Digital Repository Doctoral Projects Spring 2021 Implementation of a Clinical Pathway for Outpatient Management of Oncological Neutropenic Fever Marie L. Blacker, MSN, APRN, NP-C Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Blacker, M. L., (2021) Implementation of a Clinical Pathway for Outpatient Management of Oncological Neu-tropenic Fever. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Implementation of a Clinical Pathway for Outpatient Management of Oncological Neutropenic Fever by Marie L. Blacker A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 25, 2021 Mary Anne Hales Reynolds PhD, RN, ACNS-BC_ Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director Running head: ONCOLOGICAL NEUTROPENIC FEVER 1 Implementation of a Clinical Pathway for Outpatient Management of Oncological Neutropenic Fever Marie Lynne Blacker, MSN, APRN, NP-C Annie Taylor Dee School of Nursing, Weber State University ONCOLOGICAL NEUTROPENIC FEVER 2 Acknowledgements A sincere and heartfelt thank you to Dr. Mary Anne Reynolds, Associate Professor in the College of Nursing at Weber State University, and Dr. Anna Beck, Director of Supportive and Palliative Care at Huntsman Cancer Institute, for their mentoring during the development, implementation, and evaluation of this Doctor of Nursing Practice project. Dr. Reynolds will forever be admired for her unending level of patience and professionalism with students and her vision for scholarly perfection. Dr. Beck will be eternally respected for her vast amount of clinical knowledge in the medical arena of oncology and for her soft, approachable mannerism with others of all levels of educational and professional achievement. Both exemplify the heart of a teacher, the advice of a sage counselor, and the camaraderie of a trusted friend. ONCOLOGICAL NEUTROPENIC FEVER 3 Abstract Febrile neutropenia occurs in approximately 21% of patients receiving chemotherapy for metastatic solid tumors. Oncology patients with neutropenic fever and low risk for complications can be effectively treated in the home. The purpose of this Doctor of Nursing Practice (DNP) project was to develop and implement an evidence-based clinical pathway for the outpatient management of neutropenic fever in oncology patients at Huntsman Cancer Institute in Salt Lake City, Utah. The Multinational Association of Supportive Care in Cancer (MASCC) risk-stratification tool and guidelines from the American Society of Clinical Oncology (ASCO) were used to develop a clinical pathway and decision tree flowchart to care for oncology patients with neutropenic fever in the home. This pathway outlined high quality, cost-effective in-home treatment and established a five-day “Acute Watch” to reduce hospitalizations. Five patients developed symptoms of acute illness and were placed on “Acute Watch.” Four were successfully managed at home and avoided hospitalization. Seven nurse practitioners (NPs) and five registered nurses (RNs) were surveyed and rated the clinical pathway 9.3 on a scale of 1-10 for being clinically useful in outlining the assessment, treatment, and follow-up of febrile patients in the home. Oncology patients with neutropenic fever and low risk for complications can be effectively treated in the home by nurse practitioners. The MASCC risk-assessment tool can identify patients at low risk for complications and ASCO guidelines can be adapted to manage oncology patients at home who develop neutropenic fever. Implementation of a five-day Acute Watch program can effectively reduce hospitalizations in patient with acute illness. Keywords: neutropenia, neutropenic fever, febrile neutropenia, fever, outpatient, ambulatory care, home care, hospice, cancer, oncology, symptom management, infection, and nurse practitioners ONCOLOGICAL NEUTROPENIC FEVER 4 Implementation of a Clinical Pathway for Outpatient Management of Oncological Neutropenic Fever Cancer is a major public health concern worldwide and is the second leading cause of death in the United States, second only to the number of deaths caused by cardiovascular disease. In the year 2019, 1,762,450 new cases of cancer were projected to occur along with 606,880 cancer-related deaths in the United States (Siegel, Miller, & Jemal 2019). Cancer is a common cause of death and disability in the United States with important physical and economical consequences. Cancer, however, is complex due to its nature of disease and treatment. The treatment of cancer with anti-neoplastic agents often results in neutropenia. Neutropenia is caused by low levels of neutrophils, a type of white blood cell used to fight infection (Tallent, 2013). Patients at risk of developing neutropenia are those who have received chemotherapy within the last six weeks (Long & Koyfman, 2019). Neutropenia commonly results from cancer treatment and is usually treated in the hospital setting. New models of care are being posed that support the care of cancer patients in the home setting, specifically the care of low-risk patients that develop febrile neutropenia. Symptoms resulting from the disease process and associated neoplastic therapy can be complex, difficult to resolve and become the focus for patients and medical providers. Treatment of symptoms usually occurs in an acute care setting, however, within the past 5-10 years, there has developed a growing interest for outpatient treatment of symptoms for carefully selected low-risk patients (Moores, 2007). It is challenging to achieve optimal management of symptoms when the patient is at home and, as a consequence, cancer patients often experience poorly controlled symptoms that result in unnecessary suffering, emergency department visits, and unplanned hospitalizations (Mooney et al., 2019). ONCOLOGICAL NEUTROPENIC FEVER 5 Neutropenia is a common symptom that occurs among patients with cancer who are receiving chemotherapy and can occur with or without the presence of fever (Tallent, 2013). Neutropenia that presents with fever is considered a medical emergency that requires urgent evaluation, timely administration of intravenous broad-spectrum antibiotics, and careful medical monitoring to reduce the risk of life-threatening complications (Braga, Taplitz, & Flowers, 2020). Febrile neutropenia is a common complication and significant cause of morbidity and mortality among cancer patients and creates a heavy cost burden to those affected (Braga et al., 2020). Standard treatment of neutropenic fever includes hospitalization and administration of intravenous broad-spectrum antibiotics (Moores, 2007). Management of neutropenic fever in the home setting has the potential to avoid patient exposure to multi-drug resistant organisms found in the hospital, provide a comfortable environment, and achieve significant cost savings (Moores, 2007). In order to provide early identification and treatment in the home, a well-developed clinical pathway needs to be followed that is based on professional guidelines. The purpose of this DNP project is to develop and implement an evidence-based clinical pathway for the assessment and management of neutropenic fever in adult oncology patients enrolled in the Huntsman at Home program at Huntsman Cancer Institute in Salt Lake City, Utah. Literature review A web-based internet search was performed using Medline and Pubmed databases for guidelines related to the care of adult oncology patients in the outpatient setting. Publications were limited to peer-reviewed articles published within the past 15 years. Search terms included neutropenia, fever, febrile neutropenia, neutropenic fever, outpatient care, ambulatory care, home care, hospice, cancer, oncology, symptom management, infection, and nurse practitioners. A ONCOLOGICAL NEUTROPENIC FEVER 6 more detailed discussion of cancer, neutropenia, and care provided in the home setting is provided below. Cancer. The development and progression of cancer is a result of accumulated genomic alterations in cells within the human body. The accumulative effect of genetic alterations leads to cellular adaptations such as increased cell proliferation, enhanced creation of blood vessels, and altered response to anti-cancer medications (Cheng et al., 2015). Treatment for cancer is complex and can include a combination of measures including chemotherapy administration, radiation therapy, and surgery. Treatment often requires hospitalization for effective patient management and monitoring (Abrahm, 2014). Organizations specializing in the care of oncology patients are faced with the challenge of supporting an increasing number of patients who are both undergoing treatment and who have survived cancer. These patients need complex therapeutic interventions, extensive follow-up, and long-term care. There exists a growing need to provide more flexible models of cancer care management that include ongoing patient monitoring, education, and psychosocial support (Tralongo et al., 2011). Nearly $30 billion is spent on Medicare beneficiaries with cancer in their first year of diagnosis, with hospitalizations accounting for 25 to 50 percent of