Reducing the Door to Needle Time for Antibiotics in Suspected Neutropenic Sepsis using a Dedicated Clinical Pathway Dr Alex Williams, Oncology Specialty Doctor. Gloucestershire Oncology Centre, Cheltenham General Hospital Quality improvement and audit: improving outcomes The 2015 Clinical Oncology Audit Conference and Poster Competition. The Royal College of Radiologists, 63 Lincoln's Inn Fields, London. Wednesday 17 June 2015

Cheltenham General Hospital Oncology Centre Comprehensive cancer service for over 1 million people 14 Clinical Oncologists and 2 Medical Oncologists, 3 registrars 6 Specialty Doctors and 1 Associate Specialist. 2 Oncology Wards- acute oncology and haematology, elective admissions for chemo and radiotherapy 44 beds

A busy department, with a large number of patients daily Dedicated Helpline 24 hour a day, 7 days a week Run by oncology trained nurses and Oncology Doctors

Neutropenic Sepsis Potentially fatal complication of systemic anti-cancer therapy Requires specialist, rapid input NICE Clinical Guidelines 151 NHS Standard Contract for Cancer

Aim of Audit Initial retrospective audit Robust clinical pathway based on ‘Sepsis Six care Bundle’ for patients presenting with suspected neutropenic sepsis Reduce time to first dose of antibiotics Improve patient safety and clinical performance Adhere to NICE Guidance

Standard 100% patients presenting to an Oncology Helpline who have: received chemotherapy within six weeks infective symptoms and/or pyrexia of ≥38ºC receive antibiotics within one hour of arrival

Method December 2012-January Retrospective baseline audit 26 patients over six week period Arrival time Time antibiotics given Patient demographics Cancer details Aim of treatment Regime of chemotherapy First/Second line treatment or other Need for ITU/HDU admission Outcome- continuation of chemotherapy/cessation of chemotherapy/death

Patient Demographics Age range (median 62.5) 42% male, 48% female Aim of treatment 65% palliative, 35% radical Primary disease- 27% lymphoma, 23% breast, 11% GI, 11% leukaemia, 11% myeloma, 11% gynae 7% head and neck

Baseline Results of Door to Needle Time 32% of patients with suspected neutropenic sepsis received antibiotics within one hour of arrival to the dedicated oncology helpline.

Strategy for Change 1. Multidisciplinary Neutropenic Clinical Pathway with the principles of the Sepsis Six Care Bundle. ‘take three, give three’ Take: blood cultures lactate and bloods, urine output; Give:IV fluids, 100% O ₂, IV antibiotics

Neutropenic sepsis pathway

Strategy for Change 1 (cont.) Antibiotics given without knowledge of neutrophil count. Act on suspicion of neutropenic sepsis Agreement with consultants and microbiologists

Patient Group Direction (PGD) Nurse Led Prescribing Delivery of First dose of Antibiotics Implementation through education Strategy for Change 2.

Multidisciplinary Team Education Programme All staff working in Oncology Department Health care assistants, nursing staff, junior doctors and senior medical staff Ongoing strategy Prospective re audit Strategy for Change 3.

Prospective reaudit over 2 week period with implemented changes April-May % of patients received antibiotics within one hour presenting to oncology helpline if suspected neutropenic sepsis (compared to 32% before changes implemented)

Continued Prospective Clinical Audit MAY DOOR TO NEEDLE TIME AUDIT - CHEMOTHERAPY HELPLINE MED MRNNAMEM/FDIAGNOSISDATEARRIVEABX TIME DOOR TO NEEDLE NEUTROPHIL COUNTONGOING MANAGEMENT M01/05/ : :0035 mins6.40ADMITTED 1 NIGHT MMYELOMA04/05/ : :0020 mins3.20ADMITTED 7 NIGHTS FBREAST04/05/ : :0040 mins5.72DISCHARGED M05/05/ : :0025 mins0.26ADMITTED 4 WEEKS FGynae06/05/ : :0025 mins5.72DISCHARGED FNHL09/05/ : :0015 mins0.75ADMITTED 4 NIGHTS FNHL09/05/ : :0015 mins1.01ADMITTED ONE NIGHT FBREAST13/05/ : :0015 mins15.27DISCHARGED MMESOTHELIOMA13/05/ : ;0055 mins7.13ADMITTED 4 NIGHTS MMYELOMA13/05/ : :0010 mins11.30ADMITTED 3 NIGHTS FNHL18/05/ : :0015 mins0.64ADMITTED 5 NIGHTS MOESOPHAGUS18/05/ : :0030 mins8.12DISCHARGED FBreast21/05/ : :0010 mins6.95DISCHARGED MHEAD / NECK21/05/ : :0020 mins0.66ADMITTED 5 NIGHTS FBreast23/05/201517:00: :0030 mins15.00DISCHARGED FBREAST23/05/ : :0060 mins21.00ADMITTED MAML24/05/ : :0025 mins2.14DISCHARGED FPERITONEUM25/05/ : :0045 mins4.60DISCHARGED FBREAST26/05/ : :0025 mins0.12ADMITTED 3 NIGHTS FBREAST26/05/ : :0030 mins6.56DISCHARGED FBREAST27/05/ : :0035 mins0.01ADMITTED 5 NIGHTS M28/05/ : :0030 mins11.67DISCHARGED FBREAST29/05/201510:00: :0020 mins0.14ADMITTED FBREAST29/05/ : :0030 mins4.33DISCHARGED FNHL30/05/ : :0050 mins0.83ADMITTED FAML30/05/ : :0014 Mins0.68ADMITTED FLUNG30/05/ : ;0020 mins0.68ADMITTED Proportion of neuropenic patients-37%

Discussion NICE guidance- expeditious use of antibiotics suspected neutropenic sepsis Reduces morbidity Reduces mortality Strategies for Change Positive outcome for patients Robust dedicated clinical pathway

Conclusions Dedicated clinical care pathway Education Cost neutral changes Radical change in patient pathway Meeting External Peer Review requirements Simple changes in clinical practice lead to big changes in patients care and outcomes