Antibiotic Timing Research Articles

Time to Antibiotics (TTA) - Reassessment from the German Working Group for Fever and Neutropenia in Children and Adolescents (DGPI/GPOH)

The current German guidance from 2016 recommends a Time to Antibiotics (TTA) of<60 min in children and adolescents with febrile neutropenia (FN). Critical analysis of available studies and recent meta-analyses, and discussion of the practical consequences in the FN working group of the German Societies for Paediatric Oncology and Haematology and Paediatric Infectious Diseases. The available evidence does not support a clinically significant outcome benefit of a TTA<60 min in all paediatric patients with FN. Studies suggesting such a benefit are biased (mainly triage bias), use different TTA definitions and display further methodical limitations. In any case, a TTA<60 min remains an essential component of the 1st hour-bundle in paediatric cancer patients with septic shock or sepsis with organ dysfunction. Provided that all paediatric FN patients receive a structured medical history and physical examination (including vital signs) by experienced and trained medical personnel in a timely fashion, and provided that a sepsis triage and management bundle is established and implemented, a TTA lower than 3 hours is sufficient and reasonable in stable paediatric cancer patients with FN.

Delay in Time to Antibiotics for De Novo Inpatient Neutropenic Fever May Not Impact Overall Survival for Patients With a Cancer Diagnosis.

Neutropenic fever (NF) is an oncologic emergency for which expert consensus recommends that anti-pseudomonas antibiotics be administered within 60 minutes of detection. This study investigated whether delays in time to antibiotics (TTA) impacted overall survival (OS) for patients with hematological malignancies who developed inpatient NF via a retrospective cohort study of 187 de novo NF cases categorized by TTA (<1, 1-2, 2-3, 3-4 and >4 hours). OS at 180 days post-NF episode was compared using Kaplan-Meier estimates and multivariable Cox proportional hazards model. TTA did not significantly affect OS (P = 0.420). Patients with Charleston Comorbidity Indexes ≥3, a measure of overall health, had higher hazard (hazard ratio [HR] = 2.728, 95% confidence interval, 1.265-5.882, P = 0.010). TTA delays in the hospital may not be long enough to cause significant patient harm. Larger studies may be needed to detect small, but significant mortality differences.

Time to antibiotics is unrelated to outcome in pediatric patients with fever in neutropenia presenting without severe disease during chemotherapy for cancer

Fever in neutropenia (FN) remains an unavoidable, potentially lethal complication of chemotherapy. Timely administration of empirical broad-spectrum intravenous antibiotics has become standard of care. But the impact of time to antibiotics (TTA), the lag period between recognition of fever or arrival at the hospital to start of antibiotics, remains unclear. Here we aimed to analyze the association between TTA and safety relevant events (SRE) in data from a prospective multicenter study. We analyzed the association between time from recognition of fever to start of antibiotics (TTA) and SRE (death, admission to intensive care unit, severe sepsis and bacteremia) with three-level mixed logistic regression. We adjusted for possible triage bias using a propensity score and stratified the analysis by severity of disease at presentation with FN. We analyzed 266 FN episodes, including 53 (20%) with SRE, reported in 140 of 269 patients recruited from April 2016 to August 2018. TTA (median, 120 min; interquartile range, 49–180 min) was not associated with SRE, with a trend for less SREs in episodes with longer TTA. Analyses applying the propensity score suggested a relevant triage bias. Only in patients with severe disease at presentation there was a trend for an association of longer TTA with more SRE. In conclusion, TTA was unrelated to poor clinical outcome in pediatric patients with FN presenting without severe disease. We saw strong evidence for triage bias which could only be partially adjusted.

Time to antibiotics (TTA) in paediatric patients with fever in the setting of neutropenia

Immunocompromised cancer patients are at elevated risk of infections.[1][1] The major contributing factors that predispose cancer patients to immunodeficiency include the underlying disease and related management.[2][2] Febrile neutropenia is a common and life-threatening complication in paediatric

#47 RESULTS OF AN EDUCATIONAL COMPONENT OF DECREASING TIME TO THERAPY (DoTT) IN PEDIATRIC CANCER PATIENTS WITH FEBRILE NEUTROPENIA IN PERU

