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Emergency Department Febrile Neutropenia Pathway for Patients With Cancer Reduces Time to Antibiotic Administration

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Key Points

  • Use of an emergency department febrile neutropenia pathway significantly reduced time to antibiotic administration in patients with cancer.
  • More than half of patients received antibiotic treatment within 90 minutes.

In a study reported in the Journal of Oncology Practice, Keng et al at Cleveland Clinic found that institution of an emergency department febrile neutropenia pathway for patients with cancer reduced the time to antibiotic administration compared with historical and direct admission cohorts.

Study Details

The study included all adult patients with cancer who presented with fever to the Cleveland Clinic Emergency Department between June 2012 and June 2013. The febrile neutropenia pathway interventions included providing patients with febrile neutropenia alert cards, standardizing the definition of febrile neutropenia and recognizing it as a distinct chief complaint, revising the emergency department triage level for febrile neutropenia, creating electronic febrile neutropenia order sets, administering empiric antibiotics before neutrophil count result, and relocating febrile neutropenia antibiotics to the emergency department. The primary outcome was time to antibiotic administration, with a target of 90 minutes after emergency department presentation. (The study was initiated prior to release of ASCO and Surviving Sepsis Campaign recommendations of a target of 60 minutes.)

Outcomes were compared with those in a historical cohort of patients presenting to the emergency department between February 2010 and May 2012 and a cohort of patients directly admitted to the inpatient oncology service with a presumptive diagnosis of febrile neutropenia between June 2012 and June 2013. Directly admitted patients are judged to be clinically stable, with sicker patients being sent directly to the emergency department.

Time to Antibiotic Administration

In total, there were 276 febrile neutropenia episodes in 223 patients in the intervention group, 107 episodes in 87 patients in the historical cohort, and 114 episodes in 101 patients in the direct-admission cohort.

The median time to antibiotic administration was 81 minutes in the intervention group vs 235 minutes in the historical cohort and 169 minutes in the direct-admission cohort (P < .001 for both comparisons). In the intervention group, use of the electronic febrile neutropenia order set reduced the median time to antibiotic administration from 96 to 68 minutes (P < .001). Overall, time to antibiotic administration was within the 90-minute target range for 57% of the intervention group, with 32% receiving treatment within 60 minutes. Treatment within 90 minutes occurred for 1% of the historical cohort and 13% of the direct-admission cohort.

The median hospital length of stay was 3.3 days in the intervention group, compared with 4.3 days in the historical cohort (P = .26) and 5.6 days in the direct-admission cohort (P < .001).

The investigators concluded: “The [emergency department febrile neutropenia pathway] is a significant quality initiative with sustainable interventions and was able to demonstrate value by decreasing [time to antibiotic administration] compared to both historical and [direct admission] controls in cancer patients presenting to the [emergency department].”

Mikkael A. Sekeres, MD, of Cleveland Clinic, is the corresponding author of the Journal of Oncology Practice article.

The authors reported no potential conflicts of interest.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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