Fellow The Hospital for Sick Children The Hospital for Sick Children Toronto, Ontario, Canada
Background: While the management of febrile neutropenia in patients with cancer has clear, evidence-based guidelines, the management of previously healthy, immunocompetent children with a febrile illness and first episode of neutropenia is less understood and often similarly treated with empiric antibiotics and hospitalization. Many studies have shown that this population is at low risk of serious bacterial infections if they are well appearing with a short history of neutropenia. Therefore, less aggressive management should be considered in patients meeting low risk criteria.
Objective: The aim of our quality improvement study was to decrease the number of unnecessary hospitalizations and empiric antibiotics prescribed by 50% for healthy, well appearing patients presenting to the emergency department (ED) with a first episode of febrile neutropenia (absolute neutrophil count (ANC) < 0.5 x 109/L) over a 12-month period.
Design/Methods: A team of stakeholders from Hematology, Infectious Disease, Pediatrics and Emergency Medicine was formed. A review of the literature, peer institutions and local practices on febrile neutropenia in healthy children was performed. A guideline for the management of healthy children with first episode of febrile neutropenia was developed and refined using PDSA cycles. Using the Model for Improvement, a family of measures was developed to assess project impact over time, as well as potential unintended consequences.
Results: Baseline data was collected between June 2018 and January 2020. Nineteen low risk patients were identified. Data analysis revealed that 84% of these patients were hospitalized and/or received antibiotics. Aknowledge gap surrounding the correct definition of severe neutropenia was also identified. Many patients were misdiagnosed with neutropenia by forgetting to count the bands in the ANC. This was addressed through education and pathway modifications. In January 2020, the guideline was launched for clinical use in the ED. Seventeen patients met low risk criteria. Hospitalization and/or antibiotics use for this population decreased to 29%. All blood cultures were negative. Conclusion(s): We contributed to improving the quality of care of this population by reducing potential harm from unnecessary hospitalizations and antibiotics in low risk patients. The development of this guideline led to improve resource stewardship and value-based care. Next steps include further iterations to the guideline to increase impact along with sustainability planning.
Authors/Institutions: Charlotte Grandjean-Blanchet, The Hospital for Sick Children, Toronto, Ontario, Canada; Stephanie Villeneuve, IWK Health Centre, Halifax, Nova Scotia, Canada; Carolyn Beck, The Hospital for Sick Children, Toronto, Ontario, Canada; Michaela Cada, The Hospital for Sick Children, Toronto, Ontario, Canada; Daniel Rosenfield, The Hospital for Sick Children, Toronto, Ontario, Canada; Michelle Science, The Hospital for Sick Children, Toronto, Ontario, Canada; Michelle Fantauzzi, The Hospital for Sick Children, Toronto, Ontario, Canada; Sheila Butchart, The Hospital for Sick Children, Toronto, Ontario, Canada; Olivia Ostrow, The Hospital for Sick Children, Toronto, Ontario, Canada