that spending and chemotherapy administration accounting for the rest (Handley & Bekelman, 2019). It is common for persons diagnosed with cancer to require hospitalization. Nearly three-quarters of patients newly diagnosed with cancer are hospitalized within the first year and one in six patients have three or more hospitalizations within the first year (Handley & Bekelman, 2019). Hospitalizations can be planned, such as for the administration of chemotherapy, or unplanned, such as for the treatment of pain or nausea. Hospitalization may occur for extended ONCOLOGICAL NEUTROPENIC FEVER 7 periods of time and expose the patient to life-threatening hospital-acquired infections and other complications while acquiring high financial costs of care. It is thought that much of the care, such as administering chemotherapy, provided in both planned and unplanned hospitalizations is appropriate to be provided in the home or outpatient setting and could result in high quality of care, improved levels of patient satisfaction, and lower costs than traditional care provided in the inpatient setting (Handley & Bekelman, 2019). The term chemotherapy refers to a wide range of complex drugs used to treat cancer by killing cells that divide rapidly. Because cancer cells have lost many of the regulatory functions that are present in normal cells, they attempt to divide when other cells do not. This trait makes cancer cells susceptible to a wide range of cellular toxins such as chemotherapy and other anti-neoplastic agents that cause cellular death in a variety of ways. Normal cells are more resistant to chemotherapy drugs because they often stop dividing under unfavorable conditions. Cell types that normally divide rapidly, such as those in the bone marrow and in the lining of the intestine, are more susceptible to the toxic effects of chemotherapy and the death of these normal cells leads to the common side-effects of chemotherapy (CancerQuest, 2020). Cytotoxic chemotherapy used to treat cancer results in a predictable suppression of the hematopoietic system and impairs innate host protective mechanisms of immunity (Crawford, Dale, & Lyman 2004). Neutropenia is caused by lowering levels of certain types of white blood cells, called neutrophils (Tallent, 2013). As a result, chemotherapy predisposes patients with cancer to infections both by suppressing the production of neutrophils and by cytotoxic effects on the cells that line the alimentary tract, thereby increasing susceptibility to infection by allowing entry of microorganisms into the body (Taplitz et al., 2018). ONCOLOGICAL NEUTROPENIC FEVER 8 Neutropenia. Neutrophils are a subcategory of white blood cells and are the first cellular components of the inflammatory response. They play a critical role in the initial line of defense against bacterial and fungal infections (Taplitz et al., 2018). Neutropenia, or a decrease in the absolute neutrophil count (ANC), occurs in patients undergoing chemotherapy (Taplitz et al., 2018). Neutropenia can result from either reduced production of or increased peripheral destruction of white blood cells (de Lalla, 2003) and neutropenia can be caused by cancer itself or by the types of chemotherapy drugs that kill cancer cells and some blood-forming cells (Tallent, 2013). With oncology patients, severe neutropenia is commonly related to cytotoxic anticancer agents suppressing bone marrow production of blood components (de Lalla, 2003). As the duration of a neutropenic episode continues or the severity of a neutropenic episode increases, the risk for infection increases. The greatest risk for infection is posed to patients with profound, prolonged neutropenia following chemotherapy administration (Taplitz et al., 2018). Absolute Neutrophil Count. Diagnosis of neutropenia is made via a complete blood count (CBC) that measures the different types and amounts of white blood cells (WBC). The ANC reflects the number of segmented and band neutrophils readily available to fight infection (VanLeeuwen & Bladh, 2017). CBC blood tests are drawn twice weekly when receiving myelosuppressive therapy or if fever arises during the course of anti-neoplastic treatment to assess for treatment-induced neutropenia and associated risk for infection (Heinz et al., 2017). There is no clear cut-off value for the neutrophil count that divides patients with an increased risk of infection and mortality from those that do not (Heinz, 2017). The Common Toxicity Criteria of the National Cancer Institute is the scale most often used for grading the severity of neutropenia associated with chemotherapy for the treatment of cancer (Crawford, Dale, & Lyman, 2004). Neutropenia is typically defined as an ANC of less than 1500 cells per ONCOLOGICAL NEUTROPENIC FEVER 9 microliter. Mild neutropenia is defined as an ANC between 1000-1500 cells per microliter. Moderate neutropenia is defined as an ANC between 500 and 1000 cells per microliter and severe neutropenia is defined as an ANC less than 500 cells per microliter (White & Ybarra, 2017). Prophylactic administration of antibiotics and antifungal medications is initiated when the ANC is < 100/ul for >7 days (Flowers et al., 2013). Clinicians should also be aware that severely or profoundly neutropenic patients may present as either afebrile or hypothermic (Taplitz et al., 2018). Thursky and Worth (2015) reported that patients receiving chemotherapy for solid tumors generally have rates of neutropenia from 5% to 10% and those with hematological malignancies have rates of neutropenia of 20%. They also stated bone marrow transplant recipients have rates of neutropenia from 70% to 100 % (Thursky & Worth, 2015). Oncology patients with neutropenia are 50 times more likely to develop an infection compared with those who have normal blood assays (Tallent, 2013). It is estimated that approximately 50% of patients with neutropenic fever will develop sepsis syndrome, with 20% -30% of those developing severe sepsis and 5% - 10% developing septic shock (Thursky & Worth, 2015). Patients who have received chemotherapy within six weeks of the presence of fever are at the highest risk for having developed neutropenia (Long & Koyfman, 2019). Fever. In a neutropenic state, a temperature >100.4 can often be an important indicator of illness and is often the only sign or symptom of infection (Taplitz et al., 2018). Neutropenic fever is defined as an oral temperature of > 38.3 degrees centigrade or temperature > 38.0 degrees centigrade for one hour with an ANC < 1000 cells/microL (Long & Koyfman, 2019). Febrile neutropenia occurs frequently during chemotherapy administration. A retrospective cohort study conducted by Rapoport et al. (2018) reported febrile neutropenia ONCOLOGICAL NEUTROPENIC FEVER 10 occurred in 13% to 21% of patients receiving common myelosuppressive chemotherapy regimens for metastatic solid tumors. They also reported that 23% to 36% of febrile neutropenic episodes occur during the first cycle of chemotherapy administration (Rapoport et al., 2018). Febrile neutropenic patients present with variable risks for serious medical complications associated with systemic infections such as hypotension, acute renal disease, respiratory compromise, or heart failure. In the presence of neutropenic fever, the risk of complications is as high as 30% and the risk of mortality is as high as 11%. In the incidence of severe sepsis or septic shock, mortality can be as high as 50% (Taplitz et al., 2018). Febrile neutropenia is considered a medical emergency and requires urgent evaluation, timely administration of broad-spectrum antibiotics, and careful monitoring to optimize patient outcomes while minimizing the risk of complications. Fever accompanied by neutropenia can impact treatment efficacy and overall prognosis (Braga et al., 2020). Prevention and early identification and management of neutropenic fevers is critical because febrile illness in neutropenic patients can be a life-threatening complication of anticancer chemotherapy (de Lalla, 2003). The initial evaluation should be performed as expeditiously and thoroughly as possible, assessing for frequent sources of infection such as the oropharynx, lung, paranasal sinuses, perineum, and vascular catheter insertion sites. Prior to initiating antibiotic therapy, at least two sets of cultures should be obtained from blood and other appropriate sites, such as the throat, urine, and stool, to assess for the presence of bacterial and fungal organisms. Chest radiography is also performed to assess for pulmonary involvement. If the patient has a central venous catheter, simultaneous cultures should be obtained from the catheter as well as a peripheral site, and cultures should be obtained daily until the fever resolves (Sharma & Lokeshwar, 2005). ONCOLOGICAL NEUTROPENIC FEVER 11 A survey of 49 hospitals from 1995 to 2000 revealed gram-positive organisms accounted for 62% to 76% of all bloodstream infections compared to only 14% to 22% caused by gram-negative organisms (White & Ybarra, 2017). The proportion of infections in oncology patients caused