Early identification of high-risk neutropenia in the ambulatory setting

87 Background: The University of Illinois Cancer Center (UICC) utilizes nurse (RN) visits for laboratory review and toxicity evaluations for patients (pts) receiving chemotherapy. Upon review of nursing visits, we observed that RN visit documentation for neutropenia was variable without standard language, communication with physicians (MD), or requirement for MD evaluation. We sought to implement an early intervention strategy to prevent morbidity and mortality from high risk neutropenia (HRN). Methods: A multidisciplinary task force of oncology RNs and MDs created actual and ideal process maps, from identification of neutropenia to patient disposition. We developed a Standard Operating Protocol (SOP) involving a HRN checklist (created based on NCCN and ISDA guidelines) and new process for triage of HRN pts. RNs were required to complete the HRN checklist within the electronic health record for all pts with ANC < 1,000. If high risk features were identified, MD evaluation was required within 1 hour of RN call, with SOAP note and attending notification. Results: Over an 8 week period, 17 HRN templates were generated. The process and checklist were adjusted after the first 4 weeks with clinic wide feedback. Within the first 4 weeks, 8 templates were generated (5 MD, 3 RN); no patients met high risk neutropenia criteria and all were discharged home. Within the second 4 weeks, 9 templates were generated (3 MD, 6 RN); 3 HRN pts were identified with two direct admissions and one home discharge with favorable outcomes. Clinic staff reported greater understanding of HRN, increased satisfaction with multidisciplinary interactions, and more comfort with calling MDs for prompt patient evaluation. Conclusions: UICC successfully piloted the creation and implementation of an early identification and intervention strategy for HRN with strong multidisciplinary support. Compared to the prior 6 month period, we found that use of the SOP and checklist resulted in improvement in evaluation of quality and timeliness of HRN pts and prevented morbidity and mortality. Additionally, the checklist provoked critical thinking from end users with more thorough patient evaluations and improved documentation, resulting in aggressive intervention and better outcomes.