Abstract Background In low-and middle-income countries, a limitation for optimal treatment of children with fever and neutropenia (FN) due to chemotherapy is the delay in administering the first dose of antibiotics. DoTT is a quality improvement project implemented in Peru and aligned to the WHO Global Initiative of Childhood Cancer. A component of DoTT is an educational intervention of health care providers to decrease the time to antibiotics (TTA) in pediatric patients presenting to the emergency room (ER) with FN. Method This study was performed at Hospital Nacional Edgardo Rebagliati, a tertiary care National Hospital in Lima. We defined TTA as the time elapsed between patient′s arrival to the ER and administering the first dose of an antibiotic. Patient Time to Arrival, PTA, is the time elapsed between onset of symptoms and arrival to the hospital. The intervention consisted of a synchronous and asynchronous educational course on managing FN in children with cancer. Trainees were attending pediatricians and pediatric residents. We compared the TTA between 22 patients admitted from October to November 2021 with fever and neutropenia (after educational intervention) and baseline data of 99 patients from 2020 January and 2021 August (before intervention). Results The median age considering the two groups was 5 years, 55 patients were female and 66 were male. 104/121 patients had leukemia, and 17/121 patients had solid malignant tumors. No patients required admission to ICU or died of sepsis in the pre-intervention group, in the post-intervention group one patient required admission to ICU and one patient died of sepsis. In the pre-intervention group (97 patients), the median TTA was 171 minutes (IQR: 102–293), and in the post-intervention group, the median TTA was 60 minutes (IQR: 35–73). Early results indicate a statistically significant decrease in the TTA (p=0.001). A long PTA was observed before intervention (median= 1483 minutes) which was decreased (median=1290 minutes) in the post-intervention group (p=0.06). Conclusion This study suggests the potential impact of the educational intervention in pediatric health care professionals in to decrease of TTA in pediatric patients with cancer and FN, which encourages the team to continue with the intervention in other health care providers in the emergency room. The PTA was very high in both groups and indicated the need for an additional intervention to improve these results.

#55: Development of a quality improvement educational intervention in febrile neutropenia in pediatric cancer patients in Peru: Preliminary results of the DoTT project

Abstract Background/Aims Severe infections are the most important causes of morbidity and mortality in children with cancer. In Peru, a major limitation for an optimal treatment of children with fever and neutropenia due to chemotherapy is the delay in the administration of the first dose of antibiotics. We performed an intervention aimed to decrease the time to antibiotics (TTA) in pediatric patients presenting to the emergency room (ER) with fever and neutropenia: We increased the perception risk of neutropenic fever to the ER medical staff by explaining the importance of a timely administration of antibiotics as part of the initial approach of children with fever and neutropenia. This study forms part of a larger project (DoTT project) that is being implemented in Peru, and is aligned to the WHO Global Initiative of Childhood Cancer in Peru. Methods This study was performed at Hospital Nacional Edgardo Rebagliati, which is a tertiary care National Hospital located in Lima. We included patients younger than 14 years with hemato-oncological conditions who arrived at the Pediatric Emergency Room. The DoTT project consists in an quality improvement educational intervention for health care providers in the Pediatric ED and the Oncology and Hematology Departments, based on the Kern’s six-steps (i) Problem identification and general needs assessment, (ii) targeted needs assessment, (iii) goals and objectives, (iv) educational strategies, (v) implementation and (vi) evaluation. We defined time-to-antibiotic (TTA) by measuring the time elapsed between patient′s arrival to the ER and the administration of the fist dose of an antibiotic. We compared the TTA between thirteen patients admitted from July to December 2020 with fever and neutropenia (after intervention), and historical data from 2017–2018. Results Median age was 7 years. 9/13 patients had leukemia and 4 patients had malignant solid tumors receiving oncological treatment. Mean pre-hospital delay was 176 minutes (range, 14–906 minutes) and TTA was 133 minutes (range, 34–400 minutes). One patient died of sepsis. Age, sex, source and timing of antibiotics did not significantly affect hospital stay, antifungal use and/or antibiotic turnover. Based on our historical data, mean TTA was 206 minutes (range, 137–390). Early results indicate a decrease in the TTA, although not statistically significant, likely due to the sample size. General and targeted needs assessment was performed by the DoTT project team and administrators at Rebagliati hospital, which lead to develop a curriculum based on a 5-lectures mini-course for health care providers. Conclusions The TTA exceeds the recommended time at international level, causing the evitable morbimortality. It is necessary to perform a multidisciplinary intervention to improve antibiotic start time. Ongoing educational intervention refinement and testing of the instruments are planned.