by gram-positive organisms have been reportedly as high as 75% to 80% in some cancer centers (Rolston, 2014). Bloodstream infections are most commonly caused by gram-positive organisms such as coagulase-negative Staphylococcus, Staphylococcus aureus, Enterococcus, Streptococcus pneumonia, and Streptococcus pyogenes (White & Ybarra, 2017). Current empiric antibiotic regimens primarily target gram-negative pathogens that carry a high risk for morbidity and mortality (Braga et al., 2020). The management of febrile neutropenia in oncology patients shifted in the early 1970s based on evidence that empiric antibacterial therapy reduced deaths resulting from infection, compared with waiting for the results of microbiological assays (Flowers et al., 2013). Risk assessment. Historically, monitoring of all febrile patients with neutropenia in the hospital was considered an essential component of safe patient management. This led providers in the past to assume febrile neutropenic patients constituted a “homogeneous group” with a similar risk for serious complications and death. As a result, the standard therapeutic strategy for all febrile patients with neutropenia was the widely observed practice of in-hospital administration of intravenous broad-spectrum antibiotics until the fever and neutropenia resolved. Recently, providers have begun to understand that febrile neutropenic patients comprise a “heterogeneous population” with variable risks for serious medical complications and need for hospitalization. For low-risk patients in whom the risk for mortality is minimal, newer therapeutic approaches aim to shorten or eliminate the need for hospitalization and the standard ONCOLOGICAL NEUTROPENIC FEVER 12 of care is being safely shifted from hospital-based to outpatient or home-based treatment for the duration of the febrile period (de Lalla, 2003). When evaluating patients with febrile neutropenia, clinicians must differentiate between patients who can be safely treated and monitored in the home setting as opposed to those who require inpatient hospitalization (Brage et al., 2020). Assessment for the risk of febrile neutropenia should be carried out based on patient characteristics, underlying malignancy, and treatment-related criterion with prophylactic antimicrobial selection, timing, and duration administered accordingly (Braga et al., 2020). The patient history and physical examination should focus on common sites of infection such as the gastrointestinal tract, blood, skin, lung, and urinary (Long & Koyfman, 2019). Risk assessment tools have been developed to identify cancer patients who present with mild neutropenia as “low-risk neutropenic patients” who can be safely and effectively treated in the outpatient setting (de Lalla, 2003). The American Society of Clinical Oncology (ASCO) published clinical practice guidelines for the effective triage, risk stratification, and standardized management of this vulnerable patient population in an outpatient setting (Taplitz et al. 2018). As of yet, there are no diagnostic or grading criteria that can precisely distinguish between neutropenic patients with fever who are uninfected and neutropenic patients with fever who have bacteremia. As a result, current guidelines indicate that treatment is prudent in all cases (Braga et al., 2020). Risk stratification scores can assist in identifying patients who may be appropriate to receive outpatient treatment. Two validated risk tools that are currently employed are the Multinational Association for Supportive Care in Cancer (MASCC) and the Clinical Index of Stable Febrile Neutropenia (CISNE) Coyne et al., 2016). The most widely accepted risk index ONCOLOGICAL NEUTROPENIC FEVER 13 tool is the Multinational Association for Supportive Care in Cancer (MASCC). It identifies “low-risk” patients appropriate for antibiotic trials with a positive predictive value of 91% (Rolston, 2014). Home setting. It has been proposed, that much of the hospital care provided to cancer patients can, and should, take place in the home setting. In the United States, Johns Hopkins has administered an Oncology Hospital at Home program for more than 20 years. The program has shortened the length of hospital stays by one third and lowered costs relative to usual care by more than 30% while sustaining improved patient satisfaction with overall care (Handley & Bekelman, 2019). Hospital-level care provided at home can reduce costs and improve patient engagement without detrimental changes to the level of quality, safety, or patient satisfaction (Handley & Bekelman, 2019). Cancer patients typically have scheduled clinic visits with their primary oncologist to address symptom management, but acute chemotherapy-related symptoms often manifest at home during the interim period between clinic visits (Mooney et al., 2017). Patients and family members are instructed to notify their providers between visits with concerns or changes in condition, but they rarely do, leaving patients to cope with symptoms alone at home (Mooney et al., 2019). Waiting to address patient-reported symptoms at clinic visits miss peak periods of distressing symptoms. Poorly controlled symptoms that occur at home, especially those associated with neutropenia, can lead to unplanned clinic appointments or emergency department visits and unplanned hospitalizations (Mooney et al., 2017). Nurse practitioners who assess and treat patients in the home setting can address this gap in tracking changes and responding to patient-reported symptoms and can independently address unmet needs for symptom management as they arise outside clinic visits. Nurse practitioners can ONCOLOGICAL NEUTROPENIC FEVER 14 screen for multiple cancer-related symptoms and patient-reported behaviors and provide onsite assessment and treatment of poorly controlled symptoms, tailor self-management plans, and alert the primary oncology team to changes in the patient condition (Mooney et al., 2019). Nurse practitioners, working in the home setting, can provide critical assessment and monitoring of patients at risk for developing neutropenia and function to interpret lab values, apply research evidence, manage complex therapies, and generally improve care and system access for patients with cancer (Wall & Rawson, 2016). Nurse practitioners can provide medical oversight for patients in the home setting by performing physical assessments, medication management, IV fluid and emergency medication administration, teaching, and providing emotional support. In addition, nurse practitioners can order labs and imaging, prescribe medications, and oversee treatment plans to manage a variety of symptoms associated with chemotherapy or disease progression such as pain, constipation, diarrhea, nausea, vomiting, fatigue, weakness, anxiety, edema, anorexia, and weight loss. Nurse practitioners can assess and manage symptoms via visits performed in the home or via telehealth or telephone to keep apprised of patients’ rapidly changing status and provide prompt interventions to reduce the number of emergency room visits and subsequent hospital admissions (Mooney, Whisenant, & Beck, 2019). With the broad scope of clinical skills nurse practitioners possess, they are positioned to provide assessment, monitoring, and treatment for neutropenia for low-risk patients according to evidence-based protocols (Beck, 2017). Transition to DNP Project The methods for treating and diagnosing neutropenic fevers in oncology patients in the outpatient setting at Huntsman Cancer Institute was not previously defined with a systematic, evidence-based method of clinical management. This resulted in variations in classifying patients ONCOLOGICAL NEUTROPENIC FEVER 15 in the outpatient setting as low-, moderate-, or high-risk for complications and resulted in disparities in the methodology for assessment and management of neutropenic fevers in cancer patients in the community setting. In order to standardize the care delivered by Huntsman at Home nurse practitioners to cancer patients suffering from neutropenic fever, a clinical pathway was needed that outlined the assessment and management of patients in the home setting. A pathway would establish a communication channel between the patient’s primary oncologist and the nurse practitioner in the home so that professional collaboration was established early to achieve the highest quality, most cost-effective, and timely treatment possible. Theoretical Framework The theory used to guide this project was the Advanced Research and Clinical Practice Through Close Collaboration Model (ARCC). This model focuses on the implementation of evidence-based practice (EBP). The ARCC model aims to provide hospitals and health care organizations with a structured conceptual framework for system-wide implementation and sustainability of EBP with the goal of improving care quality and patient outcomes. This model has historically been used to achieve a “high reliability” organization or a system that consistently delivers safe, high-quality care. This model also proposes that wide-spread