No published reports have assessed the validity of TTA as a QOC measure for pediatric FN, and only one previously-published report describes TTA for FN.[11
] This report describes an intervention to reduce TTA to < 30 minutes in a single center and does not attempt to associate TTA with outcomes of hospitalization. In reviewing the TTA literature for other conditions in adults, TTA cut points for analysis or benchmarking have ranged from 3–24 hours for bacterial meningitis,[1
] 4–8 hours for community acquired pneumonia (CAP),[5
] and 1 hour in sepsis.[8
] Given the high risk for bacteremia and sepsis in children with FN, it is not surprising that most centers who are tracking TTA in pediatric FN endorse the use of a benchmark similar to that of adults with sepsis (< 60 minutes.)
In considering TTA for pediatric FN within Donabedian's QOC model of structure-process-outcome for a care episode,[12
] TTA would be considered a process measure for FN. The validity of TTA as a process measure for FN is grounded in its focus on the quality domains of efficiency, timeliness, and patient-centeredness.[13
] The appeal of TTA as a QOC measure in conditions like sepsis, CAP, and meningitis is its association with outcomes of care including mortality and length-of-stay which reflect the safety and effectiveness domains of quality. To our knowledge, no prior reports have examined a potential association of TTA with outcomes of hospitalization for FN. Any attempt to examine this association will have to account for a variety of known predictors of outcome for FN including age, the underlying malignancy and its treatment, and the degree of neutropenia among others.
In this study, TTA is used as a QOC standard in nearly half of surveyed pediatric oncology centers. An increased number of new cases per year and a larger number of nurse practitioners were associated with tracking TTA. Consistent with this finding, one-third of centers not tracking TTA report inadequate resources as a reason for not tracking although more than one-quarter of those not tracking TTA have plans to do so. Of centers tracking TTA, the vast majority report using a standard or benchmark of less than 60 minutes and do not distinguish between high and low risk patients in analyzing TTA. In a limited number of responses, centers report longer mean TTA in the ED setting compared to the inpatient unit and outpatient clinic.
The conclusions of this study are limited by factors inherent to the survey methodology. Respondents may not be representative of non-respondents and thereby introduce bias. Similarly we have no means of confirming the accuracy of the responses provided which may have been affected by recall bias and social desirability bias. Additionally, the validity of the survey instrument was not fully established with test / re-test reliability though face validity was evaluated prior to administration of the survey.
In conclusion, many pediatric cancer centers in the US and Canada are tracking TTA as a QOC measure for FN. While TTA for FN would be a welcome addition to other established QOC measures within pediatric oncology such as rates of bloodstream infection and rates of chemotherapy errors, further investigation of its validity as a measure of the process and outcomes of care are warranted before it is accepted as a standard QOC measure in the pediatric oncology community.