PMD12 Using Real-World Evidence (RWE) and a MULTI-Stakeholder Approach to Assess the MULTI-Dimensional IMPACT of a New Diagnostic Device for the EARLY Identification of Sepsis in the Italian National Health System

Sepsis is a life-threatening medical emergency affecting 48.9 millions of people worldwide, accounting for 20% of global deaths in 2017. Early identification able to reduce Time To Antibiotics (TTA) may significantly reduce disease severity and mortality. However, serious delays still affect the management of septic patients and make urgent the need for a diagnostic test. Monocyte Distribution Width (MDW) is a new biomarker recently developed for the early detection of sepsis. This study aims to conduct a multidimensional and multi-stakeholder assessment of the MDW technology being at the stage-gate between clinical validation and translation into the Italian National Health System.

Delays in time to antibiotics in inpatient oncologic neutropenic fever do not predict decreased overall survival.

e18765 Background: Neutropenic fever (NF) is relatively common oncologic emergency. Present expert consensus is that anti-pseudomonas gram-negative antibiotics should be administered within 60 minutes of detecting NF. To date studies investigating this relationship in neutropenic fever patients have been either limited in size, or have failed to reliably establish a relationship between time to antibiotics (TTA) and clinical outcomes.While some studies have shown an association between TTA and outcomes in NF patients admitted from the Emergency Department, such studies do not control for the time that patients may have been febrile in the community. To address these factors, we conducted a retrospective study on the effect of TTA on mortality in oncologic patients who developed NF as inpatients. Methods: We performed retrospective chart review of all cases of NF at an NCI designated Cancer Center between 7/1/2016 and 3/27/2019. NF was defined as temperature of 101˚ F on one occasion, or 100.4˚ F sustained over 60 minutes, with an absolute neutrophil count (ANC) less than 500. TTA and survival were calculated via chart abstraction; patients lost to follow up within 180 days were censored to the 180-day mortality group. Relationship between TTA and overall survival (OS) was analyzed via multivariable Cox regression. We excluded patients that had non-cancer related NF, were transferred from another institution with NF, were admitted from the ED with NF, or transitioned to hospice. Only the first instance of NF in any admission was analyzed. Results: A total of 187 eligible cases were identified during the study period, mean age was 57.6 +/- 13.6, 100 (53.5%) cases were in males, 114 (61.0%) cases in Caucasians, 53 (28.3%) in Black People. The 3 most common disease subtypes were acute leukemia (42.8%), plasma cell dyscrasias (27.8%), and lymphoma (16.6%). TTA showed no significant correlation with OS at any timeframe studied. Low Charlson Comorbidity Index ( &lt; 3) correlated with increased survival through ̃360 days, however the effect was non-significant at longer timeframes. Immediate antibiotic treatment ( &lt; 40 mins) correlated with poorer patient prognosis and significantly decreased OS (HR 3.08;CI: 1.30-7.28; p 0.010). Conclusions: TTA was not associated with OS in our study. For inpatients with NF, even hours long TTA may not be long enough to result in adverse clinical outcomes. Unlike NF patients presenting to the ED, where true TTA may often be many hours or even days prior to arrival, a few hours-long TTA in the hospital may not be sufficiently long enough to cause significant patient harm. Interestingly, in our cohort, those who received antibiotics quickly had adverse outcomes. It may be that in patients who were clinically unstable, TTA was shorter given the urgency of the situation. Ultimately, this study’s findings question the applicability of the 60-minute guideline when used in the inpatient setting.

Comprehensive Care Improvement for Oncologic Fever and Neutropenia from a Pediatric Emergency Department.

