Vitals Key clinical point: Instituting a care pathway hastened antibiotic administration in cancer patients with fever in the ED. Major finding: Cancer patients treated according to a febrile neutropenia care pathway in the ED received antibiotics in 81 minutes, significantly sooner than did historical and direct admission comparison cohorts at 235 and 169 minutes, respectively (P<.001 for both differences). Data source: Prospective study of 276 febrile neutropenia episodes in 223 patients, compared with 107 episodes in 87 historical patients and 114 episodes in 101 direct admission cohort patients. Disclosures: The authors reported no relevant financial disclosures. |
Cancer patients who arrive in the ED with febrile neutropenia (FN) received antibiotics much more quickly when their condition was identified as a medical emergency and a care pathway was used to guide treatment. The set of simple interventions slashed average time to antibiotics from about 4 hours to less than 1.5 hours, compared with a historical cohort, and the inexpensive interventions have had durable results.
Dr Michael Keng and his coinvestigators at the Cleveland Clinic reported the results of a single-center prospective analysis that targeted FN, a common and serious chemotherapy complication with a mortality rate that can exceed 50% in medically fragile individuals.1
“With an increasing number of outpatient chemotherapy regimens, more patients are likely to present to the emergency department with FN,” wrote Dr Keng. The FN pathway devised by Dr Keng and his associates implemented key changes designed to identify FN as an emergency and guide prompt triage, assessment, and treatment.
Study coauthor Dr Mikkael Sekeres said, “The interventions were not complicated. We standardized our definition of fever, provided patients with wallet-sized cards alerting emergency departments to the potential of this serious condition, worked with our emergency department staff to change the triage level of fever and neutropenia to be equivalent to that observed for heart attack or stroke, designed standard febrile neutropenia order sets for our electronic medical record, and relocated the antibiotics used to treat febrile neutropenia to our emergency department.”
Febrile patients with cancer in the prospective cohort (n = 223) were compared with a historical cohort of patients presenting to the ED who received usual care (n = 87), as well as to a concurrent cohort of patients who were directly admitted to the hospital (n = 114). The total number of FN episodes for the cohorts was 276, 107, and 114, respectively. Multivariable analysis was used to account for some differences in patient characteristics across cohorts.
Using the order set in the electronic health record (EHR) also made a difference: for those treated per the order set (n = 103), median time to antibiotics was 68 minutes, compared with 96 minutes when the order set was not used.
Secondary outcome measures included times to physician assessment, blood draw, and antibiotic order placement. All measures except time to physician assessment were significantly shorter for the FN pathway group than for the comparison cohorts (P<.001 for all).
Since so many changes were made at once, Dr Keng and his coauthors noted, “It is difficult to determine the impact of any one change.” Some institutions may have difficulty implementing all the interventions, but immediate triage, automated antibiotic ordering, and EHR use were the changes that had the most impact, he wrote.
“Instituting these changes took less than half a year, and the benefits have persisted for years afterward,” Dr Sekeres said in an interview.
ESC: Aldosterone Blockade Fails to Fly for Early MI in ALBATROSS
BY BRUCE JANCIN
AT THE European Society of Cardiology CONGRESS 2015
Vitals Key clinical point: Giving aldosterone antagonists to myocardial infarction (MI) patients without heart failure doesn’t improve clinical outcomes. Major finding: The 6-month rate of a multipronged composite clinical endpoint was closely similar, regardless of whether patients with acute MI without heart failure were placed on spironolactone within the first couple of days post-MI. Data source: The Aldosterone Lethal Effects Blockade in Acute Myocardial Infarction Treated With or Without Reperfusion to Improve Outcome and Survival at Six Months’ Follow-Up (ALBATROSS) trial was an open-label, multicenter French study in which 1,603 patients were randomized to 6 months of aldosterone blockade or not within the first hours after an acute MI without heart failure. Disclosures: The investigator-initiated ALBATROSS trial was funded by the French Ministry of Health. |