From the 2023 HVPA National Conference
Kolton Smith DO (Lenox Hill Hospital), Menna Elaskandrany DO, Evan Finger DO, Ethan Fried MD
Although rectal temperatures provide the closest estimate of the true core body temperature, they pose certain risks such as rectal perforation or translocation of intestinal organisms. Fevers in patients with neutropenia are hematologic/oncologic emergencies that could indicate life-threatening infections. In this patient population, rectal temperatures, although more accurate, should be avoided completely given the risk of bacterial translocation. Cytotoxic chemotherapy can lead to breakdown of mucosal surfaces which supports the notion that bacterial translocation poses a greater risk in this subset of patients.
The goal of our Quality Improvement Project (QIP) is to reduce the incidence of rectal temperatures performed in patients with neutropenia.
Under the guidance of our program director and a highly structured quality improvement curriculum, we identified our target improvement by devising a S.M.A.R.T. Aim statement (Specific, Measurable, Achievable, Relevant, Timely). We then developed a Swim Lane diagram to visualize the steps that would be necessary for accomplishing our goal of performing less rectal temperatures. Following the Plan-Do-Study-Act model for quality improvement, we then identified the regional medical floor 7 Wollman (7WO) as the most appropriate floor on which to enact our small test of change. We used the National Instituted of Health’s definition of neutropenia of an Absolute Neutrophil Count (ANC) of 1.5 K/uL or less. We worked with the Data Informatics team to create an alert system that sends us an email each time a patient on 7WO has an ANC of 1.5 K/uL or less. After receiving an email alert, the QIP team contacts the resident physician team and asks them to inform the nurses of the neutropenic patient. The nurses then place the sign that our team designed outside the patient’s room (figure 1). Through interdisciplinary discussions with the nursing staff, we established that the most appropriate team member to place the signs would be the nurses. The QIP team records each successful sign placement in a communal excel spreadsheet and then examines the chart to see if any rectal temperatures were recorded after placement of the sign. We then calculated the incidence rates of rectal temperatures in patients with neutropenia over the past 2 years as well as in our QIP patients and compared the two using the Chi2-statistic.
In hospitalized patients from 2020 to 2022, rectal temperatures were performed on 106/1021 patients with neutropenia (Incidence Rate = 0.1038, 95% Confidence Interval 0.085-0.1256). Over the first two months of our QIP project we have successfully placed signage outside the rooms of 17/17 patients with neutropenia (100% execution rate). Of the 17 patients with neutropenia, rectal temperatures were performed on 0/17 (Incidence Rate = 0, 95% Confidence Interval 0-0.217). The Incidence Rate Difference between the pre-and-post intervention groups is 0.1038 (P-value = 0.184, Confidence Interval of –0.049-0.257).
By implementing our intervention on 7WO, we were able to work with physicians, nurses, and PCA’s to decrease the number of rectal temperatures obtained in patients with neutropenia. Reaching successful prevention of rectal temperature in 38 patients will allow us to attain statistical significance.
Our QIP study was able to decrease the number of rectal temperatures performed in patients on 7WO with neutropenia. Future studies can expand our study across additional units and eventually all of Lenox Hill Hospital and reduce the likelihood of bacterial translocation in neutropenic patients.