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October 2011, Volume 15,
Number 5
Article
Development of Tools and Processes to
Improve Treatment Times in Patients With Febrile Neutropenia
Erika L. Hawley, RN, BSN,
MBA, OCN®, Molly Loney, RN, MSN, AOCN®,
and Michelle Wiece, RN, OCN®
Despite medical advances,
febrile neutropenia remains a potentially
life-threatening emergency for patients with cancer undergoing chemotherapy. A
current literature review found only two oncology nursing studies addressing
timeliness of antibiotic administration during a febrile neutropenic
episode. Anecdotal patient reports and chart audits reflected up to a
seven-hour delay in antibiotic administration for patients with febrile neutropenia presenting to the study hospital’s emergency
department. This article describes a
multidisciplinary best practice model with tools developed for achieving timely
recognition of febrile neutropenia and a one-hour
benchmark for antibiotic administration at any point of entry to the hospital.
Collaboration between the cancer center and emergency department provided a
vehicle for critically analyzing current practice and developing effective
throughput pathways. The Neutropenic Fever Team
process reduced throughput to an average of 53 minutes for patients with
febrile neutropenia. Educational tools were developed
and used to reinforce what patients and families can do to reduce the risk of
life-threatening complications. Nurses are encouraged to implement this best
practice model in different settings and to investigate how throughput
processes and educational tools improve clinical outcomes for this high-risk
population.
At a Glance
¨
Multidisciplinary team collaboration increased throughput of patients
with cancer presenting with febrile neutropenia.
¨
A Neutropenic Fever Team process with defined
roles and responsibilities for each member enabled the cancer center to achieve
a one-hour benchmark for antibiotic initiation.
¨
Oncology nurses need to offer patients tangible education and take-home
tools to reinforce what to do when potentially neutropenic
to minimize delays in seeking medical attention and the risk of
life-threatening sepsis.
Neutropenia is the most common dose-limiting toxicity of chemotherapy treatments in
patients with cancer (Nirenberg et al., 2006). Complications from
chemotherapy-induced neutropenia can significantly affect
morbidity and mortality (Nirenberg et al., 2006). All patients receiving myelosuppressive chemotherapy are at risk for developing
febrile neutropenia—marked by a fever of 38.1°C or
higher and an absolute neutrophil count (ANC) lower
than 500/mm3—which may quickly lead to sepsis, septic shock, and
death. Clinicians’ prompt assessment and treatment of symptoms of febrile neutropenia provide the best defense against this negative
outcome. According to Nirenberg, Mulhearn, Lin, and
Larsen (2004), “About 70%–75% of deaths from acute leukemia and 50% of deaths
in patients with solid tumors are related to infection secondary to neutropenia” (p. 711). Patients admitted to the hospital
with neutropenic fever may experience an average
length of stay of 9.2 days and costs for inpatient and subsequent care reported
may average $14,407 (Nirenberg et al., 2006; Weycker
et al., 2008).
In patients with neutropenia, fever may be the only
sign of infection (Robbins, 2007), yet Nirenberg et al. (2006) found patients
with cancer with a fever of 38°C or higher waited a mean time of 21 hours
before calling or going to the emergency department (ED), despite education.
Oncology nurses need to look beyond their point of contact in providing
anticipatory guidance to ensure the safe passage of patients following
chemotherapy. Potential risk for developing life-threatening sepsis or septic
shock increases as the standard of care, prompt initiation of antibiotics, is
delayed (Nirenberg et al., 2004, 2006). This topic is a priority, as barriers
to achieve this goal continue to exist.
(See
related Case Study.)
Identification of a Need
Cleveland
Clinic Cancer Center at Hillcrest Hospital in Mayfield Heights, OH, recognized
obstacles for the timely treatment of patients with cancer experiencing neutropenic fever at any point of entry to the hospital
through anecdotal experiences and chart reviews. Research revealed delays up to
seven hours when high-risk patients with febrile neutropenia
presented to an ED. The project included collaboration from a multidisciplinary
team (i.e., ED, cancer center, infectious disease, pharmacy, and quality staff)
for quick treatment and adoption of a one-hour benchmark for initiation of
antibiotics from any point of entry to the hospital. Prompt treatment required
development of standards of practice, throughput processes, and patient and
staff education via coordination and communication with the ED.
