Improving Service Provision to Manage Chemotherapy-induced Neutropenic Fever in an Oncology Unit
FMY Lim, M Tong, CC Yau, ACH Lit, JCK Lo, N Lam, WH Wong, ACK Cheng
Hong Kong J Radiol 2013;16:123-30
DOI: 10.12809/hkjr1312157
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.
中文摘要
腫瘤科中化療致中性粒細胞減少性發熱患者的改善治療
林美瑩、唐美思、邱振中、列就雄、盧祖健、林啟聽、黃偉康、鄭志堅
目的：中性粒細胞減少性發熱是細胞毒性化療的一種嚴重併發症，發病率和死亡率都相當高，迅速 啟動抗生素治療可改善臨床結果。國際指南推薦中性粒細胞減少性發熱治療的「就診—用藥」時間 （DTN）標準為不超過兩小時，即從病人到醫院至給予抗生素治療的時間應在兩個小時內。本研究 評估我們的機構是否達到DTN在兩小時內的目標。通過識別現有工作系統的制約因素，我們期望制 定策略以設立新的工作流程來改善臨床治療。
方法：本研究分為兩個回顧性審計階段。從醫院電子數據庫中篩選出化療後因中性粒細胞減少性發 熱入院的腫瘤患者，回顧所有紙質和電子病歷並進行分析，以確定施予抗生素的DTN。沿病人護理 流程找出系統因素和引致重大延誤的因素。組間總結、分享和討論首次審計結果，制定策略克服制 約因素的策略並實施。然後根據相同的標準進行第二次審計以評估新工作流程的成效。
結果：2011年4月1日至11月30日期間進行的第一階段審計中，共有32名患者。總體而言，DTN的中 位數為261分鐘（介乎62至531分鐘）；其中2例（6%）達兩小時的目標。與腫瘤診所的患者比較， 通過急診室入院的患者有較短的DTN中位數（222比315分鐘）。1例（3%）因胸部感染無法控制和 癌症惡化而死亡。廷長了DTN的因素包括（但不僅限於）：入院前等待臨床醫生評估的時間太長， 以及入院後抗生素處方發出到給藥的間隔時間太長。跨學科醫務人員會議提議並制定出克服延誤的 一系列措施。與此同時，急症室亦制定並實施新的臨床管理方案以處理中性粒細胞減少性發熱的疑 似病例。在腫瘤科和急症室內實施了新的工作流程後，於2012年4月1日至7月31日期間進行第二階段 的審計，共有30名患者。總體而言，DTN中位數減少至95分鐘（介乎25至231分鐘），減幅達64%。 在腫瘤科和急症室的DTN中位數均有減少：急症室減幅達79%（從222分鐘減至46分鐘）；腫瘤科減 幅達69%（從315分鐘減至98分鐘）。此外，63%（19/30）的患者達到了兩小時內的目標，即有11倍 的改善。
結論：經臨床審核及多個學科醫務人員的協作努力，現有工作系統和工作流程得以修改，從而使中 性粒細胞減少性發熱患者的臨床診療服務顯著改善。