Home-based care of low-risk febrile neutropenia in children-an implementation study in a tertiary paediatric hospital.

BACKGROUND: Home-based management of low-risk febrile neutropenia (FN) is safe, improves quality of life and reduces healthcare expenditure. A formal low-risk paediatric program has not been implemented in Australia. We aimed to describe the implementation process and evaluate the clinical impact. METHOD: This prospective study incorporated three phases: implementation, intervention and evaluation. A low-risk FN implementation toolkit was developed, including a care-pathway, patient information, home-based assessment and educational resources. The program had executive-level endorsement, a multidisciplinary committee and a nurse specialist. Children with cancer and low-risk FN were eligible to be transferred home with a nurse visiting daily after an overnight period of observation for intravenous antibiotics. Low-risk patients were identified using a validated decision rule, and suitability for home-based care was determined using disease, chemotherapy and patient-level criteria. Plan-Do-Study-Act methodology was used to evaluate clinical impact and safety. RESULTS: Over 18 months, 292 children with FN were screened: 132 (45%) were low-risk and 63 (22%) were transferred to home-based care. Compared with pre-implementation there was a significant reduction in in-hospital median LOS (4.0 to 1.5 days, p < 0.001) and 291 in-hospital bed days were saved. Eight (13%) patients needed readmission and there were no adverse outcomes. A key barrier was timely screening of all patients and program improvements, including utilising the electronic medical record for patient identification, are planned. CONCLUSION: This program significantly reduces in-hospital LOS for children with low-risk FN. Ongoing evaluation will inform sustainability, identify areas for improvement and support national scale-up of the program.

Where do all the undergraduate and new graduate nurses go and why? A search for empirical research evidence.

OBJECTIVE: To review the published scientific literature for studies quantifying or examining factors associated with the attrition of undergraduate nursing students in pre-registration programs and the retention of graduate nurses in the workforce. METHODS: The following selection criteria were used to systematically search the literature: target populations were either students in pre-registration nursing programs or registered nurses in their graduate year; the studies were to be primary observational or analytical (cross-sectional, case-control or prospective cohort studies) in design; and outcome measures were attrition in undergraduate programs and/or retention of graduates within the workforce. Three authors guided by a standardised procedure performed data extraction and quality assessment independently. Synthesis of the data appears in text and tabular format. Due to the heterogenic nature of the study methods, meta-analysis was not possible. RESULTS: This review found only four studies that met all inclusion criteria. All four studies examined undergraduate attrition as an outcome with two studies reporting a range of 25-27% attrition within the first year. No studies were found that quantified or examined retention of new graduates as an outcome measure. Only two of the four studies followed cohorts of students prospectively and were able to provide a high level of evidence, although each of these studies was designed to assess specific exposures as potential predictors of attrition, rather than assess actual factors associated with students leaving their program. CONCLUSION: There is a paucity of research studies in the literature from which evidence quantifying attrition and retention and the reasons why students leave undergraduate nursing programs or new graduates leave the profession can be obtained. Clearly there is a need to systematically track undergraduates and new graduates to quantify and understand attrition, retention and workforce choices within the nursing profession and begin to build this evidence-base.