction of TTA after the intervention. Various types of interventions were implemented; they most commonly aimed at professionals. Most of the studies made more than one single intervention. Conclusion This review may help centers to identify their specific sources of delay and barriers to change and to define what intervention may be the best to apply. This review supports the assertion that TTA can be considered a measure of quality of care, emphasizes the importance of education and training, and describes the very different interventions which have effectively reduced TTA. Electronic supplementary material The online version of this article (10.1007/s00520-019-05056-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland. .,Centre for Reviews and Dissemination, University of York, York, UK.
| | - Christine Schneider
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland
| | - Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, York, UK.,Leeds Children's Hospital, Leeds, UK
| | - Roland A Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland
| | - Lillian Sung
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK.,Leeds Children's Hospital, Leeds, UK
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Implementation of a Nursing Based Order Set: Improved Antibiotic Administration Times for Pediatric ED Patients with Therapy-Induced Neutropenia and Fever. J Pediatr Nurs 2019; 46:78-82. [PMID: 30856462 DOI: 10.1016/j.pedn.2019.02.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 10/17/2018] [Accepted: 02/16/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE For patients with chemotherapy-induced neutropenia and fever, delays in antibiotic administration are associated with poor outcomes, such as ICU admission and need for further interventions. The objective of this quality improvement project was to significantly reduce the time from initiation of triage to antibiotic administration for pediatric patients arriving to the emergency department with therapy-induced neutropenia and fever. METHODS An interdisciplinary team set an evidence-based goal for time to antibiotics (TTA) at 60-min. A six-month retrospective chart review of Emergency Department (ED) patients revealed a 128 min TTA mean when measured from the initiation of triage to antibiotic administration, which also reflected 0% of patients receiving antibiotics within the goal of 60 min. Members of the interdisciplinary team evaluated delays in patient care workflow and identified three primary interventions to decrease the TTA. These three evidenced-based interventions were implemented and evaluated using the Plan-Do-Check-Act (PDCA) quality improvement methodology. RESULTS By the end of the implementation period mean TTA improved to 53 min and patients received antibiotics within 60 min (83% of the time). CONCLUSION The interventions focused on both provider and nursing workflow, however the implementation of an evidence-based practice nursing order set made the greatest impact on timeliness of antibiotic delivery time.
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de Oliveira BM. Use of biomarkers in the management of febrile neutropenia episodes in children with cancer. Rev Bras Hematol Hemoter 2016; 38:93-4. [PMID: 27208564 PMCID: PMC4877618 DOI: 10.1016/j.bjhh.2015.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 10/08/2015] [Indexed: 12/02/2022] Open
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Management of fever and neutropenia in paediatric cancer patients: room for improvement? Curr Opin Infect Dis 2015; 28:532-8. [PMID: 26381997 DOI: 10.1097/qco.0000000000000208] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Fever and neutropenia is the most common complication in the treatment of childhood cancer. This review will summarize recent publications that focus on improving the management of this condition as well as those that seek to optimize translational research efforts. RECENT FINDINGS A number of clinical decision rules are available to assist in the identification of low-risk fever and neutropenia however few have undergone external validation and formal impact analysis. Emerging evidence suggests acute fever and neutropenia management strategies should include time to antibiotic recommendations, and quality improvement initiatives have focused on eliminating barriers to early antibiotic administration. Despite reported increases in antimicrobial resistance, few studies have focused on the prediction, prevention, and optimal treatment of these infections and the effect on risk stratification remains unknown. A consensus guideline for paediatric fever and neutropenia research is now available and may help reduce some of the heterogeneity between studies that have previously limited the translation of evidence into clinical practice. SUMMARY Risk stratification is recommended for children with cancer and fever and neutropenia. Further research is required to quantify the overall impact of this approach and to refine exactly which children will benefit from early antibiotic administration as well as modifications to empiric regimens to cover antibiotic-resistant organisms.
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