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Smeallie ET, Choi SW, Mody R, Guetterman TC, Nessle CN. "Better at home": Mixed methods report of intricacies in pediatric febrile neutropenia management. Cancer Med 2024; 13:e7106. [PMID: 38506249 PMCID: PMC10952020 DOI: 10.1002/cam4.7106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/02/2024] [Accepted: 03/02/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Many febrile neutropenia (FN) episodes are low risk (LR) for severe outcomes and can safely receive less aggressive management and early hospital discharge. Validated risk tools are recommended by the Children's Oncology Group to identify LR FN episodes. However, the complex dynamics of early hospital discharge and burdens faced by caregivers associated with the FN episode have been inadequately described. METHODS An adapted quality-of-life (QoL) survey instrument was administered by a convergent mixed methods design; qualitative and quantitative data from two sources, the medical record and the mixed methods survey instrument, were independently analyzed prior to linkage and integration. Code book was informed by conceptual framework; open coding was used. Mixed methods analysis used joint display of results to determine meta-inferences. RESULTS Twenty-eight patient-caregiver dyads participated with a response rate of 87%. Of the 27 FN episodes, 51.8% (14/27) were LR and 40.7% (11/27) had an early hospital discharge. The LR and early hospital discharge groups had higher mean QoL scores comparatively. Meta-inferences are reciprocal influencers and expand the complex situation; FN negatively affects the entire family, and the benefits of hospital management were outweighed by risks and worsened symptoms, so an individualized approach to management and care at home was preferred. CONCLUSION Early discharge of LR FN episodes positively impacts QoL, yet risk-stratified management for FN is intricately complex. Optimal FN management should prioritize the patient's overall health; shared decision-making is recommended and can improve care delivery. These results should be confirmed in a larger, more heterogeneous population.
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Affiliation(s)
| | - Sung W. Choi
- Department of PediatricsUniversity of MichiganAnn ArborMichiganUSA
- Division of Pediatric Hematology OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Rajen Mody
- Department of PediatricsUniversity of MichiganAnn ArborMichiganUSA
- Division of Pediatric Hematology OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Timothy C. Guetterman
- Rogel Comprehensive Cancer CenterUniversity of MichiganAnn ArborMichiganUSA
- Department of Family Medicine, Mixed Methods ProgramUniversity of MichiganAnn ArborMichiganUSA
| | - Charles N. Nessle
- Department of PediatricsUniversity of MichiganAnn ArborMichiganUSA
- Division of Pediatric Hematology OncologyUniversity of MichiganAnn ArborMichiganUSA
- Fogarty International CenterNational Institute of HealthBethesdaMarylandUSA
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Jackson TJ, Napper R, Haeusler GM, Pizer B, Bate J, Grundy RG, Samarasinghe S, Angelini P, Ball-Gamble A, Phillips B, Morgan JE. Can I go home now? The safety and efficacy of a new UK paediatric febrile neutropenia protocol for risk-stratified early discharge on oral antibiotics. Arch Dis Child 2023; 108:192-197. [PMID: 36600323 PMCID: PMC9985710 DOI: 10.1136/archdischild-2021-323254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/26/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate a new protocol of risk stratification and early discharge for children with febrile neutropenia (FN). DESIGN Prospective service evaluation from 17 April 2020 to 16 April 2021. SETTING 13 specialist centres in the UK. PATIENTS 405 children presenting with FN. INTERVENTION All children received intravenous antibiotics at presentation. Risk stratification was determined using the Australian-UK-Swiss (AUS) rule and eligibility for homecare assessed using criteria including disease, chemotherapy, presenting features and social factors. Those eligible for homecare could be discharged on oral antibiotics after a period of observation proportional to their risk group. MAIN OUTCOME MEASURES Median duration of admission and of intravenous antibiotics, and percentage of patients with positive blood cultures, significant infection, readmission within 7 days of initial presentation, intensive care unit (ICU) admission, death from infection and death from other causes. RESULTS 13 centres contributed 729 initial presentations of 405 patients. AUS rule scores were positively correlated with positive blood cultures, significant infection, ICU admission and death. 20% of children were eligible for homecare with oral antibiotics, of which 55% were low risk (AUS 0-1). 46% low-risk homecare eligible patients were discharged by 24 hours vs 2% homecare ineligible. Homecare readmission rates were 14% overall and 16% for low-risk cases (similar to a meta-analysis of previous studies). No child eligible for homecare was admitted to ICU or died. CONCLUSIONS Use of the AUS rule and homecare criteria allow for safe early outpatient management of children with FN.