implementation of EBP results in decreased costs, improved patient outcomes, higher job satisfaction of health care professionals, and lower turnover rates (Melnyk et al., 2011). The first step in the ARCC model is to assess the organization’s culture and readiness to accept the change of EBP. The assessment identifies strengths and limitations within the organization that foster or hinder the implementation of EBP. In addition, a key strategy for implementing the ARCC model is the development of a team of EBP mentors with expertise in influencing individual ONCOLOGICAL NEUTROPENIC FEVER 16 behavior change and with skills and in-depth knowledge of EBP. This team of experts is typically comprised of advanced practice nurses or veteran clinicians experienced with EBP (Melnyk et al., 2011). These individuals focus on training point-of-care clinicians to use and sustain EBP and serve as EBP experts to lead projects that facilitate EBP implementation, quality improvement, and outcomes management. When clinicians work with EBP mentors, their beliefs about the value of EBP and their ability to implement it increases. This leads to greater achievement of evidence-based care (Melnyk et al., 2011). Regarding this DNP project, an assessment of the organization’s readiness to accept EBP was not necessary. Because the clinical pathway for the treatment of neutropenic fever in oncology patients was requested by the Huntsman at Home medical director and heavily anticipated by the team of Huntsman at Home nurse practitioners, the need to assess readiness for EBP was not warranted. Assembling a team of expert clinicians to serve as EBP mentors was important in order to influence the behavior of individual clinicians. Huntsman at Home’s medical director and two lead nurse practitioners exhibited skills and knowledge of EBP. These clinicians were able to influence the initiation and education of the neutropenic fever clinical pathway in the Huntsman at Home program by championing the implementation of EBP with the team of nurse practitioners. They led the team in utilizing the pathway’s written guideline and decision tree to implement the “Acute Watch” program and improve the quality of care delivered in the home of oncological patients with acute illness and positively influence patient outcomes. The implementation of EBP at the organization was fostered by the leadership offered by the medical director and lead nurse practitioners. In addition, the team of seven nurse practitioners at Huntsman at Home consisted of three nurse practitioners prepared to the educational level of a ONCOLOGICAL NEUTROPENIC FEVER 17 Doctor of Nursing Practice (DNP). The DNPs on the team fostered the implementation of EBP and the continued use of the “Acute Watch” program to treat acutely ill patients in the home. The implementation of EBP at the organization was anticipated to be hindered by the sense of autonomy felt by physicians, oncologists, physician assistants, and nurse practitioners who, historically, were used to independently making treatment decisions for patient care. The lack of a previous institutional guideline for the treatment of neutropenic fevers in the outpatient setting was feared to hinder the implementation of the newly developed clinical pathway out of concern that some providers would not be aware of the formation of the clinical pathway and its suggested treatment guidelines. Clinical Problem The overall goal of this project was to increase the number of Huntsman at Home oncology patients treated for neutropenic fever in the home setting and guide the clinical management of these patients offered by the program’s team of nurse practitioners. This was accomplished via a four-fold approach. First, the DNP project implemented the MASCC risk-stratification tool that identified cancer patients at low risk for complications associated with receiving neutropenic care at home. This step standardized the assessment of Huntsman at Home patients who presented with fever of unknown origin. Second, this DNP project developed an evidence-based pathway in caring for neutropenic patients in the home which included completing a physical examination and laboratory assessment, referring to a higher level of care when necessary, administering medications, and monitoring patient response. This clinical pathway guided the delivery of care dictated by nurse practitioners and standardized the care delivered in the home. The development of the clinical pathway adapted ASCO guidelines for the outpatient setting to the home environment. In addition, the development of the clinical ONCOLOGICAL NEUTROPENIC FEVER 18 pathway took into consideration input from infectious disease experts at Huntsman Cancer Institue to ensure the care of the neutropenic patient in the home setting was directed in tandem with the care directed by primary oncologists in the hospital setting. Third, this DNP project refined the role of the nurse practitioner in caring for neutropenic fever in the home. The clinical pathway allowed nurse practitioners to care for low-risk patients in their home and improved the quality, safety, and cost-effectiveness of patient care delivered in treating neutropenic fevers in oncology patients. Fourth, this DNP project provided education to Huntsman Cancer Institute providers including oncologists, nurse practitioners, , and nursing staff with Community Nursing Services (CNS). The education provided outlined the details of the clinical pathway in determining a patient’s appropriateness for home assessement, treatment, and monitoring. The timeline for completing this DNP project is provided below (see Appendix A). Population. The population for this DNP project included oncology patients treated at the Huntsman Cancer Institute referred to the Huntsman at Home program by their primary oncologist. The program had been in existence for approximatley18 months before implementing this DNP project and served over 400 patients in that time. The patient population encompassed a variety of ethnic, socioeconomic, and cultural backgrounds and included both insured and uninsured individuals (Taplitz et al., 2018). Patients on Huntsman at Home service underwent a variety of antineoplastic treatment regimens depending upon their type of cancer, type of antineoplastic drug administered, state of disease progression, history of previously successful or failed chemotherapy regimens, tolerance of antineoplastic therapy, and overall state of health or deconditioning. Treatment regimens included oral chemotherapy or immune-modulating agents, intravenous antineoplastic medications, surgery, or radiation therapy. Some ONCOLOGICAL NEUTROPENIC FEVER 19 patients required 5 to 7-day hospital stays for administration of chemotherapy regimens while others qualified for outpatient clinic or home administration of anti-neoplastic agents. Setting. Huntsman at Home service is offered to cancer patients in the geographical region of Salt Lake City, Utah, a large urban area with a population of 200, 591 residents (United States Census Bureau, 2019. Huntsman at Home was founded as a home-based, inter-disciplinary palliative care program staffed by nurse practitioners employed by the Huntsman Cancer Institute, a regional cancer research and treatment hospital located in Salt Lake City, Utah. Huntsman at Home originally serviced only patients within a 20-mile radius of the Huntsman Cancer Institute. The service area has since been expanded to a 25-mile radius from the institution. Clinical need. Before this DNP project, the Huntsman Cancer Institute treated neutropenic fevers with the administration of intravenous antibiotics during an extended hospital stay according to professional guidelines developed by the Americian Society of Clinical Oncology (ASCO) that detailed management of neutropenic patients in the hospital setting (Taplitz et al., 2018). Due to the lack of standardization in home-based care of Huntsman Cancer Institute patients who present with fever of unknown origian, a systematic method for assessing and treating patients needed to be developed. Anticipated Barriers. It was expected that resistance to creating a neutropenic fever guideline for outpatient oncology patients would be minimal due to the fact that formation of the guideline was requested and received strong support from Dr. Anna Beck, the Director of Supportive Oncology and Palliative Care. With that being said, there existed the potential for personal and organizational factors to be a deterrent to obtaining approval from a large number of oncologists on one clinical pathway. In addition, oncologists were feared to have had a ONCOLOGICAL NEUTROPENIC FEVER 20 previously unfavorable experience with initiation of a care pathway that would have increased their resistance to the one presented. It was also unclear if members of the organization possessed adequate adaptive capacity to readily accept the proposed changes presented in the clinical pathway. One anticipated barrier from oncologists, nurse practitioners, and physician assistants was that