Pediatric patients who receive antibiotics for fever and neutropenia in less than 60 min have decreased intensive care needs

Abstract

Background: Antibiotic delivery to patients with fever and neutropenia (F&N) in <60 min is an increasingly important quality measure for oncology centers, but several published reports indicate that a time to antibiotic delivery (TTA) of <60 min is quite difficult to achieve. Here we report a quality improvement (QI) effort that sought to decrease TTA and assess associated clinical outcomes in pediatric patients with cancer and F&N.

Procedure: We used Lean-Methodology and a Plan-Do-Study-Act approach to direct QI efforts and prospectively tracked TTA measures and associated clinical outcomes (length of stay, duration of fever, use of imaging studies to search for occult infection, bacteremia, intensive care unit (ICU) consultation or admission, and mortality). We then performed statistical analysis to determine the impact of our QI interventions on total TTA, sub-process times, and clinical outcomes.

Results: Our QI interventions significantly improved TTA such that we are now able to deliver antibiotics in <60 min nearly 100% of the time. All TTA sub-process times also improved. Moreover, achieving TTA <60 min significantly reduced the need for ICU consultation or admission (P = 0.003) in this population.

Conclusion: Here we describe our QI effort along with a detailed assessment of several associated clinical outcomes. These data indicate that decreasing TTA to <60 min is achievable and associated with improved outcomes in pediatric patients with cancer and F&N.

Keywords: antibiotics time; fever; neutropenia; quality improvement.

Fig 1

Changes in TTA over time. TTA: time to antibiotic delivery. (A) Run Chart indicates TTA for each consecutive patient included in the study (N = 116). Phase of study is shown in Red. Target TTA of <60 min is shaded in green. Control Charts for Mean (B) and Median (C) TTA are also shown. Upper (UCL) and Lower (UCL) control limits are shown as dashed lines. The green line indicates the overall mean (B) or median (C) for the phase of study. The blue line connects the mean (B) or median (C) for each month of study.

Fig 2

Clinic flow for patients presenting with fever and possible neutropenia. TTA: time to antibiotic delivery. The top panel (A) represents flow prior to the start of this project and during the baseline period. Perceived barriers to a TTA <60 min identified by Lean Methodology and team brainstorming are indicated in red. The bottom panel (B) represents flow after project improvements were implemented. Individual steps of the process were grouped into four sub-processes for analysis and are color-coded as indicated in the legend. Non-value-added steps were eliminated by project improvements. There was no defined process for patients who developed a fever in clinic prior to project interventions.

Fig 3

Percent of cases with TTA <60 min. TTA, time to antibiotic delivery. (A) P-Chart indicates the percent of patients who received antibiotics in <60 min during the study period. Target TTA <60 of 100% is shown in green. Upper (UCL) and Lower (UCL) control limits are shown as dashed lines. The blue line connects the percent of cases with TTA <60 min for each month of study. Colored bubbles designate Plan-Do-Study-Act (PDSA) cycles. (B) Continuation of chart A representing the Maintenance Phase wherein no further PDSA cycles occurred. (C) Run-chart showing TTA for all consecutive patients in the Maintenance phase (N = 104). The green line marks TTA of 60 min and the red line marks the median TTA for the Maintenance phase.

Fig 4

Sub-process analysis. TTA, time to antibiotic delivery. Total TTA was divided into four sub-processes: (A) Check-in to Specimen Received, (B) Specimen Received to Lab Resulted, (C) Lab Resulted to Order Released, and (D) Order Released to Antibiotic Administered, which sum to yield TTA (E) Box and Whisker plots (A–E) show minimum to maximum values (whiskers), mean (asterisk), and median (horizontal line) by study period. In F, stacked bars designate average sub-process times for each month regardless of study period.