Direct admits w/ fever and neutropenia

[ChrisF]

We have a physician that gives into our parents and direct admits patients to our inpatient unit. While we understand the ER is not fun for anyone, it is the feeling of the staff that a febrile patient is safer if they are admitted through the ER. We have had patients direct admitted with sepsis which can then becomes a life threatening situation. My question is...how does everyone else handle this type of situation? Our standard of care is to give the first antibiotic within one hour of arrival. Pharmacy is not allowing us to over-ride Fortaz in our Omni-cell on the floor. They state the reason that the ER can over-ride it is because a physician is present. So we are now faced with some very sick children that cannot get their first dose of antibiotic for approximately 3 hours. Are we being unrealistic in wanting availability of medication or admissions through the ER? Is there anything we can say or show to the pharmacy director to plead our case?

Chris

[blondy2061h, MSN, RN]

We don't have an ER, so all admissions are direct admits. An ER is a terrible place for a neutropenic patient. They are full of germs, seeing hundreds of patients a day, and ER staff isn't trained on dealing with a neutropenic patient. I've had them give my patients tylenol, do rectal temps and IM injections (in thrombocytopenic patients), draw blood cultures AFTER starting antibiotics, and put in peripheral IVs rather than access their central line. All inappropriate things for a pancytopenic patient.

I'd MUCH rather see them go right to the oncology unit.

We routinely give antibiotics within an hour on the floor. Pharmacy should be able to have it up to the floor within 30 minutes.

If the patient goes septic, the ER still isn't appropriate, the ICU is (unless you routinely handle septic patients- we do).

[tapj28]

Hi ChrisF,

I agree totally with you and Blondy206.

There are practice guidelines in ONS for the neutropenic patient. You can also Google the term "treatment of the pancytopenic patient"...it will give you the basis for the practice guidelines.

Overall, it is best to have a direct admit protocol for these patients. We have standing orders, the fellow is notified of the patients admission by the charge nurse who speaks directly to the patient (I care for adults) who is at home, and based on the information received from them and from their electronic clinic record (which we can access from our unit), is instructed to come in (to our unit) right away or go to clinic in morning. We have this type of autonomy, where we actually let the physician know that the patient is coming in, the basis for why, and she/he is notified after the patient arrives on unit and their workup is initiated by nursing - based on the written protocol. This process has saved many lives, and if the admitting nurse/fellow feels the patient is in danger, a ICU bed is arranged immediately. There is NO ER involvement with our BMT patients...if a oncology patient arrives there, they will call our unit and ask for advice for where they go...if not to us.

For starters, a team of pharmacy, CNS, Medical Director, Admissions rep, Nurse Mgr, staff nurses, lab administration rep, can facilitate the writing of neutropenic patient protocol, standing orders, practice guidelines. Nurses are essential in the writing of this protocol.

Hope this helps...take care.