A Quality Improvement Initiative: Improving Time-to-Antibiotics for Pediatric Oncology Patients with Fever and Suspected Neutropenia

BackgroundThere is a high risk for adverse outcomes in immunocompromised, neutropenic pediatric oncology patients with fever if antibiotics are not received in a timely manner. As the absolute neutrophil count is typically unknown at the onset of fever, rapid antibiotic administration for all pediatric oncology patients with fever and suspected neutropenia is critical. Local ProblemDespite efforts over the years to meet the standard of time-to-antibiotic delivery to within 60 minutes of arrival, audits revealed a prolonged and wide-ranging time-to-antibiotics in our pediatric emergency department. MethodsWe conducted a quality improvement initiative to reduce the time to antibiotic delivery for this high risk patient population. The setting was a pediatric emergency department in an academic tertiary care hospital. We assembled a multidisciplinary team to apply quality improvement methods to understand the problem, implement interventions, and evaluate the outcomes. InterventionsWe targeted delays in patient triage, delays in antibiotic ordering, delays in antibiotic choice, and delays in bedside indwelling Port-a-Cath accessing procedure. Among other interventions, we instituted three unique measures: ceftriaxone was administered to all pediatric oncology patients with suspected neutropenia and fever; a system of ordering antibiotics that was driven by the ED pharmacist obtaining a verbal order from the ED attending; and a nurse-driven order set triggered by a unique triage category which empowered nurses to access a patients central line, draw and send specified blood work, and deliver an intravenous antibiotic, all potentially before an ED provider sees the patient. ResultsOver a sustained 3 year period of time, the percentage of febrile oncology patients with suspected neutropenia who met the target time-to-antibiotic delivery rose from 51% to 96%. The mean time-to-antibiotic delivery fell from 58 minutes in the pre-intervention period to 28 minutes in the post-intervention period. ConclusionsThe interventions implemented by the multidisciplinary team, using quality improvement methodology, successfully improved the percentage of febrile oncology patients receiving antibiotics within 60 minutes of arrival to a pediatric emergency department.