Cancer patients who arrive in the emergency department with febrile neutropenia (FN) received antibiotics much more quickly when their condition was identified as a medical emergency and a care pathway was used to guide treatment. The set of simple interventions slashed average time to antibiotics from about 4 hours to less than 1.5 hours, compared with a historical cohort, and the inexpensive interventions have had durable results.
Dr. Michael Keng and his coinvestigators at the Cleveland Clinic reported the results of a single-center prospective analysis that targeted FN, a common and serious chemotherapy complication with a mortality rate that can exceed 50% in medically fragile individuals [doi:10.1200/JOP.2014.002733].
“With an increasing number of outpatient chemotherapy regimens, more patients are likely to present to the emergency department (ED) with FN,” wrote Dr. Keng. The FN pathway devised by Dr. Keng and his associates implemented key changes designed to identify FN as an emergency and guide prompt triage, assessment, and treatment.
Dr. Mikkael Sekeres
Study coauthor Dr. Mikkael Sekeres said, “The interventions were not complicated. We standardized our definition of fever; provided patients with wallet-sized cards alerting emergency departments to the potential of this serious condition; worked with our emergency department staff to change the triage level of fever and neutropenia to be equivalent to that observed for heart attack or stroke; designed standard febrile neutropenia order sets for our electronic medical record; and relocated the antibiotics used to treat febrile neutropenia to our emergency department.”
Febrile patients with cancer in the prospective cohort (n = 223) were compared with a historical cohort of patients presenting to the ED who received usual care (n = 87), as well as to a concurrent cohort of patients who were directly admitted to the hospital (n = 114). The total number of FN episodes for the cohorts was 276, 107, and 114, respectively. Multivariable analysis was used to account for some differences in patient characteristics across cohorts.
Time to antibiotics for the pathway was a median 81 minutes, compared with 225 minutes for the historical cohort and 169 minutes for the direct-admission cohort (P less than .001 for both). Only two patients in the combined comparison cohorts received antibiotics within 60 minutes, while almost one-third of the prospective cohort receiving the protocol was treated within 60 minutes.
Using the order set in the EHR also made a difference: for those treated per the order set (n = 103), median time to antibiotics was 68 minutes, compared with 96 minutes when the order set was not used.
Secondary outcome measures included times to physician assessment, blood draw, and antibiotic order placement. All measures except time to physician assessment were significantly shorter for the FN pathway group than for the comparison cohorts (P less than .001 for all).
Since so many changes were made at once, Dr. Keng and his coauthors noted, “it is difficult to determine the impact of any one change.” Some institutions may have difficulty implementing all the interventions, but immediate triage, automated antibiotic ordering, and EHR use were the changes that had the most impact, he wrote.
“Instituting these changes took less than half a year, and the benefits have persisted for years afterward,” Dr. Sekeres said in an interview.
No study authors reported conflicts of interest.