Shorten time to antibiotics for oncology patients with suspected neutropenia

Practitioners at a health center in Nova Scotia improved the time to antibiotics (TTA) for children with chemotherapy-induced febrile neutropenia (FN) by instituting a quality improvement project that included making many small and easy-to-implement changes to streamline the process.

Multiple potential delays (what the authors of a report on the project call “process wastes”) to TTA included patients’ waiting to be registered or for laboratory technicians, delayed central venous access device (CVAD) access, waiting for the absolute neutrophil count (ANC) to be reported, and delayed antibiotic orders. A multidisciplinary team sought to eliminate these wastes by laying out all stakeholders’ tasks to allow them to be executed in parallel, including nurse-initiated CVAD access and planned antibiotic administration no later than 45 minutes after triage. The authors reviewed how oncology patients who visited the emergency department (ED) with suspected FN were managed under a new streamlined process and compared these results with a baseline audit to evaluate improvements.

After the new process was initiated, 49 FN encounters in 26 patients took place during a 1-year period. The TTA significantly improved to a median of 59 minutes compared with the baseline of 99 minutes for patients with confirmed FN. In addition, the percentage of patients treated within 60 minutes rose from 12% to 47% and those treated within 90 minutes from 39% to 74%. The TTA was significantly shorter if the CVAD was accessed by a nurse to collect blood samples, with a median TTA of 55 minutes compared with 99 minutes when laboratory personnel collected them. The authors also determined that use of a standardized order set was associated with a median TTA of 55 minutes compared with 79.5 minutes without use of standardized order sets. Other positive changes included having families apply topical anesthetic en route to the ED, nurse-initiated steps, information to the electronic medical record, printing important orders with the initial ED package of paperwork, and setting a time limit for ANC returns before administering antibiotics (Geerlinks A, et al. Pediatr Emer Care. 2020;36[11]:509-514).

Thoughts from Dr. Farber

Shortening the time to initiating antibiotic therapy in these potentially septic patients is quite important. You do not have to follow all the steps the authors took and can adapt some for your own circumstances, but arranging a protocol at your local hospital should not be that difficult, and could have immense benefits.