Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
University of Melbourne, Parkville, Victoria, Australia.
Support Care Cancer. 2021 Mar;29(3):1609-1617. doi: 10.1007/s00520-020-05654-z. Epub 2020 Aug 1.
Home-based management of low-risk febrile neutropenia (FN) is safe, improves quality of life and reduces healthcare expenditure. A formal low-risk paediatric program has not been implemented in Australia. We aimed to describe the implementation process and evaluate the clinical impact.
This prospective study incorporated three phases: implementation, intervention and evaluation. A low-risk FN implementation toolkit was developed, including a care-pathway, patient information, home-based assessment and educational resources. The program had executive-level endorsement, a multidisciplinary committee and a nurse specialist. Children with cancer and low-risk FN were eligible to be transferred home with a nurse visiting daily after an overnight period of observation for intravenous antibiotics. Low-risk patients were identified using a validated decision rule, and suitability for home-based care was determined using disease, chemotherapy and patient-level criteria. Plan-Do-Study-Act methodology was used to evaluate clinical impact and safety.
Over 18 months, 292 children with FN were screened: 132 (45%) were low-risk and 63 (22%) were transferred to home-based care. Compared with pre-implementation there was a significant reduction in in-hospital median LOS (4.0 to 1.5 days, p < 0.001) and 291 in-hospital bed days were saved. Eight (13%) patients needed readmission and there were no adverse outcomes. A key barrier was timely screening of all patients and program improvements, including utilising the electronic medical record for patient identification, are planned.
This program significantly reduces in-hospital LOS for children with low-risk FN. Ongoing evaluation will inform sustainability, identify areas for improvement and support national scale-up of the program.
低危发热性中性粒细胞减少症（FN）的家庭管理安全可靠，可提高生活质量并降低医疗支出。澳大利亚尚未正式实施针对低危儿童的计划。我们旨在描述实施过程并评估其临床影响。
这项前瞻性研究包括三个阶段：实施、干预和评估。制定了一个低危 FN 实施工具包，包括护理路径、患者信息、家庭评估和教育资源。该计划得到了执行层面的认可、一个多学科委员会和一名护士专家的支持。患有癌症和低危 FN 的儿童在接受静脉抗生素治疗观察过夜后，有资格转移回家，由护士每天上门护理。使用经过验证的决策规则识别低危患者，并使用疾病、化疗和患者水平标准确定适合家庭护理的条件。使用计划-执行-研究-行动（Plan-Do-Study-Act）方法评估临床影响和安全性。
在 18 个月的时间里，对 292 名 FN 患儿进行了筛查：132 名（45%）为低危患者，其中 63 名（22%）被转移至家庭护理。与实施前相比，住院中位数 LOS 显著缩短（4.0 天至 1.5 天，p<0.001），节省了 291 个住院床位日。8 名（13%）患者需要再次入院，且无不良结局。一个关键的障碍是及时筛查所有患者，计划改进包括利用电子病历进行患者识别等。
该计划显著缩短了低危 FN 患儿的住院 LOS。持续评估将为计划的可持续性、确定改进领域和支持全国范围内的计划扩展提供信息。
