Reducing ED utilization for oncologic neutropenic and non-neutropenic fever through an urgent care pathway: A quality improvement project.

Abstract

e23282 Background: Emergency department (ED) utilization by oncology patients is high and wait times can be long, potentially increasing risk of pathogen exposure. Several cancer centers have piloted pathways for oncology patients to be evaluated and treated in urgent cares (UCs), however, they are commonly underutilized for initial evaluation of acute, low risk, oncology related chief concerns. This quality improvement (QI) study aims to increase UC utilization for low risk, adult, solid oncology patients presenting with neutropenic or non-neutropenic fever at the University of California, Los Angeles Jonsson Comprehensive Cancer Center (UCLA). Methods: To evaluate the need for a clinical pathway for neutropenic and non-neutropenic fever in adult solid oncology patients, a retrospective chart review of patients seen in the UCLA ED from February to August 2024 was performed to determine the number of patients that would meet criteria for the proposed UC pathway. These criteria were based on the Multinational Association for Supportive Care in Cancer (MASCC) score for neutropenic patients, and oncology physician clinical judgement based on severity of illness and discharge or admission status for non-neutropenic patients. Demographic information, rate of preventable ED visits, time spent in ED, time to intravenous (IV) antibiotics, and time to IV fluids were also collected. These findings supported the development of a QI project, with an upcoming intervention—the oncologic fever UC management pathway. This pathway will refer eligible patients to a “Next Day Clinic” for outpatient management of non-neutropenic or neutropenic fever. Results: 40 eligible patients were evaluated during the study period. Median age was 62 years. 23/40 (57.5 %) were female. 7/40 (17.5%) were neutropenic. Based on our pre-determined criteria, 2/7 neutropenic patients would be eligible for the proposed UC pathway. Of non-neutropenic patients, 6/33 (18.2%) were discharged from the ED and also deemed eligible for the pathway. 34/40 (85%) were admitted with a median hospital length of stay of 3 days. Median time to antibiotics was 126 minutes. Median time to IV fluids was 147 minutes. Median time spent in the ED prior to admission or discharge orders was 235 minutes. 3/40 (7.5%) received a Granulocyte Colony-Stimulating Factor (G-CSF) product within 10 days preceding the ED encounter. 7/40 (17.5%) received G-CSF during the inpatient admission. 0/40 patients were evaluated in UC prior to the ED encounter. Conclusions: Baseline data from this retrospective study revealed long ED wait times, several potentially preventable ED visits, and that UCLA UC clinics are severely underutilized for initial evaluation of oncologic fever. These findings support the upcoming launch of the UC oncologic fever pathway as part of a QI project that aims to optimize high quality, patient-centered, oncologic care.