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Smith WT, Read J, Agarwal S, Tian G, Anum SJ, Choe M, Kurtz K, Tlais D, Shen X, Sarro J, Looney T, Porea T, Sauer H, Brackett J, Okcu MF, Chintagumpala M. Improving Time to Antibiotic Administration for Pediatric Oncology Patients With New-Onset Fever. JCO Oncol Pract 2024; 20:725-731. [PMID: 38354362 DOI: 10.1200/op.23.00314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 12/07/2023] [Accepted: 01/05/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE Time to antibiotic administration (TTA) in <60 minutes for children with neutropenic fever presenting to an emergency room is associated with reduced incidence of sepsis and intensive care admission. As such, TTA is used as a national quality metric for pediatric oncology patients. At our center, in 2020, 19% of the hospitalized patients with a new fever encounter were receiving antibiotics in <60 minutes, prompting a multidisciplinary approach to reach a goal of >90% in all pediatric patients with cancer with a new fever. METHODS A multidisciplinary team completed four Plan-Do-Study-Act cycles between March 2021 and September 2023. We implemented education initiatives, an updated handoff smartphrase guiding the on-call team, an antibiotic champion (AC) nursing role, a revised fever plan for handoff, a rapid-response team to address new fevers, and an algorithm for blood culture collection. Data were collected, analyzed, and reported biweekly with feedback sought for delays in TTA. RESULTS There was a total of 639 new fevers in 329 unique oncology patients. As of September 4, 2023, average TTA decreased from 89 minutes at baseline to 46.4 minutes for more than 12 months. The percentage of patients receiving first dose of antibiotic in <60 minutes also increased from 19% to 93.7%, which was sustained as well. The most effective interventions were creation of the AC role and streamlining the blood culture collection process. CONCLUSION This project demonstrates the importance of multidisciplinary involvement for providing optimal care. Specific implementation of targeted education, an AC role, and development of an algorithm streamlining the processes led to meaningful targeted improvements. Further analyses will explore the impact of these interventions on patient outcomes.
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Affiliation(s)
- Wesley T Smith
- Department of Pediatrics, Division of Hematology/Oncology, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Jay Read
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Shreya Agarwal
- Department of Pediatrics, Division of Hematology, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Gengwen Tian
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Shaniqua J Anum
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Michelle Choe
- Clinical Research Division, Department of Pediatrics, Fred Hutchinson Cancer Center, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Kristen Kurtz
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Dana Tlais
- Department of Oncology, Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Xiaofan Shen
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jill Sarro
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Thomas Looney
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy Porea
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Hannah Sauer
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Julienne Brackett
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Murali Chintagumpala
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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Mendieta A, Rios Lopez L, Vargas Arteaga M, Maradiegue E, Delgadillo Arone W, Rueda Bazalar C, Holguin A, Santillan Salas C, Maza I, Homsi M, Farias Barrios F, Assayag C, Vásquez L, Pascual C, Caniza M. A multimodal strategy to improve health care for pediatric patients with cancer and fever in Peru. Rev Panam Salud Publica 2023; 47:e140. [PMID: 37799822 PMCID: PMC10548892 DOI: 10.26633/rpsp.2023.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/14/2023] [Indexed: 10/07/2023] Open
Abstract
Objective The DoTT (Decreasing Time to Therapy) project aimed to minimize the interval between fever onset and medical interventions for children with febrile neutropenia. The objective of this study was to determine the effect of implementing the DoTT project on the hospital time to antibiotic (TTA) and patient time to arrival (PTA) at the hospital in children with febrile neutropenia admitted to the emergency department. Methods The DoTT project was implemented at a Peruvian hospital and followed the World Health Organization (WHO) multimodal improvement strategy model. Components included creating a healthcare delivery bundle and antibiotic selection pathways, training users of the bundle and pathways, monitoring patient outcomes and obtaining user feedback, encouraging use of the new system, and promoting the integration of DoTT into the institutional culture. Emergency room providers were trained in the care delivery for children with cancer and fever and taught to use the bundle and pathways. DoTT was promoted via pamphlets and posters, with a view to institutionalizing the concept and disseminating it to other hospital services. Results Admission data for 129 eligible patients in our registry were analyzed. The TTA and PTA were compared before and after the DoTT intervention. The median TTA was 146 minutes (interquartile range [IQR] 97-265 minutes) before the intervention in 99 patients, and 69 minutes (IQR 50-120 minutes) afterwards in 30 patients (p < 0.01). The median PTA was reduced from 1 483 minutes at baseline to 660 minutes after the intervention (p < 0.01). Conclusions Applying the WHO multimodal improvement strategy model to the care of children with febrile neutropenia arriving at the hospital had a positive impact on the PTA and TTA, thus potentially increasing the survival of these patients.
