No votes yet

Implementation of an Evidence-Based Order Set to Impact Initial Antibiotic Time Intervals in Adult Febrile Neutropenia

Janie T. Best
Karen Frith
Faye Anderson
Carla Gene Rapp
Lisa Rioux
Christina Ciccarello
ONF 2011, 38(6), 661-668 DOI: 10.1188/11.ONF.661-668

Purpose/Objectives: To evaluate the impact of the implementation of a standardized order set on the time interval in initiation of antibiotic therapy for adult patients with cancer and febrile neutropenia. Design: Practice change.

Setting: The oncology unit of an urban hospital in the south-eastern United States.

Sample: Adult patients with cancer and febrile neutropenia admitted six months prior to (n = 30) or during the three months following (n = 23) implementation of the order set.

Methods: Literature regarding febrile neutropenia, use of order sets, and change process was reviewed. In addition, a retrospective and concurrent chart review was conducted for adult patients admitted with febrile neutropenia. Time intervals were analyzed using SPSS® software, version 18.

Main Research Variables: Initial antibiotic times, order-set use, and length of stay.

Findings: An overall reduction in time intervals for initiation of antibiotic therapy was observed for presentation (t = 2.25; degrees of freedom [df] = 37; p = 0.031) and order (t = 2.67; df = 40.17; p = 0.012) to antibiotic administration, with an order-set usage of 31% in the inpatient unit and 71% in the emergency department.

Conclusions: Findings in the presence of low order-set usage suggest that staff education and placement of the order-set antibiotics in unit-based medication dispensing machines helped reduce time intervals for initial antibiotic therapy.

Implications for Nursing: The use of an evidence-based approach to nursing care is essential to achieving the best outcomes for patients with febrile neutropenia. Incorporation of current evidence into an order set to guide clinical practice and comprehensive nurse, pharmacy, and physician education are needed for the successful implementation of evidence-based practice changes.


Baltic, T., Schlosser, E., & Bedell, M.K. (2002). Neutropenic fever: One institution's quality improvement project to decrease time from patient arrival to initiation of antibiotic therapy. <i>Clinical Journal of Oncology Nursing, 6</i>, 337-340. doi:10.1188/02.CJON.337-340

Book, L. (2008). Neutropenic fever following chemotherapy in a patient with lymphoma. <i>Oncology Nursing Forum, 35</i>, 885-887. doi:10.1188/08.ONF.885-887

Camp-Sorrell, D. (2005). Myelosuppression. In J.K. Itano & K.N. Taoka (Eds.), <i>Core curriculum for oncology nursing</i> (4th ed., pp. 257-274). St. Louis, MO: Elsevier.

Coughlan, M., & Healy, C. (2008). Nursing care, education, and support for patients with neutropenia. <i>Nursing Standard, 22</i>(46), 35-41.

Craig, M., Cumpston, A.D., Hobbs, G.R., DeVetten, M.P., Sarwari, A.R., & Ericson, S.G. (2007). The clinical impact of antibacterial prophylaxis and cycling antibiotics for febrile neutropenia in a hematological malignancy and transplantation unit. <i>Bone Marrow Transplantation, 39</i>, 477-482. doi:10.1038/sj.bmt.1705591

Crawford, J., Dale, D.C., Kuderer, N.M., Culakova, E., Poniewierski, M.S., & Lyman, G.H. (2008). Risk and timing of neutropenic events in adult cancer patients receiving chemotherapy: The results of a prospective nationwide study of oncology practice. <i>Journal of the National Comprehensive Cancer Network, 6</i>, 109-117.

Cull, L.F., & Nolan, M.B. (2009). Treating neutropenic fever in the emergency department: Delays may be deadly! <i>Journal of Emergency Medicine, 35</i>, 36-39. doi:1016/j.jen.2007.11.002

Donohue, R.B. (2006). Development and implementation of a risk assessment tool for chemotherapy-induced neutropenia. <i>Oncology Nursing Forum, 33</i>, 347-352. doi:10.1188.06.ONF.347-352.

Dulaney, P., & Stanley, K.M. (2005). Accomplishing change in treatment strategies. <i>Journal of Addictions Nursing, 16</i>(4), 163-167.

Eaton, L.H. & Tipton, J.M. (Eds.). (2009). <i>Putting evidence into practice: Improving oncology patient outcomes.</i> Pittsburgh, PA: Oncology Nursing Society.

Glasmacher, A., von Lilienfeld-Toal, M., Schulte, S., Hahn, C., Schmidt-Wolf, I.G., & Prentice, A. (2005). An evidence-based evaluation of important aspects of empirical antibiotic therapy in febrile neutropenic patients. <i>Clinical Microbiology and Infectious Diseases, 11</i>(Suppl. 5), 17-23.

Kannangara, S. (2006). Management of febrile neutropenia. <i>Community Oncology, 3</i>, 585-591.

Klastersky, J., Paesmans, M., Rubenstein, E.B., Boyer, M., Elting, L., & Field, R., … Talcott, J. (2000). The multinational association for supportive care in cancer risk index. <i>Journal of Clinical Oncology, 18</i>, 3038-3051.