of “ignorance,” or the claim that the change to following a care pathway came on suddenly and without warning. Another anticipated possible barrier was “arrogance” or the claim that they had effectively handled their patients in the past without a guideline, so the creation of one now was unnecessary. A third anticipated barrier was the mindset of “victimization” or the claim that the creation of a clinical pathway was a personal disruption of their decision-making autonomy (Finkelman, 2018). Projected operational barriers to the project included inadequate leadership and inadequate planning. Budgetary issues were thought to be an issue as well with education and feedback provided during provider staff operational meetings. Ethical issues with the project included the fact that cancer patients are a vulnerable population with a higher risk for mortality, morbidity, and psychological burden of care. To ease the transition of providers to the adoption of a clinical pathway, it was important to demonstrate the evidence-based nature of the information guiding the assessment and treatment of neutropenic fevers in the home setting. It was imperative that the preceptor project lead be included early in the process of creating the neutropenic fever clinical pathway and kept abreast of the project development so that adequate medical oncology support was fostered and maintained. An additional barrier to the DNP project included a shortage of evidence-based practice guiding the care of neutropenic fevers in the outpatient or community setting. Most of the ONCOLOGICAL NEUTROPENIC FEVER 21 published evidence is related to the hospital, emergency department, or ambulatory care settings. An additional barrier was the lack of an established clinical pathway for the Huntsman at Home program. This DNP project created the first home-based clinical pathway for the Huntsman at Home program and proved to remove barriers between differing organizational medical teams as collaboration was sought to standardize the care of neutropenic fever in the home. Resources. Resources for the DNP project included a medical library at the Huntsman Cancer Institute that aided in providing access to scholarly publications and evidence-based recommendations for the care of oncology patients. Additional resources included a high level of physician support from the Huntsman at Home medical director who facilitated this DNP project. The estimated financial cost to the organization for creating and implementing the clinical pathway was difficult to quantify. Creating the guideline required time from the Palliative Care medical director to plan and approve project details and to meet with ancillary medical team members to facilitate implementation of the clinical pathway. Educating Huntsman at Home nurse practitioners regarding the use of the clinical pathway required approximately 30 minutes of the staff’s productive time during an organized operational meeting. Additional time was also required to educate registered nurses and nurse managers of the specifics of the outpatient neutropenic clinical pathway and the care that should be delivered in the outpatient setting. Project Plan Patients can be treated in an outpatient setting for the entire febrile episode with the administration of parenteral or oral antibiotics (de Lalla, 2003). Once outpatient therapy is deemed appropriate, it becomes important to consider methods of medication administration such as intravenous administration of antibiotics at home via home nursing, administration of ONCOLOGICAL NEUTROPENIC FEVER 22 intravenous medications at infusion centers, or self-administration of medications at home by patients or caregivers (de Lalla, 2003). Exploration of possible solutions to this clinical problem included increasing provider awareness of treating low risk neutropenic patients in the home setting rather than admitting patients to the hospital (Goodman et al., 2017). The Multinational Association for Supportive Care in Cancer (MASCC) published a risk-stratification tool that proved to be useful in identifying patients at low risk of complications and deemed safe to be managed in the outpatient setting (Coyne et al. 2016). Provider education was offered regarding the use of this clinical algorithm in identifying low-risk patients that could be safely managed in the home setting with broad-spectrum parenteral and oral antibiotics and close clinical follow-up (de Lalla, 2003). Risk assessment. An expected outcome with implementation of this clinical pathway for the outpatient management of neutropenic fevers in oncology patients was utilization of the MASCC risk-stratification tool. Adoption of this evidence-based risk-stratification tool by providers at Huntsman Cancer Institute was hoped to foster reliable screening and identification of safety risks for neutropenic patients who present with fever in the outpatient setting. The MASCC risk-assessment tool is an evidence-based model for identifying patients with a statistically significant lower risk of serious complications and a higher rate of favorable outcomes and recovery from neutropenic fever (de Lalla, 2003). Managing low-risk neutropenic patients with fever in the home setting would improve patient outcomes by protecting patients from exposure to multidrug-resistant nosocomial infections and reduce the risk of further disease and unnecessary, costly hospital admissions (Coyne et al., 2017). An impetus for developing a clinical pathway for the home-based care of neutropenic fevers was the lack of a currently established professional clinical guideline. A standardized ONCOLOGICAL NEUTROPENIC FEVER 23 guideline for care founded on evidence-based principles was anticipated to reduce the occurrence of morbidity; such as hypotension, bacteremia, or septic shock, and the incidence of mortality associated with neutropenic fever, which is currently reported at a rate of 11% of patients (Taplitz et al., 2018). An established clinical pathway allowed safe assessment and management of low-risk neutropenic patients in the home setting. This reduced the high cost of hospitalization and shielded patients from the risk of acquiring nosocomial infections from drug-resistant organisms. Provider education. Educating providers regarding appropriate selection of patients for outpatient management of neutropenic fever was imperative for improving patient safety (de Lalla, 2003). Patient selection criteria for outpatient management needed to include not only the patient’s medical condition but also their social situation, such as sufficient education to allow full adherence to the medication regimen and an understanding of risks and responsibilities inherent to the condition. Selection criteria also considered living conditions such as travel time to the hospital and easy access to transportation should a return trip to the hospital be necessary. Other considerations included insurance coverage for outpatient therapy and required financial co-pays, availability of caregivers to assist with patient monitoring and medication administration, as well as the patient’s level of comfort and assumed caregiver burden with treating the patient in the home setting (de Lalla, 2003). Another expected outcome resulting from implementation of this clinical pathway was decreased cost of care. Because inpatient treatment requires the use of parenteral, empiric, broad-spectrum antibacterial therapy, switching to early hospital discharge or caring for the patient for the entire febrile period in a the home setting with parenteral or oral antibiotics could result in considerable cost containment (de Lalla, 2003). Although more difficult to quantify, it ONCOLOGICAL NEUTROPENIC FEVER 24 was presumed that significant cost savings could still be achieved even if the patient was initially treated in the outpatient setting and then later hospitalized (de Lalla, 2003). Planning. The project began with performance of a literature review regarding the assessment and treatment of neutropenic fevers until content saturation of scholarly recourses was obtained. Based on the information gathered, a clinical pathway regarding the care of fever in the unknown presence of neutropenia was drafted. Drafting the clinical pathway included both a written guideline (see Appendix B) and a decision tree flowchart (see Appendix C). The clinical pathway included steps to assess the febrile patient including the calculation of a MASCC risk index score to identify individuals who could be safely treated in the outpatient setting as well as outlined the acquisition of laboratory tests and portable chest radiography in the home. The clinical pathway also directed the administration of prophylactic antibiotics. Care for the febrile patient was planned as a joint effort between the nurse practitioner and home health registered nurse and included monitoring the patient hourly for a period of four hours. Once antibiotics were administered and the patient was assessed to be clinically stable, based on vital signs and mental and physiological