Abstract

Background/Aims

Severe infections are the most important causes of morbidity and mortality in children with cancer. In Peru, a major limitation for an optimal treatment of children with fever and neutropenia due to chemotherapy is the delay in the administration of the first dose of antibiotics. We performed an intervention aimed to decrease the time to antibiotics (TTA) in pediatric patients presenting to the emergency room (ER) with fever and neutropenia: We increased the perception risk of neutropenic fever to the ER medical staff by explaining the importance of a timely administration of antibiotics as part of the initial approach of children with fever and neutropenia. This study forms part of a larger project (DoTT project) that is being implemented in Peru, and is aligned to the WHO Global Initiative of Childhood Cancer in Peru.

Methods

This study was performed at Hospital Nacional Edgardo Rebagliati, which is a tertiary care National Hospital located in Lima. We included patients younger than 14 years with hemato-oncological conditions who arrived at the Pediatric Emergency Room. The DoTT project consists in an quality improvement educational intervention for health care providers in the Pediatric ED and the Oncology and Hematology Departments, based on the Kern’s six-steps (i) Problem identification and general needs assessment, (ii) targeted needs assessment, (iii) goals and objectives, (iv) educational strategies, (v) implementation and (vi) evaluation. We defined time-to-antibiotic (TTA) by measuring the time elapsed between patient′s arrival to the ER and the administration of the fist dose of an antibiotic. We compared the TTA between thirteen patients admitted from July to December 2020 with fever and neutropenia (after intervention), and historical data from 2017–2018.

Results

Median age was 7 years. 9/13 patients had leukemia and 4 patients had malignant solid tumors receiving oncological treatment. Mean pre-hospital delay was 176 minutes (range, 14–906 minutes) and TTA was 133 minutes (range, 34–400 minutes). One patient died of sepsis. Age, sex, source and timing of antibiotics did not significantly affect hospital stay, antifungal use and/or antibiotic turnover. Based on our historical data, mean TTA was 206 minutes (range, 137–390). Early results indicate a decrease in the TTA, although not statistically significant, likely due to the sample size. General and targeted needs assessment was performed by the DoTT project team and administrators at Rebagliati hospital, which lead to develop a curriculum based on a 5-lectures mini-course for health care providers.

Conclusions

The TTA exceeds the recommended time at international level, causing the evitable morbimortality. It is necessary to perform a multidisciplinary intervention to improve antibiotic start time. Ongoing educational intervention refinement and testing of the instruments are planned.

中文翻译：

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#55：秘鲁儿童癌症患者发热性中性粒细胞减少症的质量改进教育干预措施的开发：DoTT 项目的初步结果

摘要

背景/目标

严重感染是儿童癌症发病率和死亡率的最重要原因。在秘鲁，对因化疗而发烧和中性粒细胞减少的儿童进行最佳治疗的一个主要限制是第一剂抗生素的给药延迟。我们进行了一项干预措施，旨在减少因发烧和中性粒细胞减少症而到急诊室 (ER) 就诊的儿科患者使用抗生素 (TTA) 的时间：我们通过解释及时治疗的重要性，增加了 ER 医务人员对中性粒细胞减少症的感知风险使用抗生素作为发烧和中性粒细胞减少症儿童初始治疗的一部分。这项研究是秘鲁正在实施的一个更大项目（DoTT 项目）的一部分，并与世卫组织在秘鲁开展的全球儿童癌症倡议保持一致。

方法

本研究是在位于利马的国家三级医院医院 Nacional Edgardo Rebagliati 进行的。我们纳入了到达儿科急诊室的 14 岁以下患有血液肿瘤疾病的患者。DoTT 项目包括针对儿科 ED 和肿瘤科和血液科的医疗保健提供者的质量改进教育干预，基于 Kern 的六个步骤 (i) 问题识别和一般需求评估，(ii) 有针对性的需求评估，( iii) 目标和目的，(iv) 教育策略，(v) 实施和(vi) 评估。我们通过测量患者到达急诊室和使用第一剂抗生素之间的时间来定义抗生素使用时间 (TTA)。

结果

中位年龄为 7 岁。9/13 患者患有白血病，4 名患者患有接受肿瘤治疗的恶性实体瘤。平均院前延迟为 176 分钟（范围，14-906 分钟），TTA 为 133 分钟（范围，34-400 分钟）。一名患者死于败血症。抗生素的年龄、性别、来源和时间对住院时间、抗真菌药的使用和/或抗生素的周转没有显着影响。根据我们的历史数据，平均 TTA 为 206 分钟（范围，137-390）。早期结果表明 TTA 下降，尽管在统计上不显着，可能是由于样本量。DoTT 项目团队和 Rebagliati 医院的管理人员进行了一般和有针对性的需求评估，从而为医疗保健提供者开发了基于 5 个讲座的迷你课程的课程。

结论

TTA 超过了国际水平的推荐时间，导致不可避免的死亡。有必要进行多学科干预以改善抗生素开始时间。正在计划对这些工具进行持续的教育干预改进和测试。