Knowles, M.S., Holton, E.F., III, & Swanson, R.A. (2005). <i>The adult learner: The definitive classic in adult education and human resource development</i> (6th ed.). Burlington, MA: Elsevier.

Koh, A., & Pizzo, P.A. (2002). Empirical oral antibiotic therapy for low risk febrile cancer patients with neutropenia. <i>Cancer Investigation, 20</i>, 420-433.

Kuderer, N.M., Dale, D.C., Crawford, J., Cosler, L.E., & Lyman, G.H. (2006). Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. <i>Cancer, 106</i>, 2258-2266. doi:10.1002/cncr.21847

Marquis, B.L., & Huston, C.J. (2009). <i>Leadership roles and management functions in nursing: Theory and application</i> (6th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams and Wilkins.

Maxwell, C., & Stein, A. (2006). Implementing evidence-based guidelines for preventing chemotherapy-induced neutropenia: From paper to clinical practice. <i>Community Oncology, 3</i>, 530-536.

McCallin, A. (2006). Interdisciplinary teamwork: Labeling is not enough. <i>Journal of the Australasian Rehabilitation Nurses' Association, 9</i>(2), 6-9.

National Comprehensive Cancer Network. (2011). <i>NCCN Clinical Practice Guidelines in Oncology: Prevention and treatment of cancer-related infections</i> [v.2.2011]. Retrieved from <a target="_blank" href='http://www.nccn.org/professionals/physician_gls/pdf/infections.pdf'>http...

Natsch, S., Kullberg, B.J., Meis, J.F., & van der Meer, J.W. (2000). Earlier initiation of antibiotic treatment for severe infections after interventions to improve the organization and specific guidelines in the emergency department. <i>Archives of Internal Medicine, 160</i>, 1317-1320.

Nirenberg, A., Bush, A.P., Davis, A., Friese, C.R., Gillespie, T.W., & Rice, R.D. (2006a). Neutropenia: State of the knowledge part 1. <i>Oncology Nursing Forum, 33</i>, 1193-1201. doi:1188/06.ONF.1193-1201

Nirenberg, A., Bush, A.P., Davis, A., Friese, C.R., Gillespie, T.W., & Rice, R.D. (2006b). Neutropenia: State of the knowledge part II. <i>Oncology Nursing Forum, 33</i>, 1202-1208. doi:10.1188/06.ONF.1202-1208

Nirenberg, A., Mulhearn, L., Lin, S., & Larson, E. (2004). Emergency department waiting times for patients with cancer with febrile neutropenia: A pilot study. <i>Oncology Nursing Forum, 31</i>, 711-715.

Perrone, J., Hollander, J.E., & Datner, E.M. (2004). Emergency department evaluation of patients with fever and chemotherapy-induced neutropenia. <i>Journal of Emergency Medicine, 27</i>, 115-119.

Rolston, K.V. (2004). The Infectious Diseases Society of America 2002 guidelines for the use of antimicrobial agents in patients with cancer and neutropenia: Salient features and comments. <i>Clinical Infectious Disease, 39</i>(Suppl. 1), S44-S48. doi:1058-4838/2004/3301S1-0008$15.30

Salter, C. (2005). Clinical pathways in the emergency department: Successful implementation of "adult patients who are febrile following chemotherapy" pathway. <i>Australasian Emergency Nursing Journal, 8</i>, 27-34. doi:10.1016/j.aenj.2005.04.005

Sano, H.S., Waddell, J.A., Solimando, D.A., Doulaveris, P., & Myhand, R. (2005). Study of the effect of standardized chemotherapy order forms on prescribing errors and antiemetic cost. <i>Journal of Oncology Pharmacy Practice, 11</i>, 21-30. doi:10.1191/1078155205jp149oa

Simms, E. (2006). The components of change: Creativity and innovation, critical thinking, and planned change. In L. Roussel, R.C. Swansburg, & R.J. Swansburg (Eds.), <i>Management and leadership for nurse administrators</i> (4th ed., pp. 55-71). Boston, MA: Jones and Bartlett.

Viscoli, C., Varnier, O., & Machetti, M. (2005). Infections in patients with febrile neutropenia: Epidemiology, microbiology, and risk stratification. <i>Clinical Infectious Diseases, 40</i>(S4), S240-S245.

Vogtlander, N.P., Van Kasteren, M.E., Natsch, S., Kullberg, B., Hekster, Y.A., & Van der Meer, J.W. (2004). Improving the process of antibiotic therapy in daily practice: Interventions to optimize timing, dosage adjustment to renal function, and switch therapy. <i>Archives of Internal Medicine, 164</i>, 1206-1212.

Wirth, R.A. (2004). <i>Lewin/Schein's change theory.</i> Retrieved from <a target="_blank" href='http://www.entarga.com/orgchange/lewinschein.pdf'>http://www.entarga.com...

Zuckermann, J., Moreira, L.B., Stoll, P., Moreira, L.M., Kuchenbecker, R.S., & Polanczyk, C.A. (2008). Compliance with a critical pathway for the management of febrile neutropenia and impact on clinical outcomes. <i>Annals of Hematology, 87</i>, 139-145.