1. ASCO’s Quality Training Program
Project Title: Treatment of febrile neutropenia at the University of Virginia
Presenter’s Name: Tri Le, MD, Tanya Thomas, RN, Michael Keng, MD
Institution: University of Virginia, Emily Couric Cancer Center
Date: 10/8/2015
Storyboard for Session 2 will be the slides up to and including the Baseline Data slide.
ASCO will be providing other versions of this PPT that provide an example and tips on adding content to your Storyboard and Presentation.

2. Institutional Overview
The University of Virginia (UVA) Department of Hematology-Oncology at the Emily Couric Clinical Cancer Center is an NCI-designated cancer center and a tertiary referral center located in Charlottesville, Virginia
The UVA Cancer Center includes more than 130 researchers from 22 different academic departments
Over 30,000 patient visits for fiscal year 2014
Current clinical practice includes 7 attendings in malignant hematology, 3 in stem cell transplant, 3 in benign hematology, and 11 in oncology
Include basic demographic information about your practice/ institution. E.g. location, patient volume, practice setting (community, academic), # of oncologists, etc.

3. Problem Statement
Febrile neutropenia is a common complication in oncology patients and is associated with significant morbidity and mortality if untreated. Both national and international guidelines recommend the administration of appropriate antibiotics within one hour of a febrile neutropenic episode. Upon review of time-to antibiotic administration for febrile neutropenia events at our institution, a significant percentage (~55% in 2012) were not administered antibiotics within 1-hour of event.
Describes the concern or opportunity objectively.
Describes the extent of the problem.
Describes the impact of the problem.
Example:
Medication lists are often inaccurate which compromises patient care. It is challenging to fit medication reconciliation into minute multi-issue visits. Providers often rely on EMR medication lists rather than patient history. No clear policy on who “owns” the list and who is “allowed” to modify and no standard process exists across the institution.

4. Team Members Team Leader: Tri Le, MD (hematology-oncology fellow)
Tanya Thomas, BSN, BA, RN, OCN (assistant nurse manager, oncology inpatient)
Michael Keng, MD (hematology attending)
Elizabeth Daniels, MSN, RN (nurse manager, oncology inpatient)
Regina DeGennaro, DNP, RN, AOCN, CNL (oncology nursing)
Stephanie Mallow-Corbett, PharmD (Director, Clinical Pharmacy Services)
Joseph Moffett, RN (Medical Emergency Response RN)
Costi Sifri, MD (Infectious Disease Attending, hospital epidemiology)
Li Jin (Bioinformatics)
Joshua Reuss (Internal Medicine Resident)
Project Sponsor:
Michael E. Williams, MD (Hematology-Oncology division chair)
Improvement Coach:
Amy E Guthrie RN, MSN, ACHPN, CPHQ
Use information from the project charter.
Project Leaders: You!
Team Members: have “fundamental knowledge” of the process you are addressing (e.g. frontline workers)
Project Sponsors: accountable for your overall effort, provides your team with direction and support, assists you with implementation when appropriate, and ensures that key stakeholders have appropriate involvement.
Be sure to specify the role/discipline and contribution for each member (frontline knowledge, influencer, etc)
Example:
Jane Smith, Floor nurse
Dr. John Doe, Physician
Dr. Mary Last, Chief, Dept of Med

5. Process Map Example: Chemotherapy Administration Process
Patient with ANC <1000 /mm2 AND temperature ≥38.0 C (100.4 F)
Notify: On call fellow, on call housestaff, MET team
Diagnostics: vital signs1, cultures6, Radiology Studies3, other labs4
Antibiotics5: Review current antibiotic coverage and adjust as appropriate. Consider infectious disease consult.
LIP: Must perform complete physical assessment and enter the febrile neutropenia order set
RN: Must perform a complete physical assessment
Initial Fever?
Diagnostics: Vital Signs1, Cultures2, Radiology Studies3, other labs4
Antibiotics5: Initiate within 60 minutes of febrile episode
Notify: On call housestaff
Diagnostics: Vital signs7
Has patient been afebrile for 24-hours?
YES NO
1 Obtain temperature, heart rate, respiratory rate, blood pressure and oxygen saturation every 15 min x4, the hourly x 2 then every 4 hours. If the respiratory rate is ≥ 20, obtain a groin temperature.
2 All cultures should be drawn or collected within 20 minutes of febrile episode. Cultures should include: blood cultures from each lumen of each central venous access device, 1 set of percutaneous cultures and a urinalysis with reflex microscopic and urine culture,
3 Chest x-rays,
4 Collect a stool specimen if patient is having diarrhea, culture any wound or lesion, collect a CBC with differential and CMP if one has not been collected within the past 24 hours, draw a lactate if patient meets SIRS criteria
5 Initiate Antibiotics within 45 minutes of febrile episode. Emperic antibiotic coverage: Cefepime (if meets SIRS criteria or concern for gram positive infection add vancomycin). If PCN allergic aztreonam and vancomycin.
6 All cultures should be drawn or collected within 20 minutes of febrile episode. Cultures should include: blood cultures from one lumen of the central venous access device, 1 set of percutaneous cultures and a urinalysis with reflex microscopic and urine culture.
7 For patients with hemodynamic stability: obtain temperture, heart rate, respiratory rate, blood pressure and oxygen saturation hourly x 2 followed by every 4 hours. For patients with hemodymanic instability (heart rate >90, respiratory rate >20 or PaCO2<32 mmHg, MAP <65 and patient is not responding to intravenous fluids): obtain a full set of vital signs every 15 minutes for 1 hour followed by a full set of vital signs every hour x 2 then every four hours. If patients are unstable, more frequent vital signs may be necessary. If more frequent vital signs are necessary, the LIP will enter the appropriate vital sign frequency.
A simple method to visually display the various steps, events, and operations that constitute a process.
Example: Chemotherapy Administration Process

