title: Identification of educational and infrastructural barriers to prompt antibiotic delivery in febrile neutropenia: a quality improvement initiative.
abstract: BACKGROUND
  Antibiotic administration within 60 minutes of presentation for medical care may be used as a treatment target for febrile neutropenia (FN); however, anecdotal evidence suggests this target is often missed. Few studies have examined the prevalence or causes of delay. We describe the median time to antibiotic administration at our institution, predictors of delay, and barriers to prompt administration to inform quality improvement strategies.
  
  
  METHODS
  A random sample of 50 episodes of FN presenting to the emergency department (ED) between 2008 and 2009 were reviewed. Times between triage, MD assessment, lab results, and antibiotic administration were recorded. Patient and ED variables were examined as possible predictors of delay. In parallel, lean methodology was used to identify system inefficiencies. A trained moderator conducted group interviews with interdisciplinary representatives involved in the emergency care of neutropenic patients to identify process barriers to prompt antibiotics.
  
  
  RESULTS
  The median time from triage to antibiotics was 216 minutes (interquartile range [IQR] = 151-274 minutes). The greatest delay occurred following the reporting of lab results (152 minutes, IQR = 84-210 minutes). Only fall season predicted a longer time to antibiotics (P = 0.03). The lean process identified unnecessary areas of delay between departments.
  
  
  CONCLUSIONS
  Time to antibiotic administration exceeded 1 hour. The chart review and lean process suggested targets for educational and infrastructural interventions, including an ED pre-printed order sheet, targeted combined subspecialty education between emergency and hematology/oncology staff, and family education. A mixed methodology approach represents a model for improving process efficiency and meeting "best-practice" targets in medicine.
authors.affiliation: Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Erica
authors.initials: E
authors.lastname: Burry
authors.forename: Angela
authors.initials: A
authors.lastname: Punnett
authors.forename: Ashley
authors.initials: A
authors.lastname: Mehta
authors.forename: Jennifer
authors.initials: J
authors.lastname: Thull-Freedman
authors.forename: Lisa
authors.initials: L
authors.lastname: Robinson
authors.forename: Sumit
authors.initials: S
authors.lastname: Gupta
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D004636:Emergency Service, Hospital; D004638:Emergency Treatment; D005334:Fever / Q000188:drug therapy* / Q000209:etiology; D006266:Health Education; D006748:Hospital Departments; D006801:Humans; D009503:Neutropenia / Q000150:complications*; D058996:Quality Improvement; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents