014 - Optimizing Time to Antibiotic Administration in Pediatric Oncology Patients with Febrile Neutropenia, 2022-2025

Publication Number: 14.5677

Melissa M. Magill, Arkansas Children's Hospital, Northwest, Springdale, AR, United States; Robert L. Saylors, University of Arkansas for Medical Sciences College of Medicine, Springdale, AR, United States; Holly D. Maples, University of Arkansas for Medical Sciences College of Pharmacy, LITTLE ROCK, AR, United States

Background: Much like sepsis, for oncology patients with febrile neutropenia (FN) the first hour after presentation to the Emergency Department (ED) is considered “the golden hour,” for treatment. Multiple studies show that when pediatric oncology patients with FN have a time to antibiotics (TTA) of ≤60min, this is independently associated with in-hospital mortality, ICU days, sepsis rate, overall mortality, and healthcare costs.

Objective: The standard of care is to infuse antibiotics in < 120 minutes from patient presentation. Our program goal is that 100% of FN patients receive antibiotics in ≤60 minutes. This is a quality improvement project to evaluate the impact of two educational interventions as well as an updated clinical practice guideline (CPG) on the TTA in pediatric oncology patients presenting to the ED with known or suspected FN.

Design/Methods: Pediatric oncology patients ages 0.5 to 19 years with suspected FN, defined as an ANC ≤500 and a fever of ≥38.3, were included. Baseline data collected from 6/2022-9/2022, from electronic health records and data generated reports from EPIC and was placed in Excel. The study Data included: Time/date of arrival to the ED, time of antibiotic order, time antibiotic verified by pharmacy, time ED nurse acknowledged and administered the antibiotic. The study intervention consisted of 1) two educational interventions (10/2022 and 12/2022 with ED staff and providers) and 2) the development and release of an updated CPG on 4/2023 related to the care of oncology patients with known or suspected FN.

Results: Overall time from arrival to antibiotic administration, time from arrival to antibiotic order, and antibiotic order to antibiotic administration were analyzed using QI Macros. A total of 84 patients, with an average age of 6.92 years (ranging from 0.5–16 years), were included. Control charts evaluating the time frame between ED triage to antibiotic order demonstrate improvement from 29.9 to 4.7 minutes (Figure 1). The interval from antibiotic order to administration improved from 50 to 38 minutes (Figure 2). The overall time from triage to antibiotic administration improved from 77.8 to 43.3 minutes (Figure 3). With this project, >90% of our FN patients receive IV antibiotics in ≤60 minutes.

Conclusion(s): While these interventions have greatly improved TTA, there is room for improvement. Currently, only 50% of providers are using the CPG. Next steps involve a project to increase provider usage of the CPG.

Figure 1: ED Triage to Antibiotic Order
PAS 2025 Figure 1 MAGILL.pdfThis control chart demonstrates improvement in the time from ED triage to antibiotic order, from 29.9 minutes to 4.7 minutes

Figure 2: Antibiotic Order to Administration
PAS 2025 Figure 2 MAGILL.pdfThis control chart demonstrates improvement in the time interval from antibiotic order to antibiotic administration from 50 minutes to 38 minutes

Figure 3: Triage to Antibiotic Administration
PAS 2025 Figure 3 MAGILL.pdfThis control chart demonstrates the overall process we have been working to improve from beginning to end, meaning time from ED triage to antibiotic administration. This metric improved from 77.8 minutes to 43.3 minutes.