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Monday, February 24, 2014
ONLINE FIRST: Fever In, Fever Out -- Improving Quality In Emergency Room Care of Patients with Fever and Neutropenia

BY MIKKAEL A. SEKERES, MD, MS

 

We’ve all heard the stories.

 

We refer our patients to the Emergency Room with fever in the setting of possible neutropenia, often soon after they have received chemotherapy for their cancer. They arrive to what they describe as the ninth circle of hell. They sit in the waiting area for an hour or more, often next to some guy trying to sell them a watch on one side, and a woman with a tubercular cough on the other. It takes hours for them to be evaluated and receive antibiotics, and even longer to be admitted to the hospital. By the time they make it to the relative comfort of their hospital bed, their counts have recovered and it’s time to be discharged.

 

Okay, that last part was a bit of hyperbole.

 

But the overall experience is not. Fever and Neutropenia is a life-threatening condition that, if left untreated, quickly leads to sepsis and death. Are our patients exaggerating about their experiences? We decided to take a look.

 

Between 2010 and 2012, we were able to identify over 100 episodes of fever and neutropenia presenting to the emergency room at our institution. It took over 40 minutes for patients to be seen by a licensed independent practitioner from the moment of registration, 73 minutes to be seen by a physician and have blood drawn. It took another hour for lab results to return, showing that a patient was neutropenic, before an order for antibiotics to be administered was placed. Those antibiotics would then finally be administered another hour-and-a-half later, for a total of almost four hours after a patient registered at the Emergency Room front desk – never mind the time it took them to drive to the ER after their first fever spike. Patients then waited another two hours – for a total of six hours from presentation – before being admitted to the hospital.

 

Not such an exaggeration, is it? So, what did we do to fix it?

 

We started by engaging a lot of stakeholders in the process, including the ER and infectious disease departments, cancer center staff, pharmacists, and electronic medical record gurus. The ER folks agreed to reclassify fever and neutropenia on the Emergency Severity Index – what they use to triage people – from less acute to more acute, on the same level as stroke or heart attack. They also agreed to eliminate any time spent in the waiting area, next to the guy selling the watches.

 

In the cancer center, we standardized how we defined fever (making it consistent with how it is defined by the Infectious Diseases Society of America), and produced wallet-sized cards with specific instructions for what patients should do if they developed a fever. The card could also be presented at the ER triage desk, to alert personnel to the seriousness of the condition.

 

The electronic medical records group created a fever and neutropenia “chief complaint” category and a standard set of orders to eliminate variability in treatment and ensure cultures were obtained. We also all agreed that antibiotics should be given prior to the return of labs confirming neutropenia, as the risk and cost of giving one antibiotic dose unnecessarily (in non-neutropenic patients) is so low.

 

The Pharmacy department made sure that antibiotics would be available in a Pyxis machine in the ER, to avoid any delays in transport from the central pharmacy area.

 

And finally, we did a lot of education across departments about the new process, with periodic updates at staff meetings.

 

But the big question is, did it work?

 

We prospectively followed patients seen in the ER over a one-year period, from 2012-2013, after the new policy was instituted. In 270 episodes of fever and neutropenia presenting to the ER, the average time for a patient to be seen by a licensed independent practitioner was cut to 14 minutes, and to be seen by a physician decreased to 43 minutes. Most importantly, the time it took to receive an antibiotic was now 80 minutes – approximately one-third of where we started. Patients were admitted to the hospital more than an hour-and-a-half sooner, also. This even led to improvements in length of stay by a median of one day.

 

Listening to our patients led to our making relatively simple interventions with people who all wanted to do the right thing. Those changes had an immediate impact on treating a serious disease, and translated to quality endpoints we could measure. And those endpoints define value to patients.

 

Sometimes, it pays to take a step back and look at our assumptions and processes in how we care for our patients, to see what can be changed to make their lives better.

 

Even if it means I’m going to have to go to a legitimate store now to buy that watch.

 

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Dr. Sekeres, OT’S Clinical Advisory Editor for Hematology/Oncology, is Professor of Medicine, Vice-chair for Clinical Research, and Director of the Leukemia Program at  Cleveland Clinic Taussig Cancer Institute, and Chair of the Hematology/Oncology Pharmacy & Therapeutics Committee.

 

Check out all the previous articles in Mikkael Sekeres’ award-winning column in this collection on the OT website: http://bit.ly/OT-SekeresCollection

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