Implementing an Evidence-Based Protocol for the Management of Neutropenic Patients in the Emergency Department

Febrile neutropenia (FN) is a potentially life threatening complication after chemotherapy. Patients (pts) are often managed as outpatients after chemotherapy, including high dose chemotherapy and hematopoietic stem cell transplantation (HSCT). Rapid delivery of broad spectrum antibiotics can prevent the development of sepsis and life threatening complications in FN pts. In the outpatient setting pts are often directed to the emergency department (ED) for evaluation, especially during evenings and weekends.  The Texas Transplant Institute and Methodist Hospital in San Antonio, Texas performed an evidenced based review and protocol development to evaluate the management of FN in very immunocompromised pts (VIP). The VIP protocol included all pts after HSCT and cancer pts within 6 weeks of chemotherapy. BMT physicians, community oncologists and oncology nurses worked with ED physicians and nurses to develop a standing protocol to rapidly triage FN pts for a focused evaluation and delivery of appropriate antibiotics within 30 minutes. This protocol was entered into the electronic medical record system for the ED, and both ED practitioners and nurses received training prior to implementation. The BMT and oncology physician practices received VIP kits to distribute that contain instructions for symptoms to report and an ID card to present on ED arrival, alerting staff that this patient was at high risk for FN. The VIP protocol was implemented and data from June through August 2012 was retrospectively reviewed. Results revealed 61 pts presented with FN and 44 (72%) had the VIP protocol ordered. The median time from presentation to delivery of antibiotic was 108 minutes in the pts who received the VIP protocol and 162 minutes in the patients who did not receive the protocol. Audits evaluating patient and ED staff compliance revealed several opportunities for improvement: 1. Maintain ongoing education and communication of ED and oncology staff, 2. Implement the VIP protocol as a standing order set instead of instructions to be followed, 3. Continue to track data on FN pts for time to evaluation, delivery of antibiotics, and admission to floor as part of Q/I program and routine audits. In conclusion, management of pts presenting with FN to the ED at our institution has improved with implementation of the VIP protocol, however, further improvement is needed and we will continue to review data after the above changes to improve the care of FN in cancer and HSCT pts.