Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Pediatr Blood Cancer. 2012 Sep;59(3):431-5. doi: 10.1002/pbc.23418. Epub 2011 Dec 6.
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.
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.
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.
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.
在医疗就诊的 60 分钟内给予抗生素治疗可能被用作发热性中性粒细胞减少症（FN）的治疗目标；然而，传闻证据表明这一目标经常无法实现。很少有研究调查过延迟的普遍性或原因。我们描述了本机构抗生素给药的中位数时间、延迟的预测因素以及及时给药的障碍，以提供质量改进策略的信息。
回顾了 2008 年至 2009 年间急诊科（ED）就诊的 50 例 FN 发作的随机样本。记录了分诊、MD 评估、实验室结果和抗生素给药之间的时间。检查了患者和 ED 变量，以确定延迟的可能预测因素。同时，采用精益方法来确定系统效率低下的原因。一名训练有素的主持人与参与中性粒细胞减少症患者急诊护理的跨学科代表进行了小组访谈，以确定及时给予抗生素的流程障碍。
从分诊到抗生素的中位数时间为 216 分钟（四分位距 [IQR] = 151-274 分钟）。实验室报告后（152 分钟，IQR = 84-210 分钟）的延迟最大。只有秋季季节预测抗生素治疗时间更长（P = 0.03）。精益流程确定了部门之间不必要的延迟区域。
抗生素给药时间超过 1 小时。图表审查和精益流程为教育和基础设施干预措施提出了目标，包括 ED 预印医嘱单、急诊和血液科/肿瘤科工作人员之间的靶向联合专科教育，以及家庭教育。混合方法方法代表了一种提高流程效率和满足医学“最佳实践”目标的模型。
