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 1 st 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 audit Actions 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) 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 siteRegimenNumber of episodes ColorectalCapecitabine1 UrologyDocetaxel+Pred1 declined IVAB`s within the 1 hr BreastFEC-T4 ColorectalFOLFOX2 LungGem/ Carbo1 ColorectalIrinotecan1

GCSF & Central line Tumour siteCentral venous access On GCSF ColorectalYes 2 patients Hickman Line no Urologyno BreastYes 2 patients Implantable Port 4 LungNono

Age Range No of patients

Arrival Point No of patient episodes 10 patients

Time To IVABS No of patients 40% 100% 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 No of patients episodes 10 patients

Discussions & Recommendations RegimenCycle noDay of cycleG-CSFCVAD Gemlcarbo18No Folfox31NoYes Folfox38NoYes Irinotecan IV215No FEC-T115YesNo Docetaxel + Pred76No FEC-T12YesNo Capecitabine317No FEC-T122Yes FEC-T221Yes 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 meeting 1.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 ActionAction LeadTarget 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 requiredBaleseng 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)