Improving Service Provision to Manage Chemotherapy-induced Neutropenic Fever in an Oncology Unit

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Objectives: Neutropenic fever is a serious complication of cytotoxic chemotherapy with significant morbidity and mortality, for which prompt initiation of antibiotics improves clinical outcomes. International guidelines recommend a ‘door-to-needle’ time (DTN) for antibiotic administration within 2 hours as a performance standard in the management of neutropenic fever. This study set out to evaluate whether this target of DTN within 2 hours was being met in our institution. By identifying hurdles in the existing system, we anticipated deriving strategies to set up new workflow arrangements to improve our practice. Methods: Two-stage retrospective audits were carried out. Oncology patients who were admitted for neutropenic fever after recent chemotherapy were identified from the hospital computer database. All paper and electronic medical records were reviewed and analysed to determine the DTN of antibiotic administration. System factors and attributes leading to major delays were identified along the patient care pathway. The result of the first audit was summarised, shared, and discussed among teams; strategies to overcome impediments were derived and implemented. A second audit using the same criteria was then carried out to evaluate the effectiveness of the changes. Results: In the first phase of audit from 1 April 2011 to 30 November 2011, there were 32 patients. Overall, the median DTN was 261 minutes (range, 62-531 minutes); two patients (6%) achieved the 2-hour target. Patients admitted through the emergency department had a shorter median DTN than those admitted through the oncology clinic (222 vs 315 minutes). One patient (3%) died due to uncontrolled chest infection and cancer progression. Major attributes to prolonged DTNs were identified. They included (but were not limited to): a long waiting time for clinician assessment prior to hospital admission, and after being hospitalised, a long time interval between antibiotic prescription and administration. A list of actions to overcome these delays was proposed and worked out in departmental multidisciplinary meetings. At the same time, in the emergency department a clinical management protocol was set up and implemented to deal with patients having suspected neutropenic fever. After implementation of new workflows (both in the oncology and emergency departments), the second phase of audit was carried out from 1 April to 31 July 2012. This entailed 30 patients. Overall, there was a 64% reduction in the median DTN to 95 minutes (range, 25-231 minutes). The reduction in median DTN was noted in patients admitted via the emergency and oncology departments, being 79% (from 222 to 46 minutes) and 69% (from 315 to 98 minutes), respectively. Moreover, 63% (19/30) of the patients achieved the 2-hour target, which translated into a 11-fold improvement. Conclusion: By modifying the existing system and workflows, clinical audits and collaborative multidisciplinary efforts significantly improved the service provided for the clinical management of patients with neutropenic fever.