35 Identifying and addressing improvement opportunities in the care of children with febrile neutropenia: a quality improvement initiative
Notice bibliographique
Résumé
Abstract Background Management of febrile neutropenia in previously healthy, presumed immunocompetent children varies. Overtreatment impacts the patients, families, and the healthcare system. With guidance from a Canadian Paediatric Society (CPS) Practice Point, most well-appearing children with an episode of febrile neutropenia can be managed with reduced exposure to antibiotics and close outpatient follow-up. Objectives The aim of this initiative was to safely reduce antibiotic use in this low-risk patient population presenting to the emergency department (ED). Design/Methods A multidisciplinary team designed a quality improvement (QI) initiative from July 2023 – July 2024. Treatment with antibiotics was classified as indicated or non-indicated according to guidance from the CPS Practice Point. Patient management from the year prior to guideline publication (baseline) was compared to the intervention period. Interventions involved guideline dissemination, provider education, and point of care tools to facilitate clinical decision-making and follow-up. Outcome measures included the proportion of children receiving antibiotics, hospital admission, and appropriate laboratory follow-up. Re-presentation to ED and missed serious bacterial infections (SBI) were monitored as balancing measures. Outcomes were evaluated using descriptive statistics and statistical process control (SPC) charts. Results Three hundred and ninety-eight (398) children with febrile neutropenia were included. The proportion of non-indicated antibiotics was 6.7% at baseline. Due to the low baseline use of non-indicated antibiotics, an SPC was used to detect special cause variation. Special cause was demonstrated with 97 consecutive cases occurring without error (non-indicated antibiotics). Following the occurrence of special cause variation until the end of the study, only 1.6% of children received non-indicated antibiotics. There was no increase in re-presentations to ED (9% vs 8%; p= 0.65) nor missed SBI (0% vs 0%). Influenza was prevalent during the intervention period, accounting for 71% of positive viral tests (n=64/90) in children with febrile neutropenia. Severe neutropenia resolved in 90% of evaluable children, with a median duration of 44 days. Four children had persistent neutropenia and were referred to Paediatric Hematology; all were diagnosed with benign or immune neutropenia. Conclusion QI methodology can facilitate the timely adoption of best practices to align local clinical care with new national guidelines. Implementation of the CPS recommendations allowed low-risk children with febrile neutropenia to avoid unnecessary antibiotic exposure and hospital admission. This work demonstrates an excellent opportunity for ED providers and paediatricians to reduce low-value treatment while simultaneously enhancing patient- and family-centered care.Figure 1.(A) P chart: Administration of non-indicated antibiotics in patients presenting to the Alberta Children’s Hospital ED with fever and neutropenia, presented as a proportion of the total patients per month. (B) G chart: Number of cases between errors (error = receipt of non-indicated antibiotics) among patients presenting to the Alberta Children’s Hospital ED with fever and neutropenia. The mean from the baseline period was used as the center line, with upper (UCL) and lower control limits (LCL) at 3-sigma above and below the mean.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,039 | 0,048 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,001 |
| Bibliométrie | 0,002 | 0,002 |
| Études des sciences et des technologies | 0,002 | 0,002 |
| Communication savante | 0,004 | 0,002 |
| Science ouverte | 0,002 | 0,007 |
| Intégrité de la recherche | 0,001 | 0,003 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».