6. Cause & Effect Diagram
Clinical Knowledge
Order Entry
Inconsistent definition of a fever
Conflicting orders
Lack of adequate education related to febrile neutropenia
Incorrect antibiotics ordered
No standard workflow related to LIPs, RNs, PCAs
Delay in order entry after fever
Delay in appropriate treatment for Febrile Neutropenia
Inadequate RN and PCA staffing
Appropriate Abx not stocked on unit
Delays in antibiotic delivery to the unit
Phlebotomy delays
Delays in administration of Abx once on unit
Antibiotic (Abx) Availability
Staff Resources

7. Diagnostic Data
Any observations, tally sheet data, interviews, that helped you understand your process, prioritize opportunities, etc.
Displayed in a Pareto chart, frequency distribution, run chart, etc. Demonstrates how you identified your opportunities for improvement and how you prioritized your specific area of focus that will relate to your aim statement.

8. Aim Statement
By year-end 2015, we aim to increase percentage of patients receiving antibiotics within one hour for the first episode of febrile neutropenia to 80% in the acute care setting at the University of Virginia.
Defines the team’s specific improvement objective – what you are trying to accomplish.
AIM statements should be SMART - specific, measurable, attainable, relevant and time bound.
Example:
By June 30, 2011, increase the accuracy of medication lists one week after physical exams and chronic disease visits to 90% by providing physicians with accurate patient generated medication lists during the targeted visit at XYZ clinic.

9. Measures
Measure: Time to antibiotic administration for patients with the first episode of febrile neutropenia.
Patient population: All patients being treated for febrile neutropenia in the inpatient setting.
Exclusions (if any): Patient being treated in the Emergency Department, Infusion Center, or ICU’s
Calculation methodology:
Numerator & Denominator: Numerator: # of patients with first episode of neutropenic fever treated with antibiotics within one hour. Denominator: # of patients with first episode of neutropenic fever
Data source: Clinical data repository, Epic, ICD Database
Data collection frequency: Every 3 months
Data quality (any limitations): Limits of our electronic patient database, inability to ensure that we are capturing all patients who present with febrile neutropenia.
Describe your outcome, process or balance measures which you will present as your baseline data and change data. If you have more than one measure you will want to create a slide for each measure.
Describe the measure and note whether it is your outcome, process or balance measure. Include the patient population (who is included and any exclusions). Specify the calculation methodology (specify the numerator, denominator if applicable). Describe the data source, data collection frequency, quality of data (any limitations).
Measures should be directly related to your AIM statement. Can also show off your data collection tools that you developed.

10. Baseline Data % of Accurate Lists One Week Post Annual Visit (p-chart)
Percentage of Patients
Links directly to the measurement implied in your primary aim statement
Example:
Time between Fever and Initial Antibiotic Administration by Year
% of Accurate Lists One Week Post Annual Visit (p-chart)
UCL
Mean
% accurate lists
LCL
Week

11. Prioritized List of Changes (Priority/Pay-Off Matrix)
Ease of Implementation
High
Low
Easy
Difficult
Impact
Increasing staffing available during acute event
Make Abx available on floor
Creating an Epic order set
Creating Epic Alert
Infectious diseases involvement with new cases
Implementation of staff educational program
Creation of an institutional clinical practice guideline
Increase overall staffing
Describe process of idea generation (brainstorming, etc)
Highlight ideas selected for this PDSA cycle 11 11

12. PDSA Plan (Tests of Change)
Date of PDSA cycle
Description of intervention
Results
Action steps
9/ present
Clinical Practice Guideline - Includes order set, educational materials, expected training, workflow
Epic Order set - antibiotics, VS, notification
Clinical Workflow - Workflow notification, vitals, cultures, antibiotic administration
Correct antibiotics ordered for all febrile neutropenic patients.
Increase in number of patients treated within 1-hour.
Modify clinical workflow based on LIP, RN, and PCA input.
Include the neutropenic order set as an option for all patients admitted to the inpatient heme-onc setting
Describe your test plan – briefly summarize PDSA cycles or multiple PDSA cycles.
Could include stakeholder analysis or communication plan if relevant.

