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Supportive Care in Cancer

, Volume 21, Issue 5, pp 1241–1251 | Cite as

Developing a national ‘low risk’ febrile neutropenia framework for use in children and young people's cancer care

  • F GibsonEmail author
  • J Chisholm
  • E Blandford
  • P Donachie
  • J Hartley
  • S Lane
  • K Selwood
  • R Skinner
  • R Phillips
  • on behalf of the CCLG Supportive Care Group
Original Article

Abstract

Purpose

A Delphi study was undertaken to develop a framework guidance that would rationalise and standardise the care of children with febrile neutropenia (FNP) across the UK.

Methods

A mailed Delphi survey was undertaken with health professionals working in children's cancer units. The survey employed two rounds of feedback on 22 practice statements drawn from a systematic review of clinical evidence. Consensus was assumed for any statement where 80+ % of respondents indicated that they “agreed” or “strongly agreed”.

Results

Consensus was reached on 21 of the 22 practice statements in round 1 that were categorised into six areas: definition of fever and neutropenia, initial management and choice of antibiotic, defining low-risk patients, strategy in low-risk patients and alternative approaches. Consensus could not be reached on whether patients needed to be afebrile to be suitable for discharge and the required length of outpatient antibiotic treatment.

Conclusions

A Delphi survey allowed the successful development of a national framework for identification and management of children with FNP. The use of an existing well-functioning professional network was key in this project's success.

Keywords

Children Febrile neutropenia Delphi survey Practice framework 

Notes

Acknowledgments

The authors would like to thank the Coordinating Centre: Children's Cancer & Leukaemia Group, CCLG Data Centre, University of Leicester, Leicester, which support the CCLG Supportive Care Group. Thanks also go to CCLG centres that participated in the study.

Conflict of interest

None.

