Outpatient parenteral antimicrobial therapy for surgery patients: A comparison with previous standard of care.

BACKGROUND: Current literature reports that outpatient parenteral antimicrobial therapy (OPAT) programs improve cure rates, and reduce length of hospitalization and costs. OPAT programs are still relatively new in Canada. OBJECTIVE: To evaluate the benefits of an OPAT program initiated at a multispecialty tertiary care facility in Toronto, Ontario, compared with the previous standard of care. METHODS: The present retrospective observational study was conducted using data from a group of surgical patients who were treated for active infections. Between February 1, 2010 and November 30, 2010, a total of 108 surgical patients were enrolled in the OPAT program. Patients were matched 1:1 with historical controls discharged between January 1, 2001 and January 1, 2010 according to age, sex, type of surgery, infection and comorbidities (Charlson Comorbidity Index). Cure rate, 30-day rehospitalization and length of stay were evaluated as primary end points. RESULTS: Of 108 eligible OPAT patients, 21 were matched to the control group using the prespecified criteria. For this cohort, the OPAT program was associated with improved cure rates (OPAT 61.7% versus control 57.1%; P>0.10), reduction in rehospitalization rate (14.3% versus 28.6%; P>0.10) and reduced length of stay (10.7 versus 13.9 days, P>0.10) compared with the control group. CONCLUSIONS: For this cohort of surgery patients, the OPAT program demonstrated a trend toward improved outcomes but did not achieve statistical significance. Due to the lack of statistical power, further evaluation is required to determine the full benefit of OPAT to patients and the health care system.

HISTORIQUE: D'après les rapports bibliographiques actuels, les programmes d'antibiothérapie parentérale ambulatoire (ATPA) améliorent les taux de guérison et réduisent la durée d'hospitalisation et les coûts. Les programmes d'ATPA sont encore relativement nouveaux au Canada. OBJECTIF: Évaluer les avantages d'un programme d'ATPA lancé dans un centre de soins tertiaires multidisciplinaire de Toronto, en Ontario, par rapport aux normes de soins antérieures. MÉTHODOLOGIE: Les chercheurs ont mené la présente étude d'observation rétrospective à l'aide des données d'un groupe de patients opérés traités en raison d'infections actives. Entre le 1er février et le 30 novembre 2010, 108 patients opérés ont été inscrits au programme d'ATPA. Les patients ont été jumelés 1:1 avec des sujets témoins historiques qui ont obtenu leur congé entre le 1er janvier 2001 et le 1er janvier 2010 d'après leur âge, leur sexe, le type d'opération, l'infection et les comorbidités (indice de comorbidité de Charlson). Les paramètres principaux étaient le taux de guérison, la réhospitalisation au bout de 30 jours et la durée d'hospitalisation. RÉSULTATS: Sur les 108 patients du programme d'ATPA admissibles, 21 ont été jumelés au groupe témoin au moyen des critères pré-définis. Dans cette cohorte, le programme d'ATPA s'associait à un meilleur taux de guérison (61,7 % pour l'ATPA par rapport à 57,1 % pour le groupe témoin; P>0,10), à une réduction du taux de réhospitalisation (14,3 % par rapport à 28,6 %; P>0,10) et à diminution de la durée d'hospitalisation (10,7 par rapport à 13,9 jours, P>0,10) que dans le groupe témoin. CONCLUSIONS: Auprès de cette cohorte de patients opérés, le programme d'ATPA démontrait une tendance vers de meilleures issues, sans pour autant avoir de signification statistique. En raison de l'absence d'efficacité statistique, il faudra approfondir l'évaluation afin de déterminer les avantages du programme d'ATPA pour les patients et le système de santé.

Assessment of Fever Advisory Cards (FACs) as an Initiative to Improve Febrile Neutropenia Management in a Regional Cancer Center Emergency Department.

PURPOSE: We aimed to improve the time to antibiotics (TTA) for patients treated with chemotherapy who present to the emergency department (ED) with febrile neutropenia (FN) by using standardized fever advisory cards (FACs). METHODS: Patients treated with chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada, with suspected FN were identified, before (April 2012 to March 2013) and after (October 2013 to March 2014) FAC implementation. The primary outcome of interest was TTA. Additional process measures included Canadian Triage and Acuity Scale score, time to physician assessment, and FAC compliance. Outcomes were analyzed with descriptive statistics and control charts to determine whether the change in primary measures were within statistical control over time. RESULTS: Between the pre-FAC cohort (n = 239) and post-FAC cohort (n = 69), TTA did not change significantly post-FACs (195 v 244 min, P = .09), with monthly averages demonstrating normal variation by statistical process control methodology. The introduction of FACs increased the percentage of patients with correctly assigned Canadian Triage and Acuity Scale scores (87% v 100%) but did not affect time to physician assessment. Compliance with FACs among patients was not ideal, with only 62.5% using them as intended. CONCLUSION: The distribution of FACs was associated with an improved incidence of correct FN triaging but did not demonstrate a meaningful improvement in the quality of FN management. This may be explained by FAC use among patients not being ideal. Next steps in the continued effort toward high-quality FN care include redesign of FACs, reinforcement of provider and patient education, and ED outreach.

Improving documentation of oral chemotherapy at a community cancer center.

PURPOSE: Safe administration of oral chemotherapy is a complex process that represents a potential threat to patient safety. Clear documentation of the plan of care for patients receiving oral chemotherapy can improve patient safety by ensuring complete health information is available to the health care team. METHODS: We undertook a rapid-cycle improvement project to improve documentation of oral chemotherapy by increasing the number of components of an oral chemotherapy care plan (as outlined by American Society of Clinical Oncology and Oncology Nursing Society) documented in the medical record before starting a new oral chemotherapy drug. Three improvement cycles were implemented, including: introduction of a standardized nursing flow sheet, use of computerized physician order entry for oral chemotherapy prescribing, and a review of computerized physician order entry to ensure all oral chemotherapy regimens were included. RESULTS: Our intervention resulted in a meaningful and sustained improvement in the number of components of oral chemotherapy care plans documented in the medical record, from a mean of 67% (eight of 12 components) to a mean of 92% (11 of 12). CONCLUSION: We are hopeful that this improvement project will enhance patient safety by improving communication within the health care team regarding the details of the chemotherapy care plan.