Background: Febrile neutropenia is a serious complication of chemotherapy. Mortality rates vary between 10% and 20% with gram-positive infections and can increase to 40% with gram-negative infections (add reference). Delays to effective antibiotics increases mortality, hence strict protocols promote early administration of appropriate antibiotics. The aim of this study was to assess compliance with these guidelines at Royal Darwin Hospital Emergency Department (RDH ED).
Methods: This was a retrospective chart review of patients presenting to the ED between 1/1/2017–1/1/2018. Data collected included time to antibiotic administration, type antibiotic administered, and allocated triage code. Performance was benchmarked with established guidelines on PGC, of which there are currently 2 differing guidelines. Secondary outcomes were time taken to be seen by a doctor; patient disposition; and time between charting and administration of antibiotics. Results of cultures were also reviewed.
Results: Due to file restrictions only 22 episodes were available. Most were triaged appropriately (91% were triaged as a category 2) and 82% received a medical assessment within 10 minutes of arrival. Depending on the guideline used to benchmark performance compliance with time to antibiotic administration was between 18-29% and compliance with recommended antibiotic regimens between 54-72%. Of concern, 3 patients did not receive antibiotics. Blood cultures were positive for 3% and urine cultures positive in 24%, however most of these were “mixed growth”.
Conclusion: This audit demonstrates poor compliance with established guidelines with regards to the timing and type of antibiotics administered to patients presenting to RDH ED with suspected febrile neutropenia. A variety of factors could contribute to the delays including delays to medical assessment, delays attributable to the process steps between documenting an antibiotic order and administration of the antibiotic, variability in practice given the existence of 2 different guidelines on PGC, and diagnostic error.