presentation, the patient was to be placed on an “Acute Watch” and seen daily for the next 7 days via a nurse practitioner or registered nurse. The clinical pathway also outlined that the nurse practitioner would communicate closely with the primary oncologist via emails and phone calls to provide updates on the patients’ status and collaborate on the patient’s treatment plan. Once the pathway was drafted, it was presented for review to Dr. Anna Beck, the Huntsman at Home Palliative Care Medical Director, and Shannon Devlin, on oncology resident working with Dr. Beck. Dr. Beck and Shannon Devlin reviewed the document and provided suggested feedback and changes. When the clinical pathway was approved by Dr. Beck, the ONCOLOGICAL NEUTROPENIC FEVER 25 pathway was presented to the Infectious Disease team at Huntsman Cancer Institute for suggested changes and approval. After approval by the Infectious Disease team was obtained, the clinical pathway was presented at a monthly operation meeting to the Huntsman at Home nurse practitioners to educate the providers of the clinical pathway and to begin the 60-day pilot. An educational PowerPoint was presented during the meeting and staff members were allowed to ask questions following the presentation (see Appendix D). Due to the COVID-19 global pandemic, collaboration meetings with the Infectious Disease Team and presentation of the clinical pathway to the Huntsman at Home nurse practitioners occurred via Zoom video communication. Implementation To implement the clinical pathway, the nurse practitioners were first educated on the assessment and treatment of patients outlined by the neutropenic fever clinical pathway. A pilot was then initiated for 60 days to assess for clinical relevance and patient safety. Education was also provided to the CNS team of registered nurses and administrators that carried out daily in-home patient care as directed by the Huntsman at Home team of nurse practitioners. Printed copies of the clinical guideline and MASCC risk-assessment tool (see Appendix E) and ANC calculator (see Appendix F) were given to the nurse practitioners and CNS RNs for ease of reference in clinical assessment and decision making. One aspect of the neutropenic fever clinical pathway that was widely implemented was execution of a five-day “Acute Watch” for high-acuity patients. The “Acute Watch” was adopted early in the daily processes of the Huntsman at Home team of nurse practitioners as a way of closely monitoring any patient with symptoms of acute illness. A category for “Acute Watch” patients was created in the medical record so that patients needing this level of ONCOLOGICAL NEUTROPENIC FEVER 26 observation were easily identified. In addition, the morning report between NPs and RNs was re-organized to prioritize discussion of “Acute Watch” patients as the first item of the day so that all team members were aware of the patient’s status and medical plan. These patients received daily in-home visits from a registered nurse or nurse practitioner and any change in patient condition was communicated quickly to the patient’s primary oncologist so that collaboration was achieved early regarding the patient’s status and necessary medical treatment. During the 60-day pilot, approximately 92 patients were on service with the Huntsman at Home program and a total of five patients were placed on an “Acute Watch,” which included patients with intractable nausea and vomiting, diarrhea, dehydration, anorexia, sudden weight loss, and electrolyte-imbalances. Four of the five patients were successfully managed at home, with one patient needing hospitalization for acute anemia and blood transfusions related to oncological disease progression. Prior to implementation of the neutropenic fever clinical pathway, fever of unknown origin was a frequently occurring diagnosis among the population of Huntsman at Home patients. Beginning in early March 2020, the COVID-19 pandemic began to infest the Salt Lake City area and the governor of Utah ordered residents to stay home in an effort to slow the spread of disease. Local businesses began to close their doors and opportunities for social gathering began to dwindle. In addition, face coverings became required during all in-person interactions along with frequent hand washing. As a result, the vulnerable population of Huntsman at Home oncology patients began limiting outings and reducing visitors in their home. These actions resulted in significantly reduced exposure of oncology patients to risks of infection and the diagnosis of fever of unknown origin became rare in occurrence. During the trial period, two patients were diagnosed with fever of unknown origin and the clinical pathway was referenced to ONCOLOGICAL NEUTROPENIC FEVER 27 determine next steps, however, both patients met the clinical pathway’s exclusion criteria and were triaged to the emergency room rather than monitored at home. Unfortunately, the 60-day trial period ended without the clinical pathway being fully implemented on a Huntsman at Home patient. Following the 60-day trial from December 3, 2020, to February 3, 2021, the nurse practitioners were surveyed to obtain feedback and assess for suggested changes to improve the implementation and clinical usefulness of the pathway (see Appendix G). Once revised, the clinical pathway for the outpatient management of neutropenic fever was placed in the electronic document center for future reference by other clinicians. Dr. Beck will present the clinical pathway to fellow oncologists at Huntsman Cancer Institute at a future meeting so that referring providers are aware of the option for managing neutropenic fever of low-risk patients in the home setting. The MASCC risk-assessment tool is part of the organization’s electronic health record and can be easily incorporated into the patient’s medical record. Evaluation and Data Analysis A chart review of patients on service with Huntsman at Home during the 60-day pilot period was performed to assess for a chief complaint of “fever” to capture patients on whom the clinical pathway would have been implemented. Data regarding patients placed on “Acute Watch” for the management of acute problematic symptoms was also obtained using chart reviews of the patient’s medical record. To evaluate the clinical usefulness of the clinical pathway in assessing, treating, and evaluating patients with neutropenic fever in the home environment, a 5-question survey was presented to seven NPs and five RNs (see Appendix G). Nurses were asked to rate the clinical ONCOLOGICAL NEUTROPENIC FEVER 28 usefulness of the neutropenic fever clinical pathway on a 5- point Likert scale, with answers ranging from strongly disagree to strongly agree. Results During the 60-day clinical trial, Huntsman at Home had approximately 92 patients on service. Unfortunately, no patients on Huntsman at Home service presented with fever that met inclusion criteria for following the clinical pathway. One patient presented with fever and neutropenia but presented with the excluding diagnosis of lymphoma and had to be triaged to the emergency department and was later hospitalized. Another patient met the inclusion criteria but decided to seek care at the emergency department before being admitted to Huntsman at Home service. Of the 92 patients on service, five patients were placed on “Acute Watch” to manage distressing symptoms that put them at risk for an emergency room visit or hospitalization. A chart review of the five patients placed on “Acute Watch” looked at the incidence of hospital readmissions. The “Acute Watch” program was attributed to reducing hospitalizations in 4 out of 5 patients, for an 80% success rate. This exceeded the expectation of a 75% success rate in reducing hospitalizations. This data is presented in Table 1 below. Table 1 Patient numbers “Acute watch” number of days* Hospital admission avoided #1 5 yes #2 5 yes #3 1 no #4 5 yes #5 5 yes *“Acute Watch” implemented with a goal of an NP or RN visit in the home for daily visits for 5 consecutive days Following the 60-day pilot period, the clinical pathway was evaluated by seven NPs and five RNs using a written survey. Nurse Practitioners and RNs rated the clinical pathway with 112 out of 120 possible points using a five-point Likert scale survey for a 93% favorable rating. ONCOLOGICAL NEUTROPENIC FEVER 29 The clinical pathway exceeded the expectation of an 80% favorable rating, which was the initial goal identified at the beginning of the DNP project. This information is presented in Table 2 below. Table 2 Strongly Disagree Disagree Neutral Agree Strongly Agree The neutropenic fever clinical pathway is clinically useful in the home-based treatment management of patients. 1 1 10 The neutropenic fever clinical pathway is clear in defining next steps for the NPs and RNs in assessment, management, and follow-up of patients with fever of unknown origin. 1 11 The neutropenic fever clinical pathway is clinically useful in reducing hospitalizations. 1 11 The “Acute Watch” program is instrumental in increasing patient safety. 