Instituting the Very Immunocompromised Alert (VIP) Protocol in a Community Hospital for a New Blood and Marrow Program

Timely administration of antibiotics in highly immunocompromised patients presenting to the emergency room with neutropenic fever reduces hospital stays, mortality due to sepsis, and costs. Current guidelines recommend that hemodynamically unstable patients receive broad-spectrum antibiotics within 30 minutes of arrival to the Emergency Department. For hemodynamically stable patients, this interval increases to one hour. As a community hospital launching a new blood and marrow transplant program, it was imperative that the Emergency Department and Oncology staff follow best practice in managing neutropenic fever.

The transplant  team, the Emergency Department, and nurse educators were enlisted to ensure that the ED physicians, ED triage nurses , Hospitalists, Critical Care Physicians and ICU nurses, and the new BMT/Oncology unit nurses recognized the unique concerns related to managing complex hematologic malignancy and blood and marrow transplant patients. The Very Immune Compromised Patient Alert (VIP) protocol was implemented. The VIP Program consists of patient and family education, a VIP card that is presented at the ED, ED staff education, and a rapid triage and intervention protocol. Departments impacted by the new protocol, including Laboratory, Microbiology and Radiology received additional training. The protocol for high-risk patients presenting to the Emergency Department with neutropenic fever was set into place in December 2013 two months before the first patient scheduled for transplant.

Post-implementation data for 23 patients demonstrated a median door to antibiotic time of 52 minutes (range 27 – 107 minutes).

Next steps:

Continue to investigate barriers to rapid deployment of this protocol in febrile neutropenic patients.

Develop and implement strategies for improvement in diagnosis and first dose of empirical therapy

Continue to track data with each VIP patient presenting to the ED and report to Cancer Committee and Quality Council quarterly.