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Affiliation(s)
- Thomas John Jackson
- Paediatric Oncology, University College London Hospital, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rachel Napper
- Regional Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, UK
| | - Gabrielle M Haeusler
- Infectious Diseases and Infection Control, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Barry Pizer
- Paediatric Oncology, Royal Liverpool Children's Hospital, Liverpool, UK
| | - Jessica Bate
- Paediatric Oncology, Southampton Children's Hospital, Southampton, UK
| | - Richard G Grundy
- Children's Cancer Leukaemia Group Chair, University of Nottingham, Nottingham, UK
| | - Sujith Samarasinghe
- Paediatric Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Paola Angelini
- Children and Young People Unit, Royal Marsden Hospital Sutton, Sutton, UK
| | | | - Bob Phillips
- Leeds Children's Hospital, Leeds, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Jessica Elizabeth Morgan
- Leeds Children's Hospital, Leeds, UK
- Centre for Reviews and Dissemination, University of York, York, UK
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Soto C, Dixon-Woods M, Tarrant C. Families' experiences of central-line infection in children: a qualitative study. Arch Dis Child 2022; 107:1038-1042. [PMID: 35863869 PMCID: PMC9606494 DOI: 10.1136/archdischild-2022-324186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Central venous access devices (CVADs), often known as central lines, are important for delivering medically complex care in children, and are increasingly used for children living at home. Central line-associated bloodstream infection (CLABSI) is a serious, life-threatening complication. Although the physical consequences of CLABSIs are well documented, families' views and experiences of CLABSI are poorly understood. DESIGN Qualitative study using semistructured interviews with participants from 11 families of a child living at home with a CVAD. PARTICIPANTS Parents of children aged 4-12 years living at home with a CVAD. Four fathers and nine mothers participated in interviews. RESULTS The risk of CLABSI is a constant fear for families of a child with a CVAD. Though avoiding infection is a key priority for families, it is not the only one: maintaining a sense of 'normal life' is another goal. Infection prevention and control require much work and expertise on the part of families, contributing significantly to families' physical and emotional workload. CONCLUSIONS Living with the risk of CLABSI poses additional burdens that impact on the physical and emotional well-being of families. Services to better support families to manage these burdens are needed.
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Affiliation(s)
- Carmen Soto
- Paediatric Oncology, University College London Hospitals NHS Foundation Trust, London, UK
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Crothers A, Haeusler GM, Slavin MA, Babl FE, Mechinaud F, Phillips R, Tapp H, Padhye B, Zeigler D, Clark J, Walwyn T, Super L, Alvaro F, Thursky K, De Abreu Lourenco R. Examining health-related quality of life in pediatric cancer patients with febrile neutropenia: Factors predicting poor recovery in children and their parents. EClinicalMedicine 2021; 40:101095. [PMID: 34746716 PMCID: PMC8548915 DOI: 10.1016/j.eclinm.2021.101095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The impact febrile neutropenia (FN) has on the health-related quality of life (HRQoL) of children with cancer and their families is poorly understood. We sought to characterize the course of child and parent HRQoL during and following FN episodes. METHOD Data on HRQoL were collected in the multisite Australian Predicting Infectious ComplicatioNs in Children with Cancer (PICNICC) study. Participants were enrolled between November 2016 to January 2018. The Child Health Utility (CHU9D) was used to assess HRQoL in children (N = 167 FN events) and the Assessment of Quality of Life (AQoL-8D) was used to assess HRQoL parents (N = 218 FN events) at three time points: 0-3 days, 7-days and 30-days following the onset of FN. Group-based trajectory modeling (GBTM) was used to characterize the course of HRQoL. FINDINGS For children, three distinct groups were identified: persistently low HRQoL over the 30-day course of follow-up (chronic: N = 78/167; 47%), increasing HRQoL after the onset of FN to 30 days follow-up (recovering: N = 36/167; 22%), and persistently high HRQoL at all three timepoints (resilient: N = 53/167; 32%). Applying these definitions, parents were classified into two distinct groups: chronic (N = 107/218, 49%) and resilient (N = 111/218, 51%). The child being male, having solid cancer, the presence of financial stress, and relationship difficulties between the parent and child were significant predictors of chronic group membership for both parents and children. Children classified as high-risk FN were significantly more likely to belong to the recovery group. Being female, having blood cancers and the absence of financial or relationship difficulties were predictive of both parents and children being in the resilient group. INTERPRETATION Approximately half the children and parents had chronically low HRQoL scores, which did not improve following resolution of the FN episode. The child's sex, cancer type, and presence of financial and relationship stress were predictive of chronic group membership for both parents and children. These families may benefit from increased financial and psychosocial support during anti-cancer treatment. FUNDING National Health and Medical Research Council Grant (APP1104527).
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Affiliation(s)
- Anna Crothers
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Australia
- Corresponding author.
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- The Paediatric Integrated Cancer Service, Parkville, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Australia
| | - Francoise Mechinaud
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, France
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK
| | - Heather Tapp
- Department of Oncology, Women's and Children's Hospital, Adelaide, Australia
| | - Bhavna Padhye
- Cancer Centre for Children, Westmead Children's Hospital, Sydney, Australia
| | - David Zeigler
- Kid's Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Julia Clark
- Infection Management Service, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Thomas Walwyn
- Department of Oncology, Perth Children's Hospital, Perth, Australia
| | - Leanne Super
- Children's Cancer Centre, Monash Children's Hospital, Monash Health, Melbourne, Australia
| | - Frank Alvaro
- Children's Cancer Department, John Hunter Children's Hospital, University of Newcastle, Newcastle, Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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