1 11 The “Acute Watch” program is effective in reducing hospitalizations. 2 10 Discussion The goal of this DNP project was to standardize the care delivered by Huntsman at Home NPs to cancer patients suffering from neutropenic fever by developing a clinical pathway that outlined the assessment and management of patients in the home setting. This goal was achieved by creating a written clinical pathway and decision tree to guide clinical decisions and team collaboration. A secondary goal of this DNP project was to establish a DNP leadership role within the organization by identifying a gap in home-based patient care and leading out an evidence-based solution to the problem. The development of a clinical pathway outlining the care of patients with neutropenic fever in the home environment was challenging because the majority of currently published scholarly research details the hospital-based management of patients. ASCO recently published guidelines pertaining to the initial outpatient management of patients with neutropenic fever in ONCOLOGICAL NEUTROPENIC FEVER 30 the ambulatory clinic and emergency room settings, but those guidelines did not include the management of patients in the home environment. Oncologists and NPs at the Huntsman Cancer Institute were widely supportive of this DNP project and the development of a home-based clinical pathway to manage neutropenic fever. Dr. Anna C. Beck, the Director of Supportive and Palliative Care, served as the preceptor consultant for this DNP project as well as Shannon Devlin, an oncology fellow. A 2-member team of infectious disease experts from the organization also collaborated on the development of the clinical pathway to provide insight regarding safe and effective patient management and evidence-based antimicrobial selection and administration. A limitation to the implementation of this clinical guideline is that during the 60-day trial period, no patients enrolled in the Huntsman at Home program presented with neutropenic fever on which the guideline could be utilized. During the 60-day trial, one neutropenic patient was seen in the home and assessed to have fever >100.4, however, the patient was excluded from implementation of the guideline due to a diagnosis of lymphoma. This patient was sent to the emergency department and later hospitalized. One aspect of the clinical pathway that was put into clinical practice was the “Acute Watch” program. The clinical pathway outlined a seven-day RN and NP Acute Watch for patients with neutropenic fever. This aspect of the program was modified to a five-day Acute Watch for any acutely ill patient on the Huntsman at Home program. The five-day Acute Watch continued to be implemented beyond the 60-day trial period and proved to have a significant impact on stabilizing patients in the home and reducing the rate of hospitalizations. During the five-day Acute Watch, patients received frequent laboratory assessment, intravenous fluid resuscitation, and intravenous medications of antibiotics, anti-emetics, and electrolyte ONCOLOGICAL NEUTROPENIC FEVER 31 replacement therapy. Due to the high acuity of patients placed on the five-day Acute Watch, Huntsman at Home NPs and primary oncologists collaborated almost daily via email and telephone communications. This increased level of communication during the five-day acute watch resulted in a high level of satisfaction from medical providers and patients as a hospital-level of care was provided in the home setting at reduced cost and inconvenience to the patients. This project was successful in adjusting ASCO guidelines for care of neutropenic fever in hospitalized patients to create a safe and evidence-based guideline that was led by a DNP-FNP nurse leader for home-based management of oncology patients that present with neutropenic fever. This project was also successful in establishing the DNP leadership role within the Huntsman at Home program. The leadership role not only included the development of the clinical pathway, but also encompassed educating team members, establishing team collaboration and communication, and outlining a five-day “Acute Watch” program that proved to be effective in treating patients at home with acute symptoms and preventing hospitalizations. Recommendations This project demonstrated that critically ill, but stable patients can be cared for safety and effectively in the home environment with the use of a clinical pathway. The Acute Watch outlined the home monitoring of patients who were at risk for complications and effectively reduced the risk for hospitalizations and the overall cost of providing care. Similarly, a clinical guideline can be created to care for patients with acute thoracic needs that are hospitalized for management of a chest tube. A newly developed ambulatory chest tube designed for outpatient management would easily be accommodated with a comparable clinical pathway and decision tree. ONCOLOGICAL NEUTROPENIC FEVER 32 Future recommendations would include engaging a longer clinical trial to vet the clinical pathway. Due to the fact that no patients were cared for within the clinical trial period, a retrospective evaluation of the clinical pathway is important to provide ongoing monitoring following implementation. It is recommended that a longer clinical trial period be allowed to facilitate implementation of the pathway in an actual clinical situation. Conclusions Oncology patients with neutropenic fever and low risk for complications can be effectively treated in the home setting with medical oversight provided by NPs. The Multinational Association of Supportive Care in Cancer (MASCC) can effectively identify patients at low risk for medical complications. Adaptation of the American Society of Clinical Oncology’s (ASCO) guidelines can be used to manage oncology patients safely and cost-effectively at home who develop neutropenic fever. The implementation of a five-day Acute Watch program with daily NP and RN visits in the home proved to be an effective method for reducing re-hospitalizations. DNP prepared NPs can be effective change agents in healthcare organizations and instrumental in implementing evidence-based solutions to fill the gaps in clinical care. ONCOLOGICAL NEUTROPENIC FEVER 33 References Abrahm, J. L. (2014). A physician’s guide to pain and symptom management in cancer patients (3rd ed.). Baltimore, MD. Johns Hopkins University Press. Beck, B. (2017). Oncology emergency department: A nurse practitioner care model. Journal of Emergency Nursing, 43(6), 575-577. Braga, C. C, Taplitz, R. A., & Flowers, C. R. (2020). Clinical implications of febrile neutropenia guidelines in the cancer patient population. 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S., & Rawson, K. (2016). The nurse practitioner role in oncology: Advancing patient care (4), 489-496. ONCOLOGICAL NEUTROPENIC FEVER 37 White, L., & Ybarra, M. (2017). Neutropenic fever. Hematology/Oncology Clinics of North America, 31, 981-993. ONCOLOGICAL NEUTROPENIC FEVER 38 Appendix A Project Timeline The creation of the clinical pathway for the outpatient management of oncological patients with neutropenic fever was carried out according to the following timeline. October 1, 2020 – Present the first draft of the neutropenic clinical pathway to the Palliative Care medical director. The medical director had four weeks to review the guideline and suggest changes. November 15, 2020- The medical director’s feedback was incorporated in a draft that was presented to the Infectious Disease team and an oncology fellow, Shannon Devlin, for feedback and suggested changes. November 20, 2020- The revised clinical pathway was presented to Dr. Anna Beck for final approval. December 3, 2020- The revised guideline was presented to the Huntsman at Home nurse practitioners who were educated on the guideline and initiated a 60-day trial of the clinical pathway and decision tree. December 10, 2020- The revised guideline was discussed with the Huntsman Infectious Disease Team to obtain feedback and revise medication management of neutropenic fever in the presence of penicillin allergy according to evidence-based guidelines. February 1, 2021 – The clinical pathway pilot implementation was completed March 1, 2021- Nurse practitioners and registered nurses were surveyed to obtain feedback regarding the clinical usefulness of the clinical pathway and to obtain suggested changes to improve the clinical pathway. March 15, 2021- The final draft of the clinical pathway was written. ONCOLOGICAL NEUTROPENIC FEVER 39 March 17, 2021- The final revised guideline was presented again to the Huntsman at Home Palliative Care Medical Director for final approval. March 22, 2021- The finalized clinical guideline was placed in the electronic document center for future reference by other clinicians. Apri1, 2021- Dr. Beck will present the clinical guideline to the primary oncologist teams, hospitalists, and supportive oncology team members. The clinical guideline will be posted on the organization’s staff resource database homepage. ONCOLOGICAL