Systems Based Practice and Practice Based Learning. How to teach? How to evaluate?

1. Systems Based Practice and Practice Based Learning.  How to teach?  How to evaluate? Deborah J. DeWaay M.D. Hospitalist/Clerkship Director, General Internal Medicine May 28th, 2010

2. Quality Improvement Projects • “An approach to the study and improvement of the processes of providing healthcare services to meet needs of clients.” http://www.qaproject.org/methods/resglossary.html

3. Quality Improvement Projects • The Projects are started July of the second year of residency. • All residents participate in a project. • They break up into groups of 2-4 and ask a question. • The question should be about the evaluation of a guideline or a known best of practice. • In addition, each group will pick a faculty mentor.

4. Jonathan Abbas MD Erin Alexander MD Lara Lambert MD Diagnosis and Empiric Treatment of Neutropenic Fever in the Emergency Room MUSC Department of Medicine Quality Improvement Project June 18, 2009 Faculty Mentors: Deborah DeWaay MD; Kit Simpson, DrPH

5. Neutropenic Fever • Neutropenic fever is a medical emergency requiring initial intervention in the emergency room. • Before empiric antibiotic therapy, infection accounted for 75% of all mortality among patients receiving chemotherapy • Early studies showed a 70% increase in mortality with a delay in administration of empiric antibiotics once neutropenic fever was identified • The Infectious Disease Society of America (IDSA) has established guidelines for the treatment of neutropenic fever of unknown origin in cancer patients (last updated 2002)

6. Guidelines for Febrile Neutropenia • Definitions: • Fever = a temperature of ≥ to 101°F • Neutropenia = absolute neutrophil count of <500cells/mm3

7. Project Question and Hypotheses In patients who meet criteria for in hospital IV antibiotics for febrile neutropenia, is the time from lab notification of neutropenia to treatment in the emergency department optimal? Hypothesis 1: Time from diagnosis of neutropenic fever to administration of antibiotics is < 60 minutes for > 95% of patients Hypothesis 2: Standard treatment with meropenem is administered in > 95% of patients receiving antibiotics

8. Quality Improvement Projects • The Department of Medicine has hired a methodologist/statistician to: • Help design the projects. • Pull the data from the databases. • Calculate the statistics on the data.

9. Analysis: Descriptive Data identifying - • Mean time to diagnosis of neutropenic fever • Mean time to antibiotic administration • Proportion of patients who receive antibiotics within 60 minutes • Proportion of patients receiving antibiotics consistent with ISDA guidelines (meropenem) Study Design Design: A retrospective review of patient records Data Set: A random selection of 25 patients presenting to the Emergency Department between September 2008 and March 2009 with cancer and febrile neutropenia

10. Quality Improvement • The next task is to pull the data from the databases, do chart reviews when necessary, and crunch the numbers.

11. Patient and Process Characteristics • Average Age: 53 years old Average WBC: 1.66 cells/mm3 • Average Temp: 100.1 Average ANC: 0.04 cells/mm3 • Average time from fever recorded at ER triage to lab reporting of neutropenia : 78 minutes (0 to 148 range) • Average time from reporting neutropenia to administering any antibiotic: 77 minutes (0 to 232 range) • Average time from triage at ER to receiving antibiotics: 155 min (60 to 300 range)

12. Hypothesis 1 Time from diagnosis of neutropenic fever to administration of antibiotics is < 60 minutes in > 95% of cases Our data does not support this hypothesis, with 44% of patients receiving antibiotics within 60 minutes of diagnosis we are significantly below the 95% goal (p=.00006)

13. Hypothesis 2 Standard treatment is administered in > 95% of febrile neutropenia patients who get antibiotics Our data does not support this hypothesis, with 52% of patients receiving appropriate antibiotics we are significantly below the 95% goal (p=.00079)

14. Proposed Interventions • Flag charts if patient is on chemo and has a fever. • Inservice for all nurses, residents and attendings on the neutropenic fever guidelines. • Make sure that an approved drug is in the pyxis.

15. Quality Improvement • We are currently implementing these changes and then will re-measure to see we can improve our choice in antibiotics and our time to antibiotic administration for neutropenic fever.

16. Knowledge Management: putting guidelines into practice. • EBM: literature searches are done before all projects are started. • Population Health: most projects are looking at certain populations [neutropenic patients]. • Medical Informatics: all patients and data are pulled from databases [not possible without an EMR]. • System Improvement: all interventions are an attempt to improve the system. • Health Education: Many interventions involve educating the healthcare team about particular guidelines.

17. References • Hughes, WT et al. 2002 Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer. Clinical Infectious Diseases. 2002. 34, 730-751. • Hathorn, JW et al. Empirical treatment of febrile neutropenia: evolution of current theraputic approaches. Clincial Infectious Diseases. 1997; 24 Suppl 2:S256 • Pizzo, PA. Management of fever in patients with cancer and treatment-related neutropenia. 1993. NEJM; 328: 1323. • Schimpff, SC et al. Empiric therapy with carbenicillin and gentamicin for febrile patients with cancer and granulocytopenia. 1971. NEJM; 284:1061.