Rapid time to antibiotics (TTA) for pediatric patients with fever and neutropenia in an emergency department decreases in-hospital mortality. Additionally, national guidelines recommend outpatient antibiotic management strategies for low-risk fever and neutropenia (LRFN). This study had two specific aims: (1) improve the percent of patients with suspected fever and neutropenia who receive antibiotics within 60 minutes of arrival from 55% to 90%, and (2) develop and operationalize a process for outpatient management of LRFN patients by October 2018. Using Lean methodologies, we implemented Plan-Do-Check-Act cycles focused on guideline development, electronic medical record reminders, order-set development, and a LRFN pathway as root causes for improvements. We used statistical process control charts to assess results. The project conducted from July 2016 to October 2018 showed special cause improvement in December 2016 on a G-chart. Monthly Xbar-chart showed improvement in average TTA from 68.5 minutes to 42.5 minutes. A P-chart showed improvement in patients receiving antibiotics within 60 minutes, from 55% to 86.4%. A LRFN guideline and workflow was developed and implemented in October 2017. Implementation of guidelines, electronic medical record reminders, and order sets are useful tools to improve TTA for suspected fever and neutropenia. Utilizing more sensitive statistical process control charts early in projects with fewer patients can help recognize and guide process improvement. The development of workflows for outpatient management of LRFN may be possible, though it requires further study.

Improving management of fever in neutropenic children with cancer across multiple sites.

To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16months. A follow-up audit was conducted after 12months. We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60minutes (RR 0.69, 95% CI 0.56-0.85, p=<0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57minutes) and sustained at follow-up (60minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.

Interventions aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN), a systematic review

PurposeMultiple interventions have been developed aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia (FN) following chemotherapy for cancer. We evaluated their effect to reduce TTA and their impact on important clinical outcomes in a systematic review.MethodsThe search covered seven databases. Biases and quality of studies were assessed with the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. Interventions could be implemented in any setting and performed by any person included in the FN management. Absolute change of TTA was the primary outcome. Registration: PROSPERO (CRD42018092948).ResultsSix thousand two hundred ninety-six titles and abstracts were screened, 177 studies were retrieved and 30 studies were included. Risk of bias was moderate to serious in 28 studies and low in two studies. All but one study reported a reduction of TTA after the intervention. Various types of interventions were implemented; they most commonly aimed at professionals. Most of the studies made more than one single intervention.ConclusionThis review may help centers to identify their specific sources of delay and barriers to change and to define what intervention may be the best to apply. This review supports the assertion that TTA can be considered a measure of quality of care, emphasizes the importance of education and training, and describes the very different interventions which have effectively reduced TTA.

Association of time to antibiotics and clinical outcomes in patients with fever and neutropenia during chemotherapy for cancer: a systematic review.

Prompt antibiotic therapy is standard of care for patients with fever and neutropenia (FN) during chemotherapy for cancer. We systematically reviewed the association between time to antibiotics (TTA) and clinical outcomes. The search covered seven databases; confounding biases and study quality were assessed with the ROBINS-I tool. Safety (death, intensive care unit (ICU) admission, sepsis) and treatment adequacy (relapse of infection, persistence or recurrence of fever) were assessed as primary outcomes. Of 6296 articles identified, 13 observational studies were included. Findings regarding safety were inconsistent. Three studies controlling for triage bias showed a possible association between longer TTA and impaired safety. Meta-analysis for TTA ≤ 60min versus > 60min was feasible on four studies, with three studies each reporting on death (OR 0.78, 95%CI 0.16-3.69) and on ICU admission (OR 1.43, 95%CI 0.57-3.60). No study reported data on treatment adequacy. Triage bias, i.e. faster treatment of patients with worse clinical condition, was identified as a relevant confounding factor. There seems to be an association between longer TTA and impaired safety. More knowledge about TTA effects on safety are important to optimise treatment guidelines for FN. Controlling for triage and other biases is necessary to gain further evidence. Registration: PROSPERO [http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018092948].

Study of Delayed Antibiotic in Pediatric Febrile Immunocompromised Patients and Adverse Events.

Bone marrow transplant (BMT) patients or patients receiving chemotherapy for oncologic diagnoses are at risk for sepsis. The association of time to antibiotics (TTA) with outcomes when adjusting for severity of illness has not been evaluated in the pediatric febrile immunocompromised (FI) population. We evaluated the association of TTA with adverse events in a cohort of FI patients presenting to our pediatric emergency department. We performed a retrospective review of consecutive FI patients presenting over a 6.5-year period. Adverse events were defined as intensive care admission within 72 hours of emergency department arrival, laboratory signs of acute kidney injury, inotropic support subsequent to antibiotics, and all-cause mortality within 30 days. Vital signs and interventions were used to define severity of illness. Adjusting for severity of illness at presentation, age, and timing of an institutional intervention designed to reduce TTA in FI patients, we analyzed the association of TTA with individual adverse events as well as with adverse events in aggregate. We analyzed 1489 patient encounters. In oncology patients, TTA was not associated with the aggregate measure of whether any adverse event subsequently occurred nor with other individual adverse events. For the BMT subpopulation, TTA >60 minutes did show increased odds of intensive care admission within 72 hours as well as for aggregate adverse events. Although TTA >60 minutes did show increased odds of aggregate adverse events in the small subgroup of BMT patients, overall TTA was not associated with adverse events in oncology patients as a whole.