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Affiliation(s)
- Ana Mendieta
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Ligia Rios Lopez
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Maria Vargas Arteaga
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Essy Maradiegue
- Instituto Nacional de Enfermedades NeoplásicasLimaPeruInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Walter Delgadillo Arone
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Carlos Rueda Bazalar
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Alexis Holguin
- Instituto Nacional de Enfermedades NeoplásicasLimaPeruInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | | | - Ivan Maza
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Maysam Homsi
- St. Jude Children’s Research HospitalMemphisUnited States of AmericaSt. Jude Children’s Research Hospital, Memphis, United States of America
| | | | - Claudia Assayag
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Liliana Vásquez
- Pan American Health OrganizationWashington, D.C.United States of AmericaPan American Health Organization, Washington, D.C., United States of America
| | - Claudia Pascual
- Pan American Health OrganizationLimaPeruPan American Health Organization, Lima, Peru
| | - Miguela Caniza
- St. Jude Children’s Research HospitalMemphisUnited States of AmericaSt. Jude Children’s Research Hospital, Memphis, United States of America
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Escobedo-Melendez G, Paniagua-Padilla J, Caniza MA. Outcomes of Care-bundle Implementation for Children With Cancer and Suspected Bloodstream Infection in a Pediatric Oncology Unit in a Resource-limited Setting. J Pediatr Hematol Oncol 2023; 45:e798-e809. [PMID: 37526415 PMCID: PMC10521769 DOI: 10.1097/mph.0000000000002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 06/20/2023] [Indexed: 08/02/2023]
Abstract
Bloodstream infections (BSIs) are a major cause of mortality among pediatric oncology patients in resource-limited settings. Effective, innovative strategies are needed to improve care and survival. In a pediatric oncology unit in Mexico, we retrospectively analyzed the risk factors for mortality related to BSI and the results of using a care-bundle intervention. The care-bundle consisted of a swift clinical evaluation, initial fluid-resuscitation support, obtaining blood cultures, and administration of effective empirical antibiotic therapy for suspected BSI. The outcomes of patients who received the care-bundle during a 12-month period were compared with those of patients treated with standard care during the 12 months preceding its implementation. The primary outcomes were BSI diagnosis, choice of antibiotics, and mortality. Of the 261 suspected BSIs treated with standard care, 33 (12.6%) infections were confirmed, and of the 308 treated with the care-bundle, 67 (21.7%) BSIs were confirmed. Thus, after implementation of the care-bundle, significantly more BSIs were diagnosed ( P =0.004), and BSI-related mortality was significantly reduced by 22.2% ( P = 0.035). Surgical resection and mechanical ventilation support were independently associated with BSI-related mortality, and receiving effective initial empirical antibiotic therapy was protective against mortality (odds ratio, 0.013; 95% CI: 0.002-0.105; P =0.001), which comprising cefepime plus amikacin or meropenem in 44 (80.0%) of the cases alive. Consistent use of a care-bundle with initial fluid resuscitation, obtaining a blood culture, and administering effective antibiotics to children with cancer and suspected BSI can decrease mortality.
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Affiliation(s)
- Griselda Escobedo-Melendez
- Institute for Research in Childhood and Adolescence Cancer, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Jenny Paniagua-Padilla
- Institute for Research in Childhood and Adolescence Cancer, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Miguela A. Caniza
- Departments of Global Pediatric Medicine and Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
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Carolan PL, Lammers SM, Anderson CM, Messinger YH. Effect of Prearrival Orders on Time to Antibiotics for Immunocompromised Oncology Patients Presenting to the Emergency Department With Fever. Pediatr Emerg Care 2023; 39:470-475. [PMID: 36066576 DOI: 10.1097/pec.0000000000002822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pediatric cancer patients with fever are at risk for invasive bacterial infection. The administration of antibiotics to these patients within the first hour of evaluation is viewed as a quality of care metric with potential to improve outcome. We sought to evaluate the impact of prearrival patient orders on the timeliness of antibiotic administration for this patient population presenting to the emergency department (ED) because of fever. METHODS A single-site pediatric ED intervention study was performed. Four hundred thirty-nine consecutively referred febrile immunocompromised pediatric oncology patients were included in the study. The intervention used structured monthly messages sent to oncology and emergency medicine providers highlighting specific roles in prehospital communication and in ED-based care emphasizing the use of standardized, prearrival order (PAO) sets. Primary outcome measures were time to antibiotic administration (TTA) and the proportions of patients receiving PAO placement and antibiotics within 60 minutes of ED arrival. Results were analyzed for the preintervention (September 2016-July 2017), intervention (August 2017-February 2018), and postintervention (March-December 2018) periods. RESULTS Improvements occurred across the study periods in the proportion of patients with PAO placement (preintervention, 68%; intervention, 82%; postintervention, 87%; P = 0.001) as well as in the percentages of patients receiving antibiotics in less than 60 minutes (preintervention, 73%; intervention, 84%; postintervention, 85%; P = 0.02). Median TTA decreased from 48 to 40 minutes ( P = 0.018). Linear regression with TTA as a dependent variable revealed that PAO placement predicted a shorter TTA, decreasing by more than 15 minutes ( B = -15.90; [95% confidence interval, -20.03--11.78]; P < 0.001). CONCLUSIONS Standardizing elements of prehospital communication and ED-based care using PAO sets resulted in significant improvements in time to antibiotics and in the proportion of febrile immunocompromised oncology patients receiving antibiotics within 60 minutes of ED arrival.
