Five years experience of clinical pathway on empirical antibiotics for patients with neutropenic fever in Accident & Emergency Department of QMH

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Authors (including presenting author) :
Tsang T C (1), Chan W K (1), Luk M Y (2), Pauline Lee (2), Albert Lie (3), Cecilia Kwok (3), Mandy Chu (4), Susanna F P HUI (4), William Chui (5), Cecilia Koo (5), Kitty Leung (5), Lau K H (6), Kwok T K (6),Tang M L (6), Ng W M (6), Kong L L (6), Dacita Suen (7), Wong L (7)
Affiliation :
(1 )Accident & Emergency Department, (2) Department of Clinical Oncology, (3) Department of Medicine, (4) Department of Obstetrics and Gynaecology, (5) Department of Pharmacy, (6) Department of Quality and Safety, (7) Department of Surgery
Introduction :
Neutropenic fever is a medical emergency and requires prompt administration of empirical antibiotics within 60 minutes(from the time of A&E registration to medication injection) as international standard. In order to reduce variation of care delivered to patients with febrile neutropenia, a clinical pathway on empirical antibiotics for target patients has been developed since 2014.
Objectives :
To administer first dose of empirical antibiotics to patients with neutropenic fever within 60 minutes starting from the time of AED registration i.e. door-to-antibiotics time (DTA).
Methodology :
This program is a cross-departmental collaboration. It started with departments of Accident & Emergency, Medicine, Pharmacy and Quality & Safety in 2014 without additional resource provided in term of manpower and financial support. Later, departments of Clinical Oncology, Obstetrics & Gynaecology and Surgery joined in the clinical pathway. A standardized chemotherapy alert card was given to our target patients and same information were recorded in CMS alert system. Patients with this card/ alert in CMS were triaged to Category 1 or 2. A set of standardized investigations including blood culture was done according to the pathway. Standardized antibiotics set were prescribed and fast track antibiotic collection from pharmacy were arranged according to the pathway. A prospective observational audit was conducted from 2014 to 2018 to review the compliance rate. All samples were audited.
Result & Outcome :
As at 20 December 2018, four years data (2014 to 2017) were analyzed. The total number of target patients who received the first dose of empirical antibiotics significantly increased by 392% in four years (n=93 in 2014; n=235 in 2015; n=349 in 2016; n=458 in 2017). The results were: 1. Percentage of target patients triaged as category 1 & 2 in AED: Increased from 89% (2014) to 93% (2015,2016 & 2017). 2. Percentage of target patients could achieve 60 minutes DTA: 86% in 2014 & 2015; 95% in 2016; and 92% in 2017 3. Mean door-to-antibiotics time: 46 minutes in 2014; 45 minutes in 2015; 38 minutes in (2016) and 40 minutes (2017) 4. Percentage of blood culture taken in AED Maintained at 99 % from 2014 to 2017 Conclusion The clinical pathway is an effective tool to meet the international standard of door-to-antibiotics (DTA) time within 60 minutes. The performance on DTA is sustainable in the past four consecutive years with the implementation of the pathway.

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