References

  1. 1.
    Pritchard-Jones K, Kaatsch P, Steliarova-Foucher E, Stiller CA, Coebergh JWW (2006) Cancer in children and adolescents in Europe: developments over 20 years and future challenges. Eur J Cancer 42:2183–2190PubMedCrossRefGoogle Scholar
  2. 2.
    Gootenberg JE, Pizzo PA (1991) Optimal management of acute toxicities of therapy. Pediatr Clin North Am 38:269–97PubMedGoogle Scholar
  3. 3.
    Hann I, Viscoli C, Paesmans M, Gaya H, Glauser M (1997) A comparison of outcome from febrile neutropenic episodes in children compared with adults: results from four EORTC studies. International Antimicrobial Therapy Cooperative Group (IATCG) of the European Organization for Research and Treatment of Cancer (EORTC). Br J Haematol 99:580–8PubMedCrossRefGoogle Scholar
  4. 4.
    Chisholm JC, Dommett R (2006) The evolution towards ambulatory and day-case management of febrile neutropenia. Br J Haematol 135:3–16PubMedCrossRefGoogle Scholar
  5. 5.
    Ammann RA, Hirt A, Luthy AR, Aebi C (2004) Predicting bacteremia in children with fever and chemotherapy-induced neutropenia. Pediatr Infect Dis J 23:61–7PubMedCrossRefGoogle Scholar
  6. 6.
    Baorto EP, Aquino VM, Mullen CA, Buchanan GR, DeBaun MR (2001) Clinical parameters associated with low bacteremia risk in 1100 pediatric oncology patients with fever and neutropenia. Cancer 92:909–13PubMedCrossRefGoogle Scholar
  7. 7.
    Klaassen RJ, Goodman TR, Pham B, Doyle JJ (2000) “Low-risk” prediction rule for pediatric oncology patients presenting with fever and neutropenia. J Clin Oncol 18:1012–9PubMedGoogle Scholar
  8. 8.
    Lucas KG, Brown AE, Armstrong D, Chapman D, Heller G (1996) The identification of febrile, neutropenic children with neoplastic disease at low risk for bacteremia and complications of sepsis. Cancer 77:791–8PubMedCrossRefGoogle Scholar
  9. 9.
    Rackoff WR, Gonin R, Robinson C, Kreissman SG, Breitfeld PB (1996) Predicting the risk of bacteremia in childen with fever and neutropenia. J Clin Oncol 14:919–24PubMedGoogle Scholar
  10. 10.
    Klaassen RJMD, Allen UMD, Doyle JJMD (2000) Randomized placebo-controlled trial of oral antibiotics in pediatric oncology patients at low-risk with fever and neutropenia. SO-J Pediatr Hematol/Oncol 22(5):405–411CrossRefGoogle Scholar
  11. 11.
    Paganini H, Rodriguez-Brieshcke T, Zubizarreta P, Latella A, Firpo V, Casimir L, Armada A, Fernandez C, Caceres E, Debbag R (2001) Oral ciprofloxacin in the management of children with cancer with lower risk febrile neutropenia. Cancer 91:1563–7PubMedCrossRefGoogle Scholar
  12. 12.
    Petrilli AS, Dantas LS, Campos MC, Tanaka C, Ginani VC, Seber A (2000) Oral ciprofloxacin vs. intravenous ceftriaxone administered in an outpatient setting for fever and neutropenia in low-risk pediatric oncology patients: randomized prospective trial. Med Pediatr Oncol 34:87–91sPubMedCrossRefGoogle Scholar
  13. 13.
    Philips R, Wade R, Stewart LA, Sutton AJ (2010) Systematic review and meta-analysis of the discriminatory performance of risk prediction rules in febrile neutropaenic episodes in children and young people. Eur J Cancer 46:2950–2964. doi: 10.1016/j.ejca.2010.05.024 CrossRefGoogle Scholar
  14. 14.
    Philips R (2008) Predicting infectious complications in febrile neutropenic children with cancer (PICNICC) CRD 2008 available from http://www.york.ac.uk/inst/crd/projects/febrile_neutropenia_lay.htm
  15. 15.
    Phillips B, Selwood K, Lane SM, Skinner R, Gibson F, Chisholm JC (2007) Variation in policies for the management of febrile neutropenia in United Kingdom Children's Cancer Study Group centres. Arch Dis Child 92:495–8PubMedCrossRefGoogle Scholar
  16. 16.
    National Institute for Health and Clinical Excellence (2005) Improving outcomes in children and young people with cancer. National Institute for Health and Clinical. Excellence, LondonGoogle Scholar
  17. 17.
    National Chemotherapy Advisory Group (2009) Chemotherapy services in England: ensuring quality and safety. Department of Health, LondonGoogle Scholar
  18. 18.
    Sung L, Phillips R, Lehrnbecher T (2011) Time for paediatric febrile neutropenia guidelines—children are not like adults. Eur J Caner 47(6):811–3CrossRefGoogle Scholar
  19. 19.
    Dalkey NC, Helmer O (1963) An experimental application of the Delphi method to the use of experts. Manag Sci 9(3):458–467CrossRefGoogle Scholar
  20. 20.
    Goodman CM (1987) The Delphi technique: a critique. J Adv Nurs 12(6):729–734PubMedCrossRefGoogle Scholar
  21. 21.
    Keeney S, Hasson F, McKenna H (2006) Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J Adv Nurs 53(2):205–212PubMedCrossRefGoogle Scholar
  22. 22.
    Soanes L, Gibson F, Bayliss J, Hannan J (2000) Establishing nursing research priorities on a paediatric haemotology, oncology, infectious diseases unit: a Delphi survey. Eur J Onc Nurs 4(2):108–117CrossRefGoogle Scholar
  23. 23.
    McIlfatrick S, Keeney S (2003) Cancer nursing priorities: a Delphi approach. J Adv Nurs 42(6):629–636PubMedCrossRefGoogle Scholar