NEUTROPENIC FEVER 40 Appendix B Neutropenic Fever Written Guideline Oncological Neutropenic Fever: Outpatient Management Clinical Pathway Purpose To develop and implement a protocol for safely assessing and treating neutropenic fevers in oncology patients appropriate for management in the home setting via the Huntsman at Home Program. Patient Population Oncology patients deemed safe to be treated in the home setting who exhibit a single oral temperature ≥ ֯ 38.3 C (101 ֯ F) or a temperature ≥ 38.0 ֯ C (100.4 ֯ F) sustained over 1 hour. Timeline of Clinical Management This guidelines in intended to be used as a rapid (non-emergent) response to a fever reported between the hours of 0800 and 2000 and is to be carried out according to the following timeline: • RN and or APRN initial home assessment within 2 hours of a reported fever • RN and or APRN initial physical exam to include all IV lines, wounds, and drains (biliary, indwelling Foley, and nephrostomy tubes). History recorded from direct patient report and not caregiver relay of information • Vital signs performed every 15 minutes for the first hour, every 30 minutes for the second hour, and hourly for the next two hours. If patient becomes clinically unstable at any point, repeat the vital signs 5 minutes later and return to vital signs every 15 minutes. (Consider transport to emergency department) • Blood samples and cultures obtained within 1 hour of initial RN home assessment and APRN consultation • Antibiotics administered within 1 hour of initial APRN home assessment and consultation • Re-evaluation of the patient every 1 hour for the next 4 hours following antibiotic administration. Re-assessment may be carried out via RN or APRN through in-person home visit, telephone visit, or telehealth visit • All patients assessed to be clinically unstable or found to meet the exclusion criteria below will be triaged to the emergency department for immediate evaluation. • Fevers reported after 2000 will be assessed via the on-call RN. o Patients with a MASCC score <21 will be triaged to the Emergency department (see Appendix E) ONCOLOGICAL NEUTROPENIC FEVER 41 o Patients with a MASCC score ≥21 will be reported to the Huntsman at Home lead APRN at 0800 the next morning for implementation of the guideline as outlined (see Appendix E) • Patients will be placed on an “Acute Watch” with daily NP visits occurring over the next 3 days and daily RN visits occurring over the next 7 days. Recommendations This guideline is recommended to be used in patients with the following: • Support from their primary oncologist for outpatient management • No history of noncompliance to medical treatment • Solid tumors who appear to be clinically stable (see definition below) • Access to a telephone and transportation 24-hours a day • Housed in close proximity (≤ 1 hour or ≤ 30 miles) to a medical facility that can provide 24-hour emergency care • Supervision via a 24-hour caregiver at home • Able to be medically supervised for at least the next 3 days via telephone call, telehealth visit, or home visit • Able to use an approved translator if non-English speaking Consider hospital admission for patients with the following: • Failure to defervesce after 2 to 3 days of initial, empirical, broad-spectrum antibiotic regimen • Fever recurrence after a period of defervescence • New signs or symptoms of clinical deterioration • Use of oral medications is no longer possible or tolerable • Change in empirical regimen or necessary use of an additional antimicrobial drug • Microbiologic tests identify species not susceptible to the initial antimicrobial regimen Restrictions This guideline is not to be used in patients with the following: • Severe or profound neutropenia (see definition below) • Non-solid tumors (such as acute leukemia or lymphoma) • Presence of biliary drain or nephrostomy tube • History of infection requiring hospitalization within the past 30 days • Active infection requiring current antibiotic therapy • Systemic candida infection within past 60 days • History of infection with fluoroquinolone-resistant, gram-negative pathogens that are co-resistant to ᵝ- lactams/cephalosporins ONCOLOGICAL NEUTROPENIC FEVER 42 • History of infection with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended spectrum Beta-lactamase (ESBL- such as E. Coli), and Klebsiella pneumoniae Carbapenemase (KPC) Definitions Clinically stable A patient who is deemed clinically stable has the following: • Clear mentation • No signs of acute illness o Resting heart rate >100 bpm o Diaphoresis o Pale or clammy skin o Respiratory distress o Acute chest or abdominal pain o Bleeding o New onset profound weakness or inability to ambulate • Stable vital signs o Oxygen saturation ≥ 90% and o Absence of hypotension and ▪ (B/P <90/60 mmHg) o Absence of orthostatic hypotension-assessed by 5 minutes of supine rest followed by 2-5 minutes of quiet standing. Orthostatic hypotension is present if there is at least a least 20 mmHg fall in systolic pressure or at least a 10 mmHg fall in diastolic blood pressure Neutropenia ANC < 1.0 x 10³/μL, or < 1.0 x 10⁹/L, or < 1,000/ μL Severe Neutropenia ANC < 0.5 x 10³/μL, or <0.5 x 10⁹/L, or <500/ μL Profound Neutropenia ANC < 0.1 x 10³/μL, or < 0.1 x 10⁹/L, or < 100/ μL MASCC Multinational Association of Supportive Care in Cancer ONCOLOGICAL NEUTROPENIC FEVER 43 Clinical Pathway Steps Step 1. Assess for a single oral temperature of ≥ 38.3 ֯ C (101 ֯ F) or a temperature ≥ 38.0 ֯ C (100.4 ֯ F) sustained over 1 hour Step 2. Determine MASCC risk score Send patient to the emergency room if • Presence of a biliary drain, nephrostomy tube, or reddened or painful IV access site • Clinically unstable • MASCC risk score <21, or • History of non-solid tumor Step 3. Obtain labs and imaging* • CBC with manual diff • CMP • Culture (urine and blood x2 sites) • UA *Labs must be obtained prior to antibiotic administration Consider additional labs if appropriate: • Culture (wound and stool) • Influenza A/B or COVID-19 • Chest x-ray • Liver function tests Step 4. Administer within 1 hour* from red bag first-dose kit • Cefepime 2 grams IM/IV or • Meropenem 1000 mg IV (in case of penicillin allergy) *First dose of empirical antibiotic should be administered after fever has been documented and labs and cultures obtained Order for caregiver to administer 6-8 hours later • Amoxicillin/Clavulanate 875 mg orally twice daily x 10 days (hold in the case of penicillin allergy) and • Levofloxacin 750 mg orally daily x 10 days *First dose of empirical antibiotic should be administered after fever has been documented and labs and cultures obtained Step 5. Provide close medical supervision for the next 4 hours following antibiotic administration including vital sign assessment and review of labs and imaging to ensure appropriate medication regimen Provide feedback to primary oncology team Place patient on “Acute Watch” -Daily Nurse Practitioner visits x 3 days -Daily RN visits x 7 days ONCOLOGICAL NEUTROPENIC FEVER 44 Step 6. Assess results of laboratory tests and cultures. Assess for presence of neutropenia. Calculate according to the ANC calculator (see Appendix F) Send patient to the emergency room if • ANC < 0.5 x 10³/μL • Bacteremia present • Cultures fail to show susceptibility to current antimicrobial regimen Step 7. Continue to re-assess based on lab values, culture results, and patient presentation as outlined in the Decision Tree Flowchart (see Appendix C) Information retrieved from Taplitz, R. A., Kennedy, E. B., Bow, E. J., Crews, J., Gleason, C., & Flowers, C. R. (2018). Outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology and Infectious Diseases Society of America Clinical Practice Guideline Update. Journal of Clinical Oncology, 36(14), 1443- 1453. ONCOLOGICAL NEUTROPENIC FEVER 45 Appendix C Decision Tree Flowchart ONCOLOGICAL NEUTROPENIC FEVER 46 Appendix D Educational PowerPoint Oncological Neutropenic Fever: Outpatient Management Clinical Pathway Marie Blacker, APRN, NP-C Anna C Beck, MD, Director of Supportive and Palliative Care (Click on the image above to view the contents of the PowerPoint) ONCOLOGICAL NEUTROPENIC FEVER 47 Appendix E MASCC Risk Assessment Tool ONCOLOGICAL NEUTROPENIC FEVER 48 Appendix F ANC Calculator ONCOLOGICAL NEUTROPENIC FEVER 49 Appendix G Nurse Practitioner and Registered Nurse Survey Nurse Practitioner and Registered Nurse Survey Oncological Neutropenic Fever: Implementation of a Clinical Pathway for Outpatient Management Strongly Disagree Disagree Neutral Agree Strongly Agree 1. The neutropenic fever clinical pathway is clinically useful in the home-based treatment management of patients. 2. The neutropenic fever clinical pathway is clear in defining next steps for NPs and RNs in the assessment, management, and follow-up of patients with fever of unknown origin. 3. The neutropenic fever clinical pathway is clinically useful in reducing hospitalizations. 4. The “Acute Watch” program is instrumental in increasing patient safety. 5. The “Acute Watch” program is effective in reducing hospitalizations.