Multidisciplinary Team Project
The team
process for timely treatment focused on the ED and cancer center. A current
shift of cancer treatment care has created a critical need to institute a rapid
response process for patients with cancer with febrile neutropenia
who present to EDs (Nirenberg et al., 2004). Hillcrest Hospital found similar
anecdotal delay experiences at Dartmouth-Hitchcock Medical Center in New
Hampshire, where the mean cycle time ranged from 70–254 minutes, depending on
patients’ point of entry into the hospital’s system—identifying a clear need
for improvement (Baltic, Schlosser, & Bedell,
2002). In addition, at an ED in New York, NY, the median waiting time before
antibiotics were given was 210 minutes (Nirenberg et al., 2004). After
conducting an initial literature review, the team adopted a 60-minute standard
from Dartmouth-Hitchcock Medical Center as a benchmark for antibiotic
administration and took it one step farther by developing a best practice
throughput model.
Team practices were as follows.
• Identified consistent
symptom criteria to define neutropenic fever
(temperature higher than 100.5°F [38.1°C], chemotherapy in prior 7–14 days)
• Added a neutropenic
fever rule-out-sepsis track to the ED triage sheet (criteria, ANC lower than
500/mm3)
• Created standard neutropenic fever admission orders
• Designed Chemotherapy Neutropenic Fever Alert magnets and wallet cards, which
included steps to follow for symptomatic patients presenting at ED for prompt
triage.
Neutropenic Fever Team Process
The
outpatient cancer center has an advantage in recognizing neutropenic
symptoms, as patients and treatment may be familiar to staff. Chart audits
revealed this patient population often presented to the ED during open hours of
the cancer center, as patients remembered through education that neutropenic fever was an emergency. The Neutropenic
Fever Team process enables quick rerouting of patients from the ED to the cancer
center for timely diagnosis and treatment (i.e., initiation of antibiotics in
one hour, if applicable) (see Figure 1).
Cancer center staff are assigned to the Neutropenic
Fever Team daily, including secretaries, medical assistants, RNs, pharmacists,
and physicians, whose roles and duties were identified clearly (see Figure
2). Staff
tools include standard orders, the process checklist, documentation guidelines,
and data collection sheets. The private cancer center neutropenic
bay room contains all supplies necessary to treat patients.
Throughput process and identification of team members are key to successful
antibiotic administration and positive patient outcomes. Cancer center staff
work together to follow processes to prevent complications and increase quality
of care. Unscheduled urgent patient visits are met with staff members rushing
to assess and appropriately administer treatment. Patients verbalize
appreciation for the urgency with which they are treated.
Targeted Education
Professional practice standards and patient education materials address
chemotherapy-induced neutropenia with a focus on
development, risk assessment, prevention, signs and symptoms, management with
antibiotics, and impact on morbidity and mortality (National Comprehensive
Cancer Network [NCCN], 2011). Additional needs include directions on what to do
when a patient with cancer becomes febrile following a course of chemotherapy
(Nirenberg et al., 2004, 2006). Chemotherapy-induced bone marrow suppression
reduces neutrophils and the body’s ability to
counteract infectious organisms. Fever must be recognized as an emergency, and
antibiotics initiated quickly, to prevent sepsis, septic shock, and death
(NCCN, 2011; Robbins, 2007).
Oncology nurses provide staff, patients, and families with critical information
about the risk and timely management of neutropenic
fever. The first educational target included the ED as a point of contact for
febrile patients with cancer when the cancer center is closed. The ED clinical
nurse specialist reviewed the following with all staff.
• Neutropenic fever as a life-threatening
emergency
• Neutropenic fever standard physician
order-sets outlining priority assessment and interventions
• ED triage guide to reinforce
febrile neutropenia rapid triage response
• Immediate feedback to
individuals about their throughput of patients with febrile neutropenia
presenting to the ED
Physician
education also was provided. An infectious disease physician reviewed neutropenic fever, potential sequelae,
assessment, and timely management with antibiotics using standard order-sets
with ED physicians. In addition, a memo with standard order-sets was mailed to
all oncologists and attending physicians.
In-services also were held for the cancer center and inpatient oncology staff
by the oncologist and oncology clinical nurse specialist. Nursing supervisors
received information to increase understanding of the needs and priorities of
patients with febrile neutropenia. Finally,
laboratory staff received information regarding the critical timeline to
confirm ANC in patients with cancer presenting to the ED with febrile neutropenia.
The project team and cancer center staff examined current patient education
about neutropenia, including reinforcing precautions
and possible signs of infection. Patients at risk received thermometers and
directions for temperature monitoring following chemotherapy. New patient and
family tools were developed, including red flag magnets and pocket or wallet
cards, which were distributed during initial treatment education. The tools
instruct patients to call the oncologist immediately if they develop a fever of
100.5°F (38.1°C) or higher.
