538 - Getting it right the first time: Increasing antibiotic stewardship in non-neutropenic febrile oncology patients presenting to the pediatric emergency department (PED)

Publication Number: 2523.538

Leslie A. Hueschen, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States; Joel Thompson, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States; Chris Kaberline, Children's Mercy Hospitals and Clinics, Prairie Village, KS, United States; Megan McCall, Children's Mercy Hospital, Kansas City, MO, United States; Robert Schremmer, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Stephanie Clark, Children's Mercy Hospitals and Clinics, Shawee, KS, United States; Ann-Janette Griffin, Children's Mercy Hospital, Shawnee, KS, United States

Background: Febrile pediatric oncology patients with central lines are at high risk for sepsis, often prompting empiric administration of broad-spectrum antibiotics. However, emerging evidence fails to support the historic 1-hour window for antibiotic administration in well-appearing patients, allowing time to tailor antibiotic therapy. Well-appearing non-neutropenic (ANC >500) patients do not require empiric anti-pseudomonal antibiotics such as cefepime. Currently, 92% of non-neutropenic febrile oncology patients in the pediatric emergency department (PED) receive cefepime.

Objective: We aim to decrease the percentage of non-neutropenic febrile oncology patients treated with cefepime in the PED from 92% to 60 % by June 30, 2025.

Design/Methods: A multidisciplinary team of PED providers, nurses, QI consultants, family advisors, and oncology providers was formed. A key driver diagram, process map, and fishbone diagram identified interventions which were implemented in a plan-do-study-act (PDSA) methodology (Fig 1).
The outcome measure was percentage of non-neutropenic febrile oncology patients who received cefepime. Process measures included order set use, percentage of antibiotics ordered before ANC resulted and the time from arrival to ANC result. Our balancing measures include readmission of patients within 7 days, admission to the Intensive Care Unit within 24 hours of ED discharge, and percentage of patients with antibiotics administered over 3 hours after arrival.

Results: Following our first PDSA (August 2024), cefepime use in non-neutropenic patients decreased from 92% to 26.8% (Fig 2). Patients with antibiotics administered prior to ANC reporting decreased (90% to 60.9%) in October 2024 (Fig 3). This decline may reflect improved provider understanding of the process, likely influenced by monthly data reviews during staff meetings. Unexpectedly, the time for ANC results increased (94 to 103 minutes), which is believed to be associated with onboarding new staff who required additional training. Future PDSA include adding a specialized sticker to lab specimens to prioritize lab results. The percentage of patients with IV antibiotics administered over 3 hours from arrival increased in September 2024 (2.3% to 29%). Remaining balancing measures did not see statistical changes.

Conclusion(s): Implementation of a new clinical pathway with order set along with family engagement allowed the most impactful improvement in antibiotics stewardship. Next steps include involving pharmacy in bedside huddles and expanding the process to the outpatient oncology clinic.

Plan-Do-Study-Act Timeline
Plan-Do-Study-Act Timeline

Percentage of non-neutropenic febrile oncology patients receiving Cefepime
Percentage of non-neutropenic febrile oncology patients receiving Cefepime

Percentage of febrile oncology patients given antibiotics before ANC resulting
Percentage of febrile oncology patients given antibiotics before ANC resulting