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Home-based care of low-risk febrile neutropenia in children—an implementation study in a tertiary paediatric hospital

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Abstract

Background

Home-based management of low-risk febrile neutropenia (FN) is safe, improves quality of life and reduces healthcare expenditure. A formal low-risk paediatric program has not been implemented in Australia. We aimed to describe the implementation process and evaluate the clinical impact.

Method

This prospective study incorporated three phases: implementation, intervention and evaluation. A low-risk FN implementation toolkit was developed, including a care-pathway, patient information, home-based assessment and educational resources. The program had executive-level endorsement, a multidisciplinary committee and a nurse specialist. Children with cancer and low-risk FN were eligible to be transferred home with a nurse visiting daily after an overnight period of observation for intravenous antibiotics. Low-risk patients were identified using a validated decision rule, and suitability for home-based care was determined using disease, chemotherapy and patient-level criteria. Plan-Do-Study-Act methodology was used to evaluate clinical impact and safety.

Results

Over 18 months, 292 children with FN were screened: 132 (45%) were low-risk and 63 (22%) were transferred to home-based care. Compared with pre-implementation there was a significant reduction in in-hospital median LOS (4.0 to 1.5 days, p < 0.001) and 291 in-hospital bed days were saved. Eight (13%) patients needed readmission and there were no adverse outcomes. A key barrier was timely screening of all patients and program improvements, including utilising the electronic medical record for patient identification, are planned.

Conclusion

This program significantly reduces in-hospital LOS for children with low-risk FN. Ongoing evaluation will inform sustainability, identify areas for improvement and support national scale-up of the program.

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References

  1. Morgan JE, Cleminson J, Atkin K, Stewart LA, Phillips RS (2016) Systematic review of reduced therapy regimens for children with low risk febrile neutropenia. Support Care Cancer 24:2651–2660

    Article  Google Scholar 

  2. Manji A, Beyene J, Dupuis LL, Phillips R, Lehrnbecher T, Sung L (2012) Outpatient and oral antibiotic management of low-risk febrile neutropenia are effective in children--a systematic review of prospective trials. Support Care Cancer 20:1135–1145

    Article  CAS  Google Scholar 

  3. Lehrnbecher T, Phillips R, Alexander S, Alvaro F, Carlesse F, Fisher B, Hakim H, Santolaya M, Castagnola E, Davis BL, Dupuis LL, Gibson F, Groll AH, Gaur A, Gupta A, Kebudi R, Petrilli S, Steinbach WJ, Villarroel M, Zaoutis T, Sung L, International Pediatric Fever and Neutropenia Guideline Panel (2012) Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol 30:4427–4438

    Article  Google Scholar 

  4. Lehrnbecher T, Robinson P, Fisher B, Alexander S, Ammann RA, Beauchemin M, Carlesse F, Groll AH, Haeusler GM, Santolaya M, Steinbach WJ, Castagnola E, Davis BL, Dupuis LL, Gaur AH, Tissing WJE, Zaoutis T, Phillips R, Sung L (2017) Guideline for the management of fever and neutropenia in children with cancer and hematopoietic stem-cell transplantation recipients: 2017 update. J Clin Oncol 35:2082–2094

    Article  CAS  Google Scholar 

  5. Haeusler GM, Slavin MA, Bryant PA, Babl FE, Mechinaud F, Thursky KA (2018) Management of fever and neutropenia in children with cancer: a survey of Australian and New Zealand practice. J Paediatr Child Health 54:761–769

    Article  Google Scholar 

  6. Herd F, Bate J, Chisholm J, Johnson E, Phillips B (2016) Variation in practice remains in the UK management of paediatric febrile neutropenia. Arch Dis Child 101:410–411

    Article  Google Scholar 

  7. Delebarre M, Tiphaine A, Martinot A, Dubos F (2016) Risk-stratification management of febrile neutropenia in pediatric hematology-oncology patients: results of a French nationwide survey. Pediatr Blood Cancer 63:2167–2172

    Article  Google Scholar 

  8. Mueller EL, Walkovich KJ, Yanik GA, Clark SJ (2015) Variation in management of fever and neutropenia among pediatric patients with cancer: a survey of providers in Michigan. Pediatr Hematol Oncol 32:331–340

    Article  Google Scholar 

  9. Phillips RS, Lehrnbecher T, Alexander S, Sung L (2012) Updated systematic review and meta-analysis of the performance of risk prediction rules in children and young people with febrile neutropenia. PLoS One 7:e38300

    Article  CAS  Google Scholar 

  10. Phillips B, Wade R, Stewart LA, Sutton AJ (2010) Systematic review and meta-analysis of the discriminatory performance of risk prediction rules in febrile neutropaenic episodes in children and young people. Eur J Cancer 46:2950–2964