Communication and Collaboration With the Emergency Department
The cancer center framed a project around a major principle from the
Oncology Nursing Society’s Statement on the Scope and Standards of Oncology
Nursing Practice to provide patients with optimal care, specifically
Standard VI, Collaboration, under the Standards of Professional Performance
(Brant & Wickham, 2004). Standards illustrate competent behavior, the role
of the professional oncology nurse, and criteria to provide patients with
effective care. Oncology nurses must use all resources necessary and work with
healthcare partners to coordinate safe patient care. The cancer center
recognized the need to collaborate with the ED to effectively treat patients
with neutropenic fever. The cancer center worked
closely with the ED to communicate the importance of quickly treating these
patients. Unfamiliar with patients with cancer experiencing febrile neutropenia, the ED staff was open and willing to
participate in a quality project. If a patient with cancer presented to the ED
within parameters of possible febrile neutropenia, ED
staff immediately notified the cancer center to institute the Neutropenic Fever Team process by rerouting patient to the
cancer center during open hours. When the cancer center is closed, ED staff
initiate the process themselves.
Prompt attention and superior assessment skills by ED nurses contributed to
immediate improvement in treatment times for at-risk patients. Every call
received from the ED was a success story, even if a patient with febrile neutropenia with antibiotic administration within one hour
was not the result of the call. A vulnerable patient population was treated
effectively in a familiar and comfortable environment, with known, specialized nurses
and trusted physicians.
Initial Outcomes
Initial
results from 42 retrospective chart reviews for patients with cancer meeting
criteria revealed ED door-to-antibiotic times improved by 22%, from a mean wait
time of 138 minutes to 91.6 minutes. In addition, cancer center
door-to-antibiotic times improved by 80%, from a mean wait time of 70 minutes
to 52.6 minutes.
Completion of this quality improvement project has prompted Hillcrest’s Cancer
Center team to share information with the entire Cleveland Clinic Health
System, as well as other institutions, with hope that patients with cancer
everywhere may benefit from this potentially life-saving practice model.
Future Directions
As
outpatient chemotherapy-treated patient volume increases, the need for prompt
attention and immediate treatment for febrile neutropenia
also increase. Most patients with cancer present to the ED first with a fever,
so working partnerships between the cancer center and ED are critical. Cancer
centers are challenged to implement innovative processes, such as the Neutropenic Fever Team, to improve patient throughput and
quality care by reaching a 60-minute benchmark for antibiotic administration.
Future research should examine the throughput model presented in this article
and its effect on improving outcomes for patients with cancer experiencing
febrile neutropenia over a longer period of time.
Tangible tools, paired with ongoing targeted education of patients, families,
and healthcare workers, are keys to prompt recognition and communication about
potentially life-threatening symptoms associated with neutropenia.
References
Baltic, T., Schlosser, E., & Bedell, M.K. (2002).
Neutropenic fever: One institution’s quality
improvement project to decrease time from patient arrival to initiation of
antibiotic therapy. Clinical Journal of Oncology Nursing, 6,
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Brant, J.M., & Wickham, R.S. (Eds.). (2004). Statement on the scope and
standards of oncology nursing practice. Pittsburgh, PA: Oncology Nursing
Society.
National Comprehensive Cancer Network. (2011). NCCN Guidelines™: Prevention
and treatment of cancer-related infections [v.2.2011]. Retrieved
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Nirenberg, A., Bush, A.P., Davis, A., Friese,
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Journal of Oncology Nursing, 31, 711–715.
Robbins, G.K. (2007). Fever in the neutropenic adult
patient. Retrieved from http://www.uptodateonline.com/utd/content/topic.do?topicKey=immuninf/4688&view
Weycker, D., Malin, J., Edelsberg, J., Glass, A., Gokhale,
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Erika L. Hawley, RN, BSN, MBA, OCN®, is a
senior oncology clinical coordinator in the HER2 Family at Genentech in
Twinsburg, OH; and Molly Loney, RN, MSN, AOCN®,
is a clinical nurse specialist for special projects in the Cleveland Clinic and
Michelle Wiece, RN, OCN®, is a clinical coordinator in the
Cleveland Clinic Cancer Center, both at Hillcrest Hospital in Mayfield Heights,
OH. The authors take full responsibility for the content of the article. The
authors did not receive honoraria for this work. The content of this article
has been reviewed by independent peer reviewers to ensure that it is balanced,
objective, and free from commercial bias. No financial relationships relevant
to the content of this article have been disclosed by the authors, planners,
independent peer reviewers, or editorial staff. (Submitted August 2009.
Revision submitted March 2010. Accepted for publication May 12, 2011.)
Author Contact: Erika L.
Hawley, RN, BSN, MBA, OCN®, can be reached at hawley.erika@gene.com, with copy to editor at CJONEditor@ons.org.
