Improving door-to-needle times for patients with suspected neutropenic sepsis

Interprofessional clinical pathway program effects on patient outcomes in the setting of neutropenic fever: An integrative review

PURPOSE

Neutropenic fever (NF) is an oncologic emergency linked to substantial healthcare costs, treatment delays, and increased patient mortality. Clinical pathways have emerged as a coordinated, interprofessional approach to NF management. The aim of this review was to examine the research question: What is the effect of an interprofessional clinical pathway program on outcomes (time-to-antibiotic, mortality, cost, readmissions and length of stay) in patients presenting with NF?

METHODS

Using the integrative review method of Whittemore and Knafl, the databases PubMed, CINAHL and Scopus were searched for articles published in English between 1997 to present that met the following criteria: (1) reported clinical pathway implementation, and (2) reported outcome data on patients 18 years or older who were diagnosed with NF.

RESULTS

Of the 17 included articles, 13 demonstrated improvement in reducing time-to-antibiotic following clinical pathway implementation. Three studies reported a reduction in mortality and two studies reported no change in patient mortality after NF clinical pathway integration. One study demonstrated a reduction in hospital readmissions, while three studies showed improvement in length of stay. None of the included studies reported data on cost reduction. Half of the articles articulated the different members of the interprofessional teams.

CONCLUSION

The implementation of interprofessional clinical pathway programs for NF had positive effects on patient outcomes in this review. Measuring patient and institutional outcomes is necessary to evaluate the effectiveness of interprofessional clinical pathways in NF care. Future research should incorporate these measurements to improve the development and implementation of NF clinical pathways.

The role of temperature in the detection and diagnosis of neutropenic sepsis in adult solid tumour cancer patients receiving chemotherapy

PURPOSE

The primary aim of this study was to examine the value of temperature as a diagnostic and prognostic indicator of infection and sepsis in neutropenic patients. A secondary aim was to gain insight into the presenting symptoms reported by these patients at home or on their initial admission assessment.

METHODS

A cohort study was carried out using a case note review of 220 emergency admissions to a regional cancer centre. All participants were neutropenic and were diagnosed with infection on admission. The main outcome measures were relationships between Early Warning Scores and temperature values at home, on admission and during the hospital stay.

RESULTS

22% of patients who became acutely unwell did not have a fever. Pearson correlations showed only small associations between highest temperature value at any time point and highest early warning scores (r(202) = 0.176, P = .012). Temperature at home (B = 0.156, P = .336) and temperature on admission (B = 0.200, P = .052) did not predict highest Early Warning Scores.

CONCLUSIONS

Body temperature is not a consistently reliable diagnostic or prognostic indicator for outcomes in patients with neutropenia and symptoms of infection. It can assist with early presentation and recognition of infection in many neutropenic patients. However, over-reliance on temperature risks missing the opportunity for early detection and treatment.

Management of oncological emergencies on the acute take

In 2008, recommendations from the National Confidential Enquiry into Patient Outcome and Death identified large variations in the quality and safety of delivery of systemic anti-cancer therapy. In 49% of cases it was felt there was room for improvement and in 27% of cases treatment actually caused or hastened death. Every hospital with an emergency department and/or specialist oncology beds should therefore have a fully functioning acute oncology service to align acute oncology with urgent care. Many patients will still present via the acute take and therefore acute physicians need to be aware of the role of the acute oncology teams and management of oncology emergencies. This article discusses the role of the acute oncology team, management of acute oncology emergencies, namely neutropenic sepsis, metastatic spinal cord compression and superior vena cava obstruction, and important points for acute teams to consider.