Improving Timely Antibiotic Administration for Pediatric Oncology Patients With Neutropenic Fever Seen in the Emergency Department

Emily J Woods; Laura E Walker; Heather A Heaton; Lori N Scanlan-Hanson; Janet L Finley; Ole J Olson; Shakila P Khan; Mark S Mannenbach

doi:10.1016/j.mayocpiqo.2022.10.002

Improving Timely Antibiotic Administration for Pediatric Oncology Patients With Neutropenic Fever Seen in the Emergency Department

Mayo Clin Proc Innov Qual Outcomes. 2022 Nov 5;6(6):597-604. doi: 10.1016/j.mayocpiqo.2022.10.002. eCollection 2022 Dec.

Authors

Emily J Woods¹, Laura E Walker², Heather A Heaton², Lori N Scanlan-Hanson^{2

3}, Janet L Finley^{2

3}, Ole J Olson⁴, Shakila P Khan⁵, Mark S Mannenbach⁶

Affiliations

¹ Department of Emergency Medicine, University of Utah, Salt Lake City, UT.
² Department of Emergency Medicine, Mayo Clinic, Rochester, MN.
³ Department of Nursing, Mayo Clinic, Rochester, MN.
⁴ Department of Pharmacy, Mayo Clinic, Rochester, MN.
⁵ Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
⁶ Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Mayo Clinic, Rochester, MN.

Abstract

Objective: To improve the care for pediatric oncology patients with neutropenic fever who present to the emergency department (ED) by administering appropriate empiric antibiotics within 60 minutes of arrival.

Patients and methods: We focused on improving the care for pediatric oncology patients at risk of neutropenia who presented to the ED with concern for fever. Our baseline adherence to the administration of empiric antibiotics within 60 minutes for this population was 53% (76/144) from January 1, 2010, to December 21, 2014. During 2015, we reviewed data monthly, finding 73% adherence. We used the Lean methodology to identify the process waste, completed a value-stream map with input from multidisciplinary stakeholders, and convened a root cause analysis to identify causes for delay. The 4 causes were as follows: (1) lack of staff awareness; (2) missing patient information in electronic medical record; (3) practice variation; and 4) lack of clear prioritization of laboratory draws. We initiated Plan-Do-Study-Act cycles to achieve our goal of 80% of patients receiving appropriate empiric antibiotics within 60 minutes of arrival in the ED.

Results: Five Plan-Do-Study-Act cycles were completed, focusing on the following: (1) timely identification of patients by utilizing the electronic medical record to initiate a page to the care team; (2) creation of a streamlined intravascular access process; (3) practice standardization; (4) convenient access to appropriate antibiotics; and (5) care team education. Timely antibiotic administration increased from 73%-95% of patients by 2018. More importantly, the adherence was sustained to greater than 90% through 2021.

Conclusion: A structured and multifaceted approach using quality improvement methodologies can achieve and sustain improved patient care outcomes in the ED.

Keywords: ED, emergency department; EM, emergency medicine; EMR, electronic medical record; NF, neutropenic fever; PDSA, Plan-Do-Study-Act; POP, pediatric oncology patient.