Optimising door-to-needle-time in children with febrile neutropenia in the paediatric emergency unit-a quality improvement study.
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INTRODUCTION AND BACKGROUND: Febrile Neutropenia is one of the leading causes of treatment-related mortality in children with malignancies. Door-to-needle-time (DTNT), defined as the time between arrival at hospital and antibiotic administration, of <60 minutes is considered standard of care in managing this oncological emergency. OBJECTIVES: In this quality improvement (QI) study, we aim to determine the proportion of children with febrile neutropenia (FN) receiving timely antibiotics in the Paediatric Emergency unit and improve this by 50% over 6 months using the Plan-Do-Study-Act framework. Secondary objectives included identifying factors associated with delays in achieving optimal DTNT and the impact of these delays on clinical outcomes. METHODS: Baseline data of children less than 18 years of age on cancer chemotherapy presenting with neutropenic fever between January 2022 and June 2023 were collected ambispectively. A fishbone root cause analysis was performed. Interventions were planned and prioritised using a prioritisation matrix. QI measures were initiated subsequently in the form of the development and implementation of a validated clinical care pathway that described the triaging, clinical assessment, laboratory investigations, antibiotic dosing and patient disposition. Additionally, mannequin-assisted, followed by bedside training on chemoport handling, was performed. Post-intervention data, including the 6-months sustenance phase, were collected, and outcomes were analysed. RESULTS: In the baseline, intervention and sustenance periods, 129, 80 and 47 episodes of FN, respectively, were documented. Median DTNT reduced by 50% from a baseline of 80 minutes interquartile range (IQR 65-105) to 40 minutes (IQR 30-40) post-intervention (p < 0.001). The proportion of children with optimal DTNT increased from 22% to 92.5% (p < 0.001). DTNT > 60 minutes was significantly associated with intensive care admissions. Root-Cause-Analysis revealed difficult peripheral venous access, lack of awareness and implementation challenges as the most important causes for delays in antibiotic administration. CONCLUSIONS: The median DTNT was significantly delayed in patients with FN. Inadequate knowledge and skills training, delays in vascular access and lack of implementation of standard protocols were identified as the key factors responsible for delays in antibiotic administration. QI strategies aimed at improving awareness and skill with rigorous training programs as well as clinical pathway implementation, significantly improved the time to antibiotic administration.