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Affiliation(s)
| | | | - Cynthia M Anderson
- Department of Hematology Oncology, Children's Minnesota, Minneapolis, MN
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5
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Woods EJ, Walker LE, Heaton HA, Scanlan-Hanson LN, Finley JL, Olson OJ, Khan SP, Mannenbach MS. Improving Timely Antibiotic Administration for Pediatric Oncology Patients With Neutropenic Fever Seen in the Emergency Department. Mayo Clin Proc Innov Qual Outcomes 2022; 6:597-604. [PMID: 36386574 PMCID: PMC9643833 DOI: 10.1016/j.mayocpiqo.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE To improve the care for pediatric oncology patients with neutropenic fever who present to the emergency department (ED) by administering appropriate empiric antibiotics within 60 minutes of arrival. PATIENTS AND METHODS We focused on improving the care for pediatric oncology patients at risk of neutropenia who presented to the ED with concern for fever. Our baseline adherence to the administration of empiric antibiotics within 60 minutes for this population was 53% (76/144) from January 1, 2010, to December 21, 2014. During 2015, we reviewed data monthly, finding 73% adherence. We used the Lean methodology to identify the process waste, completed a value-stream map with input from multidisciplinary stakeholders, and convened a root cause analysis to identify causes for delay. The 4 causes were as follows: (1) lack of staff awareness; (2) missing patient information in electronic medical record; (3) practice variation; and 4) lack of clear prioritization of laboratory draws. We initiated Plan-Do-Study-Act cycles to achieve our goal of 80% of patients receiving appropriate empiric antibiotics within 60 minutes of arrival in the ED. RESULTS Five Plan-Do-Study-Act cycles were completed, focusing on the following: (1) timely identification of patients by utilizing the electronic medical record to initiate a page to the care team; (2) creation of a streamlined intravascular access process; (3) practice standardization; (4) convenient access to appropriate antibiotics; and (5) care team education. Timely antibiotic administration increased from 73%-95% of patients by 2018. More importantly, the adherence was sustained to greater than 90% through 2021. CONCLUSION A structured and multifaceted approach using quality improvement methodologies can achieve and sustain improved patient care outcomes in the ED.
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Affiliation(s)
- Emily J. Woods
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Laura E. Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | | | - Lori N. Scanlan-Hanson
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
- Department of Nursing, Mayo Clinic, Rochester, MN
| | - Janet L. Finley
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
- Department of Nursing, Mayo Clinic, Rochester, MN
| | - Ole J. Olson
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Shakila P. Khan
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Mark S. Mannenbach
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Mayo Clinic, Rochester, MN
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6
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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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Butt AJ, Kanwal F, Hafeez H, Nasir KS, Abrar W, Munawar M, Yaqub S. Time to antibiotics (TTA) in paediatric patients with fever in the setting of neutropenia. Clin Med (Lond) 2022; 22 Suppl 4:82-83. [PMID: 38614611 PMCID: PMC9600804 DOI: 10.7861/clinmed.22-4-s82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Anosha Jabeen Butt
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Fareeha Kanwal
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Haroon Hafeez
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | | | - Wajeeha Abrar
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Marrium Munawar
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Samran Yaqub
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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Wattier RL, Esbenshade AJ. From "More is Better" to "Less is More": A Commentary on Antimicrobial Use in Pediatric Oncology. J Pediatric Infect Dis Soc 2022; 11:229-238. [PMID: 35099542 DOI: 10.1093/jpids/piab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/09/2021] [Indexed: 11/14/2022]
Abstract
Reducing avoidable antimicrobial exposure to pediatric patients with cancer is achievable and necessary to promote optimal short- and long-term outcomes. Multiple evidence-based practices are already well established but should be more consistently implemented. Important opportunities exist to further improve the evidence to guide selective antimicrobial use in pediatric oncology.
