O2115: Use of a Clinical Practice Guideline to Optimize Time to Antibiotic Administration in Pediatric Oncology Patients with Febrile Neutropenia

Purpose/Objectives: For pediatric oncology patients with febrile neutropenia (FN), timely administration of antibiotics decreases morbidity and mortality. The standard of care from the Infectious Diseases Society of America is to infuse antibiotics in < 120 minutes from patient presentation, with many pediatric institutions moving this target to < 60 minutes. Our program goal is that 100% of these patients receive antibiotics in < 60 minutes. This is a quality improvement project to evaluate the impact of an updated clinical practice guideline (CPG) on the time to antibiotics in pediatric patients presenting to the Emergency Department (ED) with known or suspected FN.

Design/Methods: Pediatric oncology patients ages 6 months to 19 years with suspected FN, defined as an ANC < 500 currently or suspicion of ANC < 500 within 48-72 hours, had baseline data collected from June- September 2022, from electronic health records and data generated reports from EPIC and was placed in Excel. Data from each patient visit included: Time/date of arrival to the ED, time of antibiotic order, time antibiotic verified by pharmacy, time ED nurse acknowledged and then administered the antibiotic. The study intervention consisted of the development and release of an updated CPG related to the care of oncology patients with known or suspected neutropenia presenting to our ED, which was created in committee between our ED, Hematology/Oncology, and Hospitalist physicians in conjunction with our Clinical Effectiveness and Outcomes and Antibiotic Stewardship staff. This CPG was released late April 2023. Data for this study was collected 5/1/2023 to 3/31/2024.

Overall time from arrival to antibiotic administration, time from arrival to antibiotic order, and antibiotic order to antibiotic administration were analyzed using QI Macros. Control charts were used to track data changes over time and to assess variation.

Results: A total of 84 patients, with average age of 6.92 years (ranging from 6 months – 16 years), were included. Control charts evaluating the time frame between 1) ED arrival and placing the antibiotic order (Figure 1) demonstrate this time frame decreasing from 39 to 13 minutes. The interval from ED arrival to antibiotic administration decreased from 85 to 52 minutes. Conversely, using ED triage time as a start time for analysis, demonstrates the time from triage to antibiotic order decreasing from 29.9 to 4.7 minutes and the time from triage start to antibiotic administration 77.8 to 43.3 minutes (Figure 2).

Conclusion/Discussion: While the introduction of a CPG has greatly improved the time interval from “Triage” and “Arrival” to medication order, Triage to Antibiotic order improved most significantly. Control charts demonstrate special cause variation and significant improvement in time. We will continue to work with our providers to utilize the CPG and assess other areas for improvement in the patient process overall.