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Nurse-initiated pre-prescribed antibiotic orders to facilitate prompt and appropriate antibiotic administration in febrile neutropenia

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Abstract

Purpose

To assess the impact of a pathway allowing nurse initiation of first dose intravenous (IV) antibiotics on time to antibiotic administration (TTA) in adult inpatients with febrile neutropenia (FN).

Methods

This study evaluated the impact on TTA of a clinical pathway (November 2017 to April 2018) allowing nurse initiation of pre-prescribed antibiotics in adult haematology patients with FN, compared with a prior cohort (November 2016 to April 2017) in which antibiotics were only prescribed and administered after medical review. The primary endpoint for comparison was TTA, calculated as the time between the first recorded fever and IV antibiotic administration. Secondary endpoints included appropriateness of initial antibiotic choice, 30-day all-cause mortality and admission to intensive care unit (ICU).

Results

Forty-seven eligible FN episodes in 40 patients and 61 episodes in 52 patients were evaluated in the pre- and post-implementation groups, respectively. Baseline characteristics were comparable between groups. Median (IQR) TTA, in the pre-implementation group [66 min (40–100 min)] was significantly prolonged versus post-implementation group [29 min (20–41 min); p < 0.001]. A significantly higher proportion of episodes were administered appropriate initial antibiotics in the post-versus pre-implementation groups (100% vs. 89%, p = 0.03). There was no significant change in 30-day all-cause mortality (0% vs. 5%, p = 0.3) or ICU admission within 48 h of fever (0% vs. 2%, p > 0.99) between pre- and post-implementation groups, respectively.

Conclusions

A pathway allowing nurse initiation of pre-prescribed antibiotic orders for FN significantly reduced TTA from first recorded fever and increased the proportion of appropriate initial antibiotic choices without significantly impacting on patient outcomes.

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Acknowledgements

The authors would like to acknowledge Patrick Date for his contribution to the collection of preliminary audit data (12/1/2011 to 4/12/2015).

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Authors and Affiliations

  1. Departments of Pharmacy and Infectious Diseases, Austin Health, Melbourne, Australia

    Steven T Walker & Jason Trubiano

  2. Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia

    Steven T Walker & Carl Kirkpatrick

  3. Department of Medicine, University of Melbourne, Melbourne, Australia

    Steven T Walker, Karen Urbancic & Jason Trubiano

  4. Department of Medicine, Austin Health, Melbourne, Australia

    Samuel Grigg

  5. The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre; The National Centre for Antimicrobial Stewardship, Melbourne Health, Victoria, Australia

    Karen Urbancic & Jason Trubiano

  6. Department of Clinical Haematology, Olivia Newton-John Cancer and Research Institute, Austin Health, Melbourne, Australia

    Emma Cohen & Andrew Grigg

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  1. Steven T Walker
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Steven T Walker and Samuel Grigg. The first draft of the manuscript was written by Steven T Walker, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Steven T Walker.

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Walker, S.T., Grigg, S., Kirkpatrick, C. et al. Nurse-initiated pre-prescribed antibiotic orders to facilitate prompt and appropriate antibiotic administration in febrile neutropenia. Support Care Cancer 28, 4337–4343 (2020). https://doi.org/10.1007/s00520-019-05290-2

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  • DOI: https://doi.org/10.1007/s00520-019-05290-2

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