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Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
| | - Adam J Esbenshade
- Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University, Nashville, Tennessee, USA
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Wadhwa A, Oakley J, Richman J, Bhatia S, Kutny MA. Time to Antibiotic for Pediatric Oncology Patients With Febrile Neutropenia at Regional Emergency Departments. Pediatr Emerg Care 2022; 38:e94-e99. [PMID: 32569251 DOI: 10.1097/pec.0000000000002160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES We compared the time to antibiotic (TTA) for pediatric oncology patients with febrile neutropenia (FN) presenting at regional emergency departments (EDs) with those presenting at a pediatric referral ED, and examined its association with need for aggressive medical care. METHODS We abstracted data for pediatric oncology patients (age, <21 years) admitted for FN between August 2012 and August 2017 at a single children's hospital and compared the TTA between those referred from a regional ED across the state and those admitted via the referral ED at the children's hospital. Factors associated with delay in antibiotic administration (TTA, >60 minutes) were estimated using generalized linear modeling with generalized estimating equations (GEEs). Delay in antibiotic administration was examined for its association with the need for aggressive medical care (>1 fluid bolus, intensive care unit admission, inotropic or invasive ventilator support) within 24 hours of admission as an exploratory aim. RESULTS Three-hundred eighty-nine FN admissions (regional ED, 26.7%; referral ED, 73.3%) occurred in 205 eligible patients. Median TTA was significantly (P < 0.0001) greater among patients presenting at a regional ED (117.5 minutes [range, 9-722 minutes]) vs referral ED (46 minutes [range, 6-378 minutes]). Presentation at regional ED was the only factor associated with delay in antibiotic administration (odds ratio, 9.73; 95% confidence interval, 5.37-17.63; P < 0.0001). Delay in antibiotic administration was not associated with greater need for aggressive medical care (odds ratio, 1.34; 95% confidence interval, 0.55-3.29; P = 0.5). CONCLUSIONS Pediatric oncology patients with FN presenting to regional EDs have longer TTA as compared with those presenting to a referral ED at a children's hospital.
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Affiliation(s)
| | - Jamie Oakley
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Joshua Richman
- Division of Pediatric Hematology and Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham
| | | | - Matthew A Kutny
- From the Division of Hematology and Oncology, Department of Pediatrics
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Kuehnel NA, McCreary E, Henderson SL, Vanderloo JP, Hoover-Regan ML, Sharp B, Ross J. Comprehensive Care Improvement for Oncologic Fever and Neutropenia from a Pediatric Emergency Department. Pediatr Qual Saf 2021; 6:e390. [PMID: 38571520 PMCID: PMC10990408 DOI: 10.1097/pq9.0000000000000390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022] Open
Abstract
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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Affiliation(s)
- Nicholas A Kuehnel
- From the Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Erin McCreary
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Sheryl L Henderson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Joshua P Vanderloo
- Department of Pharmacy, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Margo L Hoover-Regan
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Brian Sharp
- From the Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Joshua Ross
- From the Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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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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Phang KG, Roberts JR, Ebeling M, Garner SS, Basco WT. Opioids or Steroids for Pneumonia or Sinusitis. Pediatrics 2020; 146:peds.2019-3690. [PMID: 32616629 PMCID: PMC7397734 DOI: 10.1542/peds.2019-3690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To compare the frequency of opioid and corticosteroid prescriptions dispensed for children with pneumonia or sinusitis visits on the basis of location of care. METHODS We evaluated 2016 South Carolina Medicaid claims data for 5 to 18 years olds with pneumonia or sinusitis. Visits were associated with 1 of 3 locations: the emergency department (ED), urgent care, or the ambulatory setting. RESULTS Inclusion criteria were met by 31 838 children. Pneumonia visits were more often linked to an opioid prescription in the ED (34 of 542 [6.3%]) than in ambulatory settings (24 of 1590 [1.5%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (106 of 542 [19.6%]) than in ambulatory settings (196 of 1590 [12.3%]; P ≤ .0001). Sinusitis visits were more often linked to an opioid prescription in the ED (202 of 2705 [7.5%]) than in ambulatory settings (568 of 26 866 [2.1%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (510 of 2705 [18.9%]) than in ambulatory settings (1922 of 26 866 [7.2%]; P ≤ .0001). In logistic regression for children with pneumonia, the ED setting was associated with increased odds of receiving an opioid (adjusted odds ratio [aOR] 4.69) or steroid (aOR 1.67). Similarly, patients with sinusitis were more likely to be prescribed opioids (aOR 4.02) or steroids (aOR 3.05) in the ED than in ambulatory sites. CONCLUSIONS School-aged children received opioid and steroid prescriptions for pneumonia or sinusitis at a higher frequency in the ED versus the ambulatory setting.
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Affiliation(s)
| | - James R. Roberts
- Medical University of South Carolina, Charleston, South Carolina
| | - Myla Ebeling
- Medical University of South Carolina, Charleston, South Carolina
| | - Sandra S. Garner
- Medical University of South Carolina, Charleston, South Carolina
| | - William T. Basco
- Medical University of South Carolina, Charleston, South Carolina
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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: 10] [Impact Index Per Article: 2.0] [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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