Improving the treatment of patients with low-risk neutropenic fever: A quality improvement project at the Cleveland Clinic Taussig Cancer Institute (TCI).

Abstract

101 Background: NF is an oncologic emergency and has historically resulted in inpatient (inpt) management. The Multinational Association for Supportive Care in Cancer (MASCC) score can be used to identify NF pts at LR for complications who can be safely managed in the outpatient (outpt) setting. Despite established guidelines supporting outpt management of LRNF, provider awareness is low and inpt admission for intravenous antibiotics (abx) continues to be standard of care. Methods: A multidisciplinary team performed a QI project to improve management of LRNF (baseline cohort of LRNF pts treated from Jan - Mar 2014, N = 13). Inpt provider education began in the Q2 2014. Providers calculated MASCC scores for pts with non-leukemia hematologic malignancies and solid tumors at the time of admission. Data was collected in a prospectively maintained registry. Pts identified as LR by MASCC score were admitted under observation and placed on oral abx. If exclusion criteria and social barriers were not identified, discharge (dc) within 24 hrs of admission was planned. To ensure pt safety, close follow up included phone follow up within 48 hrs of dc and a provider visit within 72 hrs. Results: 52 pts were admitted to the TCI inpt oncology unit with NF from Oct 2014 - June 2015. 34 pts (65%) had LRNF (MASCC score, < 21). 9 pts (26%) were dc within 24 hrs. Only 2 LRNF pts had a culture proven infection – both Enterococcus UTIs. 3 pts required readmission for reasons other than scheduled inpt chemotherapy: 1 high risk pt for new symptoms and 2 LRNF pts (22%) dc within 24 hours for recurrent fever; neither had culture proven infection. Pts with LRNF had an average LOS of 3.3 days compared to 6.2 days in the historical cohort. There were no deaths due to NF in either cohort. Conclusions: Calculating a MASCC score at admission identifies pts who are potential candidates for outpt, oral abx therapy. This pilot study demonstrates that provider education followed by implementation of a system to ensure close follow up may result in earlier dc for LRNF pts without increasing risk of complications or readmission. Further follow up will occur Q3 2015 and data will be presented on changes in cost measures.