APNs in Outpatient Management of Febrile Neutropenia

SAN DIEGO, California—Clinical trials over the last decade have led to the development of pathways in which certain febrile neutropenic cancer patients are managed as outpatients. At M. D. Anderson Cancer Center, advanced practice nurses (APNs) take an active, complex role in the management of these patients. Their role was summarized in a poster presentation at the Oncology Nursing Society’s 26th Annual Congress (abstract 227).

"Clinical trials have shown there is a subset of patients who are best treated at home, but they have to come back to the hospital to be checked," said Eva Lu T. Lee, MSN, RN, CS, ANP, OCN, an M. D. Anderson Emergency Center advanced practice nurse.

These are patients with solid tumors—sarcomas, breast cancer, lung cancer, genitourinary cancers, and gastrointestinal cancers. "Their neutropenia is not prolonged. The leukemia, lymphoma, and bone marrow transplant patients are in more danger, and so they are automatically admitted to the hospital," said Ms. Lee, lead author of the analysis of the APN’s role in this setting.

Approximately 40% of the patients presenting with fever at the M.D. Anderson Emergency Center are neutropenic, according to her analysis. Patients with an absolute neutrophil count of 1,000 or less are grouped according to the expected duration of their neutropenia, their cancer type, and any other comorbid conditions.

To be eligible for treatment as an outpatient, the patient must live within 30 miles of the hospital and have a 24-hour companion, a telephone, and transportation.

The oral outpatient treatment is amoxicillin/clavulate potassium (Aug-mentin) plus ciprofloxacin (Cipro) or clindamycin (Cleocin)/ciprofloxacin. The intravenous outpatient treatment is clindamycin/ceftazidime or clindamycin/aztreonam (Azactam).

After the initial clinic visit when the patient presents with a fever, those selected for outpatient treatment must return to the Emergency Center for the next 2 days for reevaluation. At those visits, they are seen by the physician and by the advanced practice nurse. On the fourth, fifth, and sixth day, the nurse checks them by phone and tracks the results of laboratory and other tests. On the seventh day, the physician and nurse see patients for their final evaluation.

According to the analysis by Ms. Lee and her coauthors—Noemi Badrina, MSN, RN, OCN; Rosalie Valdres, MSN, RN, CS, FNP; and Sally Fernandez, MSN, RN, CS, ANP)—the advanced practice nurse, in addition to her other duties, educates the patient and family about the course of neutropenia, the antibiotic regimen, and the importance of compliance. The APN teaches the patient about symptoms, infection control, and the need to monitor temperature three times a day and keep a record of symptoms.

The advantages of outpatient treatment are that it is cost-effective, prevents nosocomial infections, and does not disrupt the patient’s quality of life, Ms. Lee pointed out. The disadvantages are that the patient may not comply with therapy or return for follow-up. The worst-case scenario is the development of sepsis or other complications without medical treatment immediately available.

The final aspect of the advanced practice nurse’s role is to collect data for research. For this study, the nurses’ data showed that among febrile neutropenic patients treated as outpatients initially, over a 2-year period, 70% completed the outpatient treatment, 19% were admitted, and 12% did not complete the treatment for other reasons.

Ms. Lee and her colleagues concluded that "the APN has a multifaceted role in the outpatient management of the febrile neutropenic cancer patient."