  24. 24.
    Morita T, Bito S, Kurihara Y, Uchitomi Y. Development of a clinical guideline for palliative sedation therapy using the Delphi method. J Palliat Med 8(4):716–729Google Scholar
  25. 25.
    Sowter J, Cortis J, Clarke DJ (2011) The development of evidence based guidelines for clinical practice portfolios. Nurse Ed Today (epub ahead of print)Google Scholar
  26. 26.
    Biondi PD, Nekolaichuk CL, Stiles C, Fainsinger R, Hagen N (2008) Applying the Delphi process to palliative care tool development: lessons learned. Support Care Cancer 16:935–942CrossRefGoogle Scholar
  27. 27.
    Hasson F, Keeney S, McKenna H (2000) Research guidelines for the Delphi survey technique. J Adv Nurs 32(4):1008–1015PubMedGoogle Scholar
  28. 28.
    Centre of Evidence-based Medicine, Oxford http://www.cebm.net/index.aspx?o=1025 Accessed August 2012
  29. 29.
    Scottish Intermediate Guidelines Network (2011) SIGN 50: a guideline developers' handbook. Healthcare Improvement Scotland. http://www.sign.ac.uk/guidelines/fulltext/50/index.html Accessed January 2012
  30. 30.
    Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients' care. Lancet 362(9391):1225–1230PubMedCrossRefGoogle Scholar
  31. 31.
    Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw J (2011) How can we improve guideline use? A conceptual framework of implementability. Implement Sci 22:6–26Google Scholar
  32. 32.
    Kastner M, Estey E, Bhattacharyya O (2011) Better guidelines for better care: enhancing the implementability of clinical practice guidelines. Expert Rev Pharmacoecon Outcomes Res 11(3):315–324PubMedCrossRefGoogle Scholar
  33. 33.
    Grol R (2010) Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 39(8 Suppl 2):1146–1154Google Scholar
  34. 34.
    Grimshaw J (2004) Implementing clinical guidelines: current evidence and future implications. J Contin Educ Health Prof 24(Suppl 1):531–537Google Scholar
  35. 35.
    Avery A, Savelyich BS, Sheikh A, Cantrill J, Morris CJ, Fernando B, Bainbridge M, Horsfield P, Teasdale S (2005) Identifying and establishing consensus on the most improtant safety features of FP computer systems: e-Delphi study. Inform Prim Care 13(1):3–12PubMedGoogle Scholar
  36. 36.
    Jones S, Murphy F, Edwards M, James J (2008) Doing things differently: advantages and disadvantages of web questionnaires. Nurse Res 15(4):15–26PubMedGoogle Scholar
  37. 37.
    Vehovar V, Lozar Manfreda K (2008) Internet surveys. In: de Leeuw D, Hox JJ, Dillman DA (eds) The international handbook of internet surveys. Lawrence Earlbaum, New YorkGoogle Scholar
  38. 38.
    Parahoo K (2008) Questionnaires. Chapter in Watson R, McKenna H, Cowman S, Keady J. Nursing research: designs and methods. Churchill Livingstone, Elsevier, Edinburgh.Google Scholar
  39. 39.
    Mullen CA, Petropoulos D, Roberts WM, Rytting M, Zipf T, Chan KW, Culbert SJ, Danielson M, Jeha SS, Kuttesch JF, Rolston KV (1999) Outpatient treatment of fever and neutropenia for low risk pediatric cancer patients. Cancer 86(1):126–34PubMedCrossRefGoogle Scholar
  40. 40.
    Paganini H, Gomez S, Ruvinsky S, Zubizarreta P, Latella A, Fraquelli L, Iturres AS, Casimir L, Debbag R (2003) Outpatient, sequential, parenteral-oral antibiotic therapy for lower risk febrile neutropenia in children with malignant disease: A single-center, randomized, controlled trial in Argentina. Cancer 97(7):1775–80PubMedCrossRefGoogle Scholar
  41. 41.
    Paul M, Soares-Weiser K, Leibovici L (2003) {beta} lactam monotherapy versus {beta} lactam-aminoglycoside combination therapy for fever with neutropenia: systematic review and meta-analysis. BMJ 326:1111PubMedCrossRefGoogle Scholar
  42. 42.
  43. 43.
    Contopoulos-Ioannidis DG, Giotis ND, Baliatsa DV, Ioannidis JP (2004) Extended-interval aminoglycoside administration for children: A meta-analysis. Pediatrics 114(1):e111–8PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • F Gibson
    • 1
    Email author
  • J Chisholm
    • 2
  • E Blandford
    • 3
  • P Donachie
    • 3
  • J Hartley
    • 4
  • S Lane
    • 5
  • K Selwood
    • 6
  • R Skinner
    • 7
  • R Phillips
    • 8
  • on behalf of the CCLG Supportive Care Group
  1. 1.Great Ormond Street Hospital for Children NHS Foundation Trust and London South Bank UniversityLondonUK
  2. 2.Children and Young People’s DepartmentRoyal Marsden Hospital NHS Foundation TrustSuttonUK
  3. 3.Children’s Cancer and Leukaemia GroupUniversity of LeicesterLeicesterUK
  4. 4.Department of Microbiology, Virology and Infection ControlGreat Ormond Street Hospital for Children NHS TrustLondonUK
  5. 5.Children’s Oncology UnitChildren’s HospitalOxfordUK
  6. 6.Alder Hey Children’s NHS Foundation Trust HospitalLiverpoolUK
  7. 7.Great North Children’s HospitalNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
  8. 8.University of York and Leeds General InfirmaryLeedsUK

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