    Article  Google Scholar 

  11. Paolino J, Mariani J, Lucas A, Rupon J, Weinstein H, Abrams A, Friedmann A (2019) Outcomes of a clinical pathway for primary outpatient management of pediatric patients with low-risk febrile neutropenia. Pediatr Blood Cancer 66:e27679

    Article  Google Scholar 

  12. Haeusler GM, Thursky KA, Slavin MA, Mechinaud F, Babl FE, Bryant P, de Abreu Lourenco R, Phillips R (2018) External validation of six pediatric fever and neutropenia clinical decision rules. Pediatr Infect Dis J 37:329–335

    Article  Google Scholar 

  13. Haeusler GM, Thursky KA, Mechinaud F, Babl FE, de Abreu Lourenco R, Slavin MA, Phillips R (2017) Predicting infectious complications in children with cancer: an external validation study. Br J Cancer 117:171–178

    Article  Google Scholar 

  14. Orme LM, Babl FE, Barnes C, Barnett P, Donath S, Ashley DM (2014) Outpatient versus inpatient IV antibiotic management for pediatric oncology patients with low risk febrile neutropenia: a randomised trial. Pediatr Blood Cancer 61:1427–1433

    Article  CAS  Google Scholar 

  15. Teh BW, Brown C, Joyce T, Worth LJ, Slavin MA, Thursky KA (2018) Safety and cost benefit of an ambulatory program for patients with low-risk neutropenic fever at an Australian centre. Support Care Cancer 26:997–1003

    Article  Google Scholar 

  16. Pinnock H, Barwick M, Carpenter CR et al (2017) Standards for reporting implementation studies (StaRI) statement. BMJ 356:i6795

    Article  Google Scholar 

  17. National Centre For Infections in Cancer, Paediatric Low Risk Febrile Neutropenia Toolkit. [updated March 2020. Available from: https://cancerandinfections.org/kids-low-risk-toolkit accessed 03/06/2020]

  18. The Royal Children's Hospital, Melbourne, Australia, Clinical Practice Guideline on Fever and suspected or confirmed neutropenia in children with cancer. 2020 [updated January 2020. Available from: https://wwww.rch.org.au/clinicalguide/ accessed 02/04/2020

  19. Ammann RA, Bodmer N, Hirt A, Niggli FK, Nadal D, Simon A, Ozsahin H, Kontny U, Kühne T, Popovic MB, Lüthy AR, Aebi C (2010) Predicting adverse events in children with fever and chemotherapy-induced neutropenia: the prospective multicenter SPOG 2003 FN study. J Clin Oncol 28:2008–2014

    Article  Google Scholar 

  20. Scoville R. 6 Essential Practices for Sustainable Improvement 2017 [Available from: http://www.ihi.org/communities/blogs/six-essential-practices-for-sustainable-improvement accessed 18/01/2019

  21. Haeusler GM, Phillips R, Lehrnbecher T et al (2015) Core outcomes and definitions for pediatric fever and neutropenia research: a consensus statement from an international panel. Pediatr Blood Cancer 62:483–489

    Article  Google Scholar 

  22. Haeusler GM, Phillips RS, Lehrnbecher T, Sung L, Ammann RA (2013) The reporting of outcomes in studies of fever and neutropenia in children with cancer: time for consensus. Pediatr Blood Cancer 60:1563–1564

    Article  Google Scholar 

  23. Harris P, Taylor R, Thielke R et al (2009) Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42:377–381

    Article  Google Scholar 

  24. Haeusler GM, Thursky KA, Slavin MA, Babl FE, de Abreu Lourenco R, Allaway Z, Mechinaud F, Phillips R, Australian PICNICC study group and the PREDICT network (2020) Risk stratification in children with cancer and febrile neutropenia: a national, prospective, multicentre validation of nine clinical decision rules. EClinicalMedicine 18:100220

    Article  Google Scholar 

  25. McGinn T, Guyatt G, Wyer P et al (2000) Users’ guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group. JAMA 284:79

    Article  CAS  Google Scholar 

  26. Chan RJ, Marx W, Bradford N, Gordon L, Bonner A, Douglas C, Schmalkuche D, Yates P (2018) Clinical and economic outcomes of nurse-led services in the ambulatory care setting: a systematic review. Int J Nurs Stud 81:61–80

    Article  Google Scholar 

  27. Hooper MH, Weavind L, Wheeler AP, Martin JB, Gowda SS, Semler MW, Hayes RM, Albert DW, Deane NB, Nian H, Mathe JL, Nadas A, Sztipanovits J, Miller A, Bernard GR, Rice TW (2012) Randomized trial of automated, electronic monitoring to facilitate early detection of sepsis in the intensive care unit*. Crit Care Med 40:2096–2101

    Article  Google Scholar 

  28. Shimabukuro DW, Barton CW, Feldman MD, Mataraso SJ, Das R (2017) Effect of a machine learning-based severe sepsis prediction algorithm on patient survival and hospital length of stay: a randomised clinical trial. BMJ Open Respir Res 4:e000234

