Door to Needle Neutropenic Sepsis Audit(Macmillan Chemotherapy Unit )

May 11– October 11

Baleseng Nkolobe

NWLH NHS Trust Chemotherapy Lead Nurse/Matron

Auditors

• Audit lead: Baleseng Nkolobe

• Other staff carrying out the audit:• L. James

• Lead Consultant: Oncologist and Haematologist

Scope of the Audit

• Trust site specific: – Patients treated at NPH Macmillan Chemotherapy

Unit

• Following NCAG report • 6 monthly audit since January 2009

Speciality Adults only– Haematology – Solid tumour

Background

• The aim of this audit is to measure how long (time) patients receive

antibiotics from the time they are assessed by medical/nursing team

and diagnoses of neutropenic sepsis is made in an emergency unit

in NWLH NHS Hospitals.

• As stated in the measures for AOS Peer Review Measures “a

patient should enter a pathway from the time the neutropenic sepsis

diagnosis is made… admission to the pathway does not require

confirmation by blood test” measure 11-3Y-308

Standard Being Audited

• Patient Safety – Diagnoses of neutropenic sepsis to 1st dose of IV antibiotics

• Effectiveness of the action taken after the last audit (October 10-April 11)

Aims

• To measure time from diagnoses of neutropenic sepsis to first dose of intravenous antibiotics comparing it to Oct10-Apr 11 auditActions from Oct 10- Apr 11 audit

• No of patients decreased compared to September10 audit only 1 patient was admitted with diagnoses of neutropenis sepsis

• The IAVB`s were administered in 7 hours (100% failure)• E-mail sent to A+E matron and CCSG informed of results

Method

• Retrospective audit using formulated criteria for collecting data

• Data collected from information from medical notes and EPR timeline viewer

Findings/Results

• 11 patients episodes for 10 different patients compared to 1 episode in April 11

(1 patient attended A+E 2 times)

• 1 Patient from the 10 audited refused IVAB`s when offered within an hour, this patient was audited as he had neutropenic sepsis

• 1 excluded as not neutropenic

Only 10 patient episodes audited

Tumour site & Regimen

Tumour site Regimen Number of episodes

Colorectal Capecitabine 1

Urology Docetaxel+Pred 1 declined IVAB`s within the 1 hr

Breast FEC-T 4

Colorectal FOLFOX 2

Lung Gem/ Carbo 1

Colorectal Irinotecan 1

GCSF & Central line

Tumour site Central venous access

On GCSF

Colorectal Yes 2 patients Hickman Line

no

Urology no no

Breast Yes 2 patients Implantable Port

4

Lung No no

Age RangeN

o o

f p

atie

nts

0

2

4

6

8

10

18-24 25-34 35-44 45-54 55-64 65 & above

Age Range

Arrival Point

0

2

4

6

8

10

12

A&E MAU

Arrival Point

No

of

pat

ien

t ep

iso

des

10 patients

Time To IVABS

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1 hr 2hrs 3-4hrs 6hrs 7hrs

Oct10-Apr11

may11-oct11

No

of

pat

ien

ts

40%

100%

20%20%

10%

40%

10%

Results/Findings

IVABs given• 1 x Augmentin+ Clarithromycin• 1 x Clarithromycin + Co-amoxiclav• 2 x Meropenem • 1 x Piperacillin+ Tazobactam• 4 x Tazocin (+ 1 patient was also given G-CSF and 1

patient declined the IVABS)• 1 x Tazocin + Vancomycin

(Paracetamol *2)

Time To Admission

0

1

2

3

4

5

6

2-3 hrs 3-4 hrs 4-5 hrs 6-7 hrs 8-9 Hrs

Apr-11

Oct-11

No

of

pat

ien

ts

epis

od

es

10 patients

Discussions & Recommendations

Regimen Cycle no Day of cycle G-CSF CVADGemlcarbo 1 8 No NoFolfox 3 1 No YesFolfox 3 8 No YesIrinotecan IV 2 15 No No

FEC-T 1 15 Yes NoDocetaxel + Pred 7 6 No NoFEC-T 1 2 Yes NoCapecitabine 3 17 No NoFEC-T 1 22 Yes Yes FEC-T 2 21 Yes Yes

• Number of solid tumour patients admitted in the last six months have increased from 1 to 10.• However, 40% of patients were treated within an hour of diagnoses/assessment in A+E.• The FEC-T regimen patients 2/4 had central venous access device (3/4patients were on first cycle of

treatment) • The FOLFOX regimen is a regimen that requires patients to have a CVAD which is a contributing factor• The average length of stay for the 4 patients who were treated within an hour of diagnoses was 5 days,

however; the longest admission was 13 days. This was a patient who also had a CVAD.

• But for the 6 other patients who were treated after an hour of diagnoses an average stay in hospital of 7 days. The longest hospital stay in this group was also 13 days. The patient who stayed the longest in hospital in this group declined the IVAB`s when they were offered within an hour of admission.

• Recommendations: TO BE DISCUSSED AT CCS Group meeting1. Patients starting chemotherapy to watch neutropenic sepsis DVD from the NWL Cancer Network

to re-iterate the importance of treatment for neutropenic sepsis

Feedback

•Head of Service (Clinical Chemotherapy Services)

•Clinical Chemotherapy Services Meeting

•NWLH NHS Trust Audit•A+E Matron and Lead Consultant

Actions Agreed and Dates

Action Action Lead Target

completion date

Teaching for A+E medical and nursing staff

As part of Acute Oncology Services teaching

B

FEB 12 date changed TBC

Introduction of neutropenic sepsis DVD for patients who are starting chemotherapy

Baleseng Nkolobe – Chemotherapy Lead Nurse

April 2012

Re-audit required Baleseng Nkolobe – Chemotherapy Lead Nurse

April 12

References

• National Chemotherapy Advisory Group (2009) Chemotherapy services in England: Ensuring quality and safety

• National Confidential Enquiry into Patient Outcomes and Death (2008)

• National Cancer Peer Review Programme: Manual for cancer services. Acute oncology-including metastatic spinal cord compression (2011)

• http://www.macmillan.org.uk/