While he was an attending physician at Montefiore Medical Center in New York City, Adam F. Binder, MD, and his colleagues developed an initiative to encourage the appropriate use of intravenous vancomycin for cancer patients with neutropenic fever.
For this work, he was hailed as a Choosing Wisely Champion here at the recent American Society for Hematology (ASH) 2018 annual meeting.
This program is run by ASH in cooperation with the American Board of Internal Medicine Foundation (ABIM), which began the Choosing Wisely initiative in 2012. The annual Choosing Wisely Champions campaign recognizes the efforts of practitioners who are working to eliminate the costly and potentially harmful overuse of tests and procedures.
In a presentation about his work, Binder explained that febrile neutropenia is a relatively common adverse event associated with myelosuppressive cancer therapies, and current guidelines for empiric therapy do not recommend the use of vancomycin. So he was rather concerned to find that clinicians were overprescribing vancomycin for neutropenic fever.
“There was some anecdotal concern from oncologists and the antibiotic stewardship team that we may have been overprescribing vancomycin,” he said. “Some of the preliminary data that turned this from just anecdotal to objective evidence came out of a larger project that was looking at methicillin-resistant Staphylococcus aureus (MRSA) screening as a way to de-escalate the use of vancomycin in patients presenting with pneumonia.”
For that project, they looked at a cohort of 88 patients with hematologic malignancies who either presented to the emergency department with neutropenic fever or developed it in hospital.
Of this group, 45 patients (51%) had an inappropriate initiation of vancomycin.
“If vancomycin was started in the ER and then discontinued when they got to the floor, that was considered to be inappropriate, because the oncology team made the decision that it wasn’t necessary,” explained Binder.
Next, Binder and colleagues identified what he believed were the top three barriers to more appropriate use of vancomycin. One was changing individual practice patterns. “Physicians get used to practicing a certain way, even though there’s evidence suggesting that vancomycin up front doesn’t improve overall mortality,” he said. “But some may feel comfortable starting broader and then de-escalating.”
Another challenge was the ever-changing residency staff. “We had residents rounding on service and switching every 2 to 4 weeks, and most were second- and third-year residents and most of them had never rounded on an oncology floor,” he said. “So they didn’t know the appropriate management of neutropenic fever.”
A third barrier was a lack of nursing empowerment in driving change or for enforcing guidelines.
An interdisciplinary team was created, which included an antibiotic stewardship team, pharmacists, and hematologists, and together they developed an institutional algorithm to guide prescriptions related to febrile neutropenia. They also conducted recurring educational initiatives emphasizing criteria for appropriate vancomycin initiation based on well-established guidelines.
“The whole team gave their input and having everyone’s consensus meant that it was more likely that the algorithm would be followed than if it had been developed by just a small group,” Binder commented.
Once the guidelines were in place, they wanted to make sure that they were easily accessible. “That’s one of the problems,” he said. “One of our concerns is that guidelines are put online and you can click on them to read them, but no one ever looks at them. We wanted to make sure that the guidelines were seen.”
To circumvent that problem, the guidelines were printed out and laminated and these boards were placed at all work stations. “So no matter where you were, and no matter where you sat down, you’d have them staring at you in the face,” Binder emphasized. “A year later and the boards are still up and people are still using them. It’s a nice example of sustainability.”
After this intervention was put in place, along with educational initiative, inappropriate initiation of vancomycin dropped to 34%. There was also a 1-day reduction in the duration of vancomycin therapy.
Binder said this is an improvement to what they had seen previously (51% inappropriate vancomycin), but there is still a lot of work to be done, “because 34% is still high.”
“This is really just the beginning,” he said. “The changes need to be sustainable, and we need to continue to look for new interventions. One of our next projects is to have a clinical decision-making tool within the order set.”