13. PDSA Plan (Tests of Change)
Date of PDSA cycle
Description of intervention
Results
Action steps
Education
12/ present
Computer Based Learning Modules - modules created for LIPs, RNs, PCAs/PCTs
IPE Simulation sessions related to identification and treatment of febrile neutropenia.
Reference sheets created for other acute care units.
Inpatient lectures for LIPs.
Increased confidence and competence in caring for oncology patients with febrile neutropenia in the inpatient setting. This increase is demonstrated via pre-and post-simulation testing.
Revise the CBLs and include the CBLs as part of the required training for all newly hired clinicians.
Expand the simulation sessions to include pharmacy and other inpatient units.
Describe your test plan – briefly summarize PDSA cycles or multiple PDSA cycles.
Could include stakeholder analysis or communication plan if relevant.

14. PDSA Plan (Tests of Change)
Date of PDSA cycle
Description of intervention
Results
Action steps
EPIC BPA
8/2015
Best Practice Advisory created to identify patients who meet the criteria for febrile neutropenia. The BPA will notify the LIP, pharmacy, RN, PCA when they open the patient’s chart. A link to the order set will be included in the BPA notification.
Ongoing, BPA currently running in background, ensuring that correct patients are captured.
Currently manually recording patients on 8-West to ensure proper BPA is triggered.
Anticipated late Approval for the BPA to “Go-Live” for all patients in the inpatient setting.
Describe your test plan – briefly summarize PDSA cycles or multiple PDSA cycles.
Could include stakeholder analysis or communication plan if relevant.

15. Materials Developed Educational materials:
Simulation center training
Online learning modules
Monthly lecture given by inpatient fellow
Established a new clinical practice guideline
Epic Order Set
New clinical workflow for floor staff
Automatic MET Nurse involvement
E.g. patient education materials; visual of tools to test as part of tests of change.
This slide is optional for a team to include. If your team did not develop any materials related to your project (e.g. patient education tools; survey), you may delete this slide.

16. # of patients treated within 60-min, 60-180 min, and 180+ min
Time to Antibiotics
# of patients treated within 60-min, min, and 180+ min
2013 vs 2015
Should be one of the measures outlined on the measurement slide which is directly related to your aim statement. Annotate chart to identify when intervention/PDSA cycles began, label the x and y axis, and indicate the type of chart used. Note if rules of special cause are present indicating improvement is significant.
Example:
% of Accurate Lists One Week Post Annual Visit
UCL
Mean
% accurate lists
LCL
Intervention Started Week 8
Week

17. % of patients treated within 60-min, 60-180 min, and 180+ min
Time to Antibiotics
% of patients treated within 60-min, min, and 180+ min
2013 vs 2015
Should be one of the measures outlined on the measurement slide which is directly related to your aim statement. Annotate chart to identify when intervention/PDSA cycles began, label the x and y axis, and indicate the type of chart used. Note if rules of special cause are present indicating improvement is significant.
Example:
% of Accurate Lists One Week Post Annual Visit
UCL
Mean
% accurate lists
LCL
Intervention Started Week 8
Week

18. Conclusions
With the implementation of our clinical practice guideline and educational materials, we have substantially increased the % of patients treated with antibiotics in under 60-minutes (84% in 2015 versus 19% in 2013)
We are continuing to collect data for 2015, and hope to meet our goal of 80% of patients treated within 60-minutes
Conclusions should be directly related to your change data. Describe whether or not you saw improvement or if you met your aim. This is different than lessons learned.

19. Next Steps/Plan for Sustainability
Implementation of the Epic BPA
Continue to measure the post intervention compliance and adherence to the practice standards outlined in the CPG
Continuing the educational program, including CBL’s (updated yearly), simulation sessions, and monthly lectures
Collaborate with key stakeholders in the Emergency Department, Pediatrics and the outpatient infusion center clinics to develop processes for expansion of the febrile neutropenia standard work to these settings
Describe additional tests of change, how intervention will be incorporated into standard work flow, etc.
Example:
Increase and measure reliability of process elements of our intervention
Continue to measure post encounter medication list accuracy to evaluate intervention
Collaborate with IT to develop system fixes (e.g end date for antibiotics)
Explore utility of patient portal for inter-visit medrec