Implementation of a Protocol for Management of Febrile Neutropenia in the Emergency Department at Veteran Health Indiana.

Background: Febrile neutropenia (FN) is a life-threatening oncologic emergency requiring timely evaluation and treatment. Unrecognized fever and infection can progress quickly and have been shown to increase morbidity and mortality in patients with malignancy. It is critical to identify patients with neutropenic fever on presentation to the emergency department (ED) and to initiate treatment immediately. Observations: This quality improvement initiative sought to optimize ED care of patients presenting with FN. Delays in antibiotic prescribing for patients with FN presenting to the ED were identified. A protocol was implemented to streamline clinical decision making and decrease the time from triage to the first dose of antibiotics in the ED. Key interventions included obtaining ED staff support, developing a standard empiric therapy protocol, increasing prescriber awareness of the neutropenic fever protocol and integrating it into the electronic health record. Before the protocol, the mean time from triage to the first dose of antibiotics was 3.3 hours with only 6% of patients receiving appropriate empiric therapy within 1 hour. Postimplementation, the average time to antibiotics decreased to 2.3 hours. In the postimplementation group, 17% of patients within 1 hour. Conclusions: Early identification and timely empiric antibiotic therapy are critical to improving outcomes for patients presenting to the ED with FN. Additional optimization of the order sets along with increased protocol comfort and staff education will help to further reduce the time to antibiotic administration in alignment with guideline recommendations.