    Article  Google Scholar 

  29. Haeusler GM, Thusky KA, Slavin MA et al (2020) Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia. EClinicalMedicine (accepted) 23:100394

    Article  Google Scholar 

  30. Tew M, Forster D, Teh BW, Dalziel K (2019) National cost savings from an ambulatory program for low-risk febrile neutropenia patients in Australia. Aust Health Rev 43(5):549–555

  31. Teuffel O, Amir E, Alibhai SM et al (2011) Cost-effectiveness of outpatient management for febrile neutropenia in children with cancer. Pediatrics 127:e279–e286

    Article  Google Scholar 

  32. Pinnock H, Epiphaniou E, Sheikh A et al (2015) Developing standards for reporting implementation studies of complex interventions (StaRI): a systematic review and e-Delphi. Implement Sci 10:1–9

    Article  Google Scholar 

  33. Hull L, Goulding L, Khadjesari Z et al (2019) Designing high-quality implementation research: development, application, feasibility and preliminary evaluation of the implementation science research development (ImpRes) tool and guide. Implement Sci 14:1–20

    Article  Google Scholar 

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Acknowledgements

We gratefully acknowledge the Victorian Paediatric Integrated Cancer Service for their support and endorsement of the Low-risk Febrile Neutropenia Program.

Funding

Program implementation was supported by a grant from Better Care Victoria (BCV), Department of Health and Human Services, Victorian State Government. Baseline data collection was supported by a grant from National Health and Medical Research Association (NHMRC) Project Grant (APP1104527).

Author information

Authors and Affiliations

  1. Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia

    Gabrielle M. Haeusler, Benjamin Teh, Monica A. Slavin & Karin A. Thursky

  2. University of Melbourne, Parkville, Victoria, Australia

    Gabrielle M. Haeusler, Benjamin Teh, Monica A. Slavin & Karin A. Thursky

  3. Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia

    Gabrielle M. Haeusler, Benjamin Teh, Monica A. Slavin & Karin A. Thursky

  4. The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia

    Gabrielle M. Haeusler & Lynda Gaynor

  5. Infection Diseases Unit, Department of General Medicine, Royal Children’s Hospital, Parkville, Victoria, Australia

    Gabrielle M. Haeusler & Penelope A. Bryant

  6. Murdoch Children’s Research Institute, Parkville, Victoria, Australia

    Gabrielle M. Haeusler, Franz E. Babl & Penelope A. Bryant

  7. Hospital In The Home Department, Royal Children’s Hospital, Parkville, Victoria, Australia

    Lynda Gaynor & Penelope A. Bryant

  8. Department of Emergency Medicine, Royal Children’s Hospital, Parkville, Victoria, Australia

    Franz E. Babl

  9. Children’s Cancer Centre, Royal Children’s Hospital, Parkville, Victoria, Australia

    Lisa M. Orme

  10. Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia

    Ahuva Segal & Penelope A. Bryant

  11. Unité d’hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France

    Francoise Mechinaud

  12. Centre for Reviews and Dissemination, University of York, York, UK

    Bob Phillips

  13. Centre for Health Economics Research and Evaluation, University of Technology Sydney, New South Wales, Australia

    Richard De Abreu Lourenco

  14. Department of Medicine, University of Melbourne, Parkville, Victoria, 3010, Australia

    Monica A. Slavin & Karin A. Thursky

  15. Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia

    Monica A. Slavin & Karin A. Thursky

  16. NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia

    Karin A. Thursky

Authors
  1. Gabrielle M. Haeusler
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  2. Lynda Gaynor
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  3. Benjamin Teh
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  4. Franz E. Babl
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  5. Lisa M. Orme
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  6. Ahuva Segal
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  7. Francoise Mechinaud
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  8. Penelope A. Bryant
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  9. Bob Phillips
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  10. Richard De Abreu Lourenco
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  11. Monica A. Slavin
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  12. Karin A. Thursky
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Contributions

All authors contributed to the study conception and design. Data collection was performed by Dr. Gabrielle Haeusler and Ms. Lynda Gaynor. Analysis was performed by Dr. Gabrielle Haeusler, Ms. Lynda Gaynor and Prof Karin Thursky. The first draft of the manuscript was written by Dr. Gabrielle Haeusler and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Gabrielle M. Haeusler.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki. The study had local Human Research Ethics Committee approval from The Royal Children’s Hospital Human Research Ethics Committee (ethics number 36040).

Consent to participate

Informed consent was obtained from all individual participants or parent/guardian of patients included in the study.

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Not applicable.

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Haeusler, G.M., Gaynor, L., Teh, B. et al. Home-based care of low-risk febrile neutropenia in children—an implementation study in a tertiary paediatric hospital. Support Care Cancer 29, 1609–1617 (2021). https://doi.org/10.1007/s00520-020-05654-z

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  • DOI: https://doi.org/10.1007/s00520-020-05654-z

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