Protocol for a systematic review of time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN) and interventions aiming to reduce TTA

BackgroundFever and neutropenia (FN) is a common complication of chemotherapy for cancer. Prompt empiric broad-spectrum antibiotic therapy in FN is typically considered standard of care, but the definition of prompt is not clear. We seek to systematically review the available data on the association between time to antibiotics (TTA) administration and clinical outcomes in patients with FN being treated with chemotherapy. There have been several efforts to reduce TTA in patients with FN, by implementing specific interventions, presuming there will be a beneficial effect on patient-important outcomes. This systematic review will also collect data on such interventions and their effect to reduce TTA and potentially change clinical outcomes.Methods/designThe search will cover MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, CINAHL, CDSR, CENTRAL, and LILACS. A full-search strategy is provided. Lists of studies identified by references cited and forward citation searching of included articles will also be reviewed. Studies will be screened, and data extracted by one researcher and independently checked by a second. Confounding biases and quality of studies will be assessed with the risk of bias in non-randomised studies-of interventions (ROBINS-I) tool.Data will be presented in narrative and tabular forms; in addition, if appropriate data is available, random effects meta-analysis will be used to examine TTA.A detailed analysis plan, including an assessment of heterogeneity and publication bias, is provided.DiscussionThis study aims to evaluate the association between TTA and patient-important clinical outcomes. Additionally, it will identify, critically appraise, and synthesise information on performed interventions and its effect to reduce TTA as a way of gaining insight into the potential use of these approaches. This will provide better knowledge for an adjusted treatment approach of FN.Systematic review registrationPROSPERO [CRD42018092948]

Implementation of a Nursing Based Order Set: Improved Antibiotic Administration Times for Pediatric ED Patients with Therapy-Induced Neutropenia and Fever

PurposeFor patients with chemotherapy-induced neutropenia and fever, delays in antibiotic administration are associated with poor outcomes, such as ICU admission and need for further interventions. The objective of this quality improvement project was to significantly reduce the time from initiation of triage to antibiotic administration for pediatric patients arriving to the emergency department with therapy-induced neutropenia and fever. MethodsAn interdisciplinary team set an evidence-based goal for time to antibiotics (TTA) at 60-min. A six-month retrospective chart review of Emergency Department (ED) patients revealed a 128 min TTA mean when measured from the initiation of triage to antibiotic administration, which also reflected 0% of patients receiving antibiotics within the goal of 60 min. Members of the interdisciplinary team evaluated delays in patient care workflow and identified three primary interventions to decrease the TTA. These three evidenced-based interventions were implemented and evaluated using the Plan-Do-Check-Act (PDCA) quality improvement methodology. ResultsBy the end of the implementation period mean TTA improved to 53 min and patients received antibiotics within 60 min (83% of the time). ConclusionThe interventions focused on both provider and nursing workflow, however the implementation of an evidence-based practice nursing order set made the greatest impact on timeliness of antibiotic delivery time.

Impact of time to antibiotic on hospital stay, intensive care unit admission, and mortality in febrile neutropenia.

To determine if time to antibiotics (TTA) improves outcomes of hospital length of stay, admission to the intensive care unit, and 30-day mortality in adult patients with febrile neutropenia. This retrospective cohort study evaluated the impact of time to antibiotic, in the treatment of febrile neutropenia, on hospital length of stay, admission to the intensive care unit, and 30-day mortality. Cases included were patients 18years or older hospitalized with febrile neutropenia from August 1, 2006 to July 31, 2016. To adjust for other characteristics associated with hospital length of stay, admission to the intensive care unit, and 30-day mortality, a multivariate analysis was performed. A total of 3219 cases of febrile neutropenia were included. The median hospital length of stay was 7.0days (IQR 4.1-13.3), rate of intensive care unit admission was 13.6%, and 30-day mortality was 6.6%. Multivariate analysis demonstrated time to antibiotics was not associated with hospital length of stay but was associated with admission to the intensive care unit admission and 30-day mortality. Delays in time to antibiotic of up to 3hours did not impact outcomes. A shorter time to antibiotic is important in treatment of febrile neutropenia; however, moderate delays in antibiotic administration did not impact outcomes. Further investigation is needed in order to determine if other indicators of infection, in addition to fever, or other supportive management, in addition to antibiotics, are indicated in the early identification and management of infection in patients with neutropenia.

