Nurse-initiated pre-prescribed antibiotic orders to facilitate prompt and appropriate antibiotic administration in febrile neutropenia.

PURPOSE: To assess the impact of a pathway allowing nurse initiation of first dose intravenous (IV) antibiotics on time to antibiotic administration (TTA) in adult inpatients with febrile neutropenia (FN). METHODS: This study evaluated the impact on TTA of a clinical pathway (November 2017 to April 2018) allowing nurse initiation of pre-prescribed antibiotics in adult haematology patients with FN, compared with a prior cohort (November 2016 to April 2017) in which antibiotics were only prescribed and administered after medical review. The primary endpoint for comparison was TTA, calculated as the time between the first recorded fever and IV antibiotic administration. Secondary endpoints included appropriateness of initial antibiotic choice, 30-day all-cause mortality and admission to intensive care unit (ICU). RESULTS: Forty-seven eligible FN episodes in 40 patients and 61 episodes in 52 patients were evaluated in the pre- and post-implementation groups, respectively. Baseline characteristics were comparable between groups. Median (IQR) TTA, in the pre-implementation group [66 min (40-100 min)] was significantly prolonged versus post-implementation group [29 min (20-41 min); p < 0.001]. A significantly higher proportion of episodes were administered appropriate initial antibiotics in the post-versus pre-implementation groups (100% vs. 89%, p = 0.03). There was no significant change in 30-day all-cause mortality (0% vs. 5%, p = 0.3) or ICU admission within 48 h of fever (0% vs. 2%, p > 0.99) between pre- and post-implementation groups, respectively. CONCLUSIONS: A pathway allowing nurse initiation of pre-prescribed antibiotic orders for FN significantly reduced TTA from first recorded fever and increased the proportion of appropriate initial antibiotic choices without significantly impacting on patient outcomes.

The Quality of Care in the Emergency Management of Cancer Patients With Febrile Neutropenia: A Records-Based Cohort.

INTRODUCTION: Febrile neutropenia is one of the most severe oncological emergencies associated with the treatment of cancer. Patients with febrile neutropenia are at grave risk of developing life-threatening sepsis unless there is rapid initiation of treatment. The aim of this study was to evaluate the quality of ED care of patients with febrile neutropenia using the 3 quality dimensions of safety, effectiveness, and timeliness of care. METHODS: A retrospective review of all available records of adult cancer patients with febrile neutropenia who presented to 1 urban emergency department in Atlantic Canada was conducted over 5 years. RESULTS: Examining the 9 quality indicators of the 431 patients included in the study identified areas for improvement in each of the 3 dimensions. More than one third of the participants were unsafely discharged from the emergency department despite the severity of their conditions. Patients in the study were not seen promptly by the physician and did not receive timely treatment during different phases of their visit. Most importantly, the delay in antibiotic administration presented a major risk for this population. DISCUSSION: Aspects of care provided to this cohort of febrile neutropenia patients were inconsistent with the recommended evidence. Strengthening ED care is necessary to reduce the gap between evidence-based and actual care. Quality initiatives can be implemented to improve care to become safer, effective, and timely. Nurses who are in direct contact with the patients and who are actively involved in every single process of the health care system are well positioned to lead this change.

A cohort study on protocol-based nurse-led out-patient management of post-chemotherapy low-risk febrile neutropenia.

PURPOSE: International guidelines adopt risk stratification approach to manage patients with low-risk febrile neutropenia patients. We developed this out-patient program using shared-care model with professional input and patient empowerment, so as to reduce patients' psychological burden from hospitalization and to improve the cost-effectiveness of management. METHOD: This is a prospective cohort study to compare the efficacy and safeness of the out-patient program when compared with traditional in-patient care. Patients with solid tumors, developed febrile neutropenia with Multinational Association of Supportive Care in Cancer score of at least 21, and good performance status were included. After initial assessment and the first dose of oral antibiotics, patients were observed in the ambulatory center. Stable patients were discharged home after 4 h of observation and nurse counseling. Patients' condition and clinical progress were regularly reviewed by specialist nurses within the following week by telephone and nurse clinic follow-up. The primary objective of the study is success rate, which defined as the resolution of fever and infection, without hospitalization or any change in antibiotics. RESULTS: From September 2014 to December 2016, a total of 38 patients were enrolled. Majority were female with breast cancer (97%). Two patients required hospitalization due to persistent fever. The success rate of the out-patient program was not significantly different from the historical in-patient cohort (94.9 versus 97.4%, p = 0.053). No mortality was observed. Patients' compliance to the program was 100%, to telephone follow-up, nurse clinic visits, and daily temperature record. CONCLUSION: Out-patient management of patients with low-risk febrile neutropenia is effective and safe through implementation of a structured protocol with joint inputs and engagement from clinicians, oncology nurses, and patients.

The impact of emergency department triage on the treatment outcomes of cancer patients with febrile neutropenia: A retrospective review.

INTRODUCTION: The emergency department (ED) is an important entry point for patients with cancer requiring acute care due to oncological emergencies. Febrile neutropenia (FN) is one of the most common oncological emergencies and carries a significant risk of morbidity and mortality. There is evidence from previous studies that FN patients wait far longer in the ED than recommended by international guidelines. PURPOSE: The aim was to examine whether individuals with cancer presenting at the ED with FN were triaged appropriately, and to explore if, and how, triage affected their treatment outcomes. METHODS: A retrospective cohort design was employed to collect data over five years from all available ED records of adult cancer patients who presented with fever. RESULTS: Of the 431 eligible patients, 63% (n = 272) were assigned triage scores that were detrimental to their immediate health. Findings from the multiple linear regression analyses showed that inaccurate or under triage was significantly associated with delayed times for the initial physician assessment, administration of antibiotics, and decision on admission. The absence of fever at the time of triage assessment contributed significantly to the prediction of under triage. CONCLUSION: The allocation of patients with FN to a lower, inaccurate priority was partly responsible for the inability of those patients to meet the standard benchmarks for the initial physician assessment and the administration of antibiotics identified by the triage and febrile neutropenia guidelines. Ongoing strategies are needed to both enhance the application of the triage guidelines and institute organizational and system changes that promote timeliness and effectiveness throughout the entire ED episode of care.

Febrile neutropenia risk assessment tool: improving clinical outcomes for oncology patients.

PURPOSE: To develop, implement and evaluate the effectiveness of a nurse-led risk assessment tool to reduce the incidence of febrile neutropenia (FN) and evaluate the nurse's role in FN risk assessment in a hospital-based oncology unit. METHODS AND SAMPLE: A FN risk assessment tool was developed, implemented and evaluated. A comparative prospective observational chart review was undertaken to evaluate the tool. Clinical data were collected from 459 patients' records from August 2008 through July 2009. Patients had no intervention during the first six months (n = 233). Patients in the following six months (n = 226) had the FN risk assessment completed and appropriate granulocyte-colony stimulating factor prescribed. A self-questionnaire was utilised to evaluate the nurses' role in FN risk assessment. KEY RESULTS: The incidence of FN was reduced by 52% (p = 0.02). Hospital days, dose reductions and treatment delays were reduced. Nurses felt they were the most appropriate person to carry out the assessment. CONCLUSIONS: Through consistent risk assessment, nurses could determine which patients were at high risk of developing FN leading to significant reduction in life-threatening infections, hospitalisations, dose reductions and delays. Nurses can be confident and competent in decision-making to reduce life-threatening infections through the use of an FN risk assessment tool.