Reducing emergency department and clinic visits for fever in pediatric patients with benign neutropenia: development of a quality improvement project at Rady Children's Hospital San Diego.
Abstract
Issues:Neutropenia can be classified based on pathophysiology as severe versus benign based on bone marrow reserve of neutrophil precursors, which determines the risk of serious bacterial infections (SBI). The current guidelines for management of fever in neutropenic patients are reliant on the knowledge gained in the oncology setting. There are no clear guidelines for management of fever in patients with benign neutropenia regarding evaluation or antibiotic administration, despite their lower risk of SBI. This leads to significant practice variation in management of patients with benign neutropenia who present with fever and may result in unnecessary hospital visits or antibiotic administration, leading to poor quality of life for these patients and avoidable use of healthcare resources. We initiated a quality improvement project to address this issue at Rady Children’s Hospital, San Diego, (RCHSD) with the goal of decreasing the percentage of emergency department (ED) visits for patients with benign neutropenia from a baseline of 60% febrile events to 30% febrile events by May 31, 2025.
Description: We collected baseline data via manual chart review from Jan 2023 to Nov 2023 to identify how febrile events were managed in patients with benign neutropenia at RCHSD (Table 1). None of the patients were identified as having a serious bacterial infection. We then sent a survey to all hematology providers at our institution to identify their practice of managing fever in patients with benign neutropenia. Based on the survey results, we created an Ishikawa chart (Figure 1) to identify barriers, and a key driver diagram (Figure 2) to identify possible interventions. We created an ideal process map based on the input from the hematology providers and the proposed algorithm (Figure 3) was agreed upon by the hematology providers.
Lessons Learned/Expected Outcomes: Some of the main barriers identified were variation in practices and lack of uniform guidelines in management of fever in patients with benign neutropenia. We plan to use the model of improvement methodology with the key driver diagram to guide improvement efforts.
Recommendations: Next steps include presenting the proposed algorithm to the fellows and other providers in the department of hematology-oncology, and to the ED providers before going live with the project. We also plan to present it to general pediatricians at the CPMG (Children’s Physician Medical Group) conference. We will post the algorithm in the inpatient and hematology/oncology clinic workroom and make it easily accessible to all providers on division shared folder. We plan to create a Smart Phrase on EPIC to have a standardized plan in the notes of all patients with a diagnosis of suspected or established benign neutropenia. We will discuss our progress and gain feedback in subsequent QI and division meetings.