Improving Time to Antibiotics for Pediatric Oncology Patients With Fever and Suspected Neutropenia by Applying Lean Principles.

Fever in the setting of neutropenia is a potentially life-threatening complication of cancer treatment. A time of less than 60 minutes from presentation to antibiotic administration is therefore recommended. To use Lean Six Sigma methodology, a quality improvement initiative, to improve time to antibiotics (TTA) for children with chemotherapy-induced febrile neutropenia presenting to the emergency department. Lean Six Sigma is a quality improvement method that engages all impacted stakeholders and focuses on streamlining the process by removing process wastes. Stakeholders identified multiple process wastes in an in-depth study of 49 fever episodes in patients attending a tertiary care pediatric hospital, including patients waiting to be registered, waiting for laboratory technicians, delay in accessing central venous access device, waiting for absolute neutrophil count, and delayed antibiotics orders. We implemented multiple solutions: engaging patients in the process through predischarge tours of the emergency department, home application of topical anesthetic, nurse-initiated pathway, early access of central venous access device for all blood work, and planned antibiotic administration no later than 45 minutes after triage. We prospectively determined the impact of these interventions on TTA. The TTA significantly improved to a median of 59 minutes (interquartile range, 38.5-77.5 minutes) compared with the baseline of 99 minutes (interquartile range, 72.0-132.0 minutes; P < 0.0001). Lean methodology effectively identifies barriers and provides solutions to remove barriers and improve administration of antibiotics in febrile oncology patients. These can be widely applied, including in smaller institutions with minimal increased utilization of resources.

Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial

Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care. After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training. The trial is registered at ClinicalTrials.gov, number NCT01988428. 2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone. In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity. The NutsOhra Foundation, Netherlands Society of Internal Medicine (NIV).

Assessment of Fever Advisory Cards (FACs) as an Initiative to Improve Febrile Neutropenia Management in a Regional Cancer Center Emergency Department.

We aimed to improve the time to antibiotics (TTA) for patients treated with chemotherapy who present to the emergency department (ED) with febrile neutropenia (FN) by using standardized fever advisory cards (FACs). Patients treated with chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada, with suspected FN were identified, before (April 2012 to March 2013) and after (October 2013 to March 2014) FAC implementation. The primary outcome of interest was TTA. Additional process measures included Canadian Triage and Acuity Scale score, time to physician assessment, and FAC compliance. Outcomes were analyzed with descriptive statistics and control charts to determine whether the change in primary measures were within statistical control over time. Between the pre-FAC cohort (n = 239) and post-FAC cohort (n = 69), TTA did not change significantly post-FACs (195 v 244 min, P = .09), with monthly averages demonstrating normal variation by statistical process control methodology. The introduction of FACs increased the percentage of patients with correctly assigned Canadian Triage and Acuity Scale scores (87% v 100%) but did not affect time to physician assessment. Compliance with FACs among patients was not ideal, with only 62.5% using them as intended. The distribution of FACs was associated with an improved incidence of correct FN triaging but did not demonstrate a meaningful improvement in the quality of FN management. This may be explained by FAC use among patients not being ideal. Next steps in the continued effort toward high-quality FN care include redesign of FACs, reinforcement of provider and patient education, and ED outreach.

111: Attitudes Towards Performance Measures and Pay-For-Performance in Academic Emergency Departments

We surveyed academic emergency department (ED) medical directors and chairmen on attitudes about the Joint Commission for the Accreditation of Hospitals and Organization (JCAHO) Core measures, the Surviving Sepsis Guidelines, and the planned Centers for Medicare & Medicaid Services (CMS) pay-for-performance program (P4P) for time to antibiotics (TTA) in pneumonia. We also asked what actions are being implemented in anticipation of P4P for TTA.