Network Audit Door – needle target Neutropenic sepsis Melanie Robertson Nurse Consultant Oncology / Cancer Lead Clinician City Hospitals Sunderland NHS Foundation Trust

What is Neutropenic sepsis? Sepsis is the invasion of normally sterile parts of the body by microbes (infection) and the resulting inflammatory response to this, causing an alteration in the body’s normal physiology. Neutropenic sepsis is the occurrence of sepsis in patients who have a neutrophil count of <1.0×109/L

Terms Neutropenic Sepsis Septic Shock Febrile Neutropenia Moderate neutropenia Severe neutropenia Prolonged neutropenia

Immediate treatment of Neutropenic sepsis Resuscitate the patient if required, e.g. if hypovolaemic or septic shock is present. Does the patient have signs of sepsis, e.g. fever, tachycardia, hypotension? Full history and examination Send blood cultures, full infection screen Take bloods for FBC, U&Es, CRP. Antibiotics - begin with broad spectrum according to local guidelines, e.g. Tazocin and an aminoglycoside.

Ongoing Management Look for clues to the source of infection (consider changing anti-biotic therapy accordingly in conjunction with microbiology) Discover the underlying cause for the neutropenia (liaise with Oncology / haematology according to trust guidelines) look for the following which may indicate the severity of the illness: Acute respiratory distress syndrome (commonly associated with viridans group streptococci) Disseminated intravascular coagulation (DIC). Multiple organ failure

The One Hour to Antibiotic Pathway 11-3Y-308 The hospital should agree a patient pathway specification which includes the following: • any patient with certain signs, symptoms and clinical circumstances (to be decided by the hospital as part of the specification) which suggest the likelihood of neutropaenic sepsis, should be entered on the pathway; • the pathway should be designed for the patient to receive a first dose of antibiotics within one hour of entry onto the pathway, i.e. from the time the diagnosis of likely neutropaenic sepsis was made; • the diagnosis of the likelihood of neutropaenic sepsis and entry to the pathway should not require prior confirmation of neutropaenia by blood test and neither should starting the antibiotic within the one hour treatment deadline; • the pathway should not be confined only to patients identified by the patient flagging system; • the nature of and route of administration of the antibiotics depends on clinical circumstances and should be covered by the network acute oncology treatment protocols. Compliance: The pathway, agreed by the hospital acute oncology lead. The reviewers should enquire as to the working practice of the hospital with regards to this pathway and its distribution in the hospital

The One Hour to Antibiotic Audit 11-3Y-309 There should be an audit of the following parameter, for the hospital, across all settings which deal with the assessment and initial management of patients with neutropaenic sepsis: The percentage of all patients clinically diagnosed as likely to have neutropaenic sepsis (according to the specifications in the hospital's one hour to antibiotic pathway) who receive their first dose of antibiotic within one hour of them being clinically diagnosed. The audit should be carried out of all patients received over a continuous period of six months, taken from the twelve month period immediately prior to the peer review or self-assessment. The results of the hospital's one hour to antibiotic audit should be presented to and discussed at a meeting of the NAOG and any actions agreed as a result of the audit. Compliance: The results of the audit, agreed by the hospital acute oncology lead. A relevant extract of a meeting of the NAOG showing that such a discussion has taken place and actions agreed. Note: The results themselves are not subject to the peer review. They are used here as evidence that the audit has been performed

City Hospitals Sunderland Time period – Oct 2011 - March 2012 – 6 months Number of Patients treated with neutropenic sepsis 46 Number of cases audited- 52 Places where patients with Neutropenic sepsis where treated A+E Chemotherapy Day Unit B28 – Haematology Ward AMU Proportion that received antibiotics within one hour of arriving in hospital – 23 pts (50%) Issues identified no documented time that A/B were given but documented they were given, time delay due to a/w blood culture technians to come to ward, patients transferred from one area to another before A/B given, poor venous access Local action Pathway changed to make it easier to follow and complete. PGDs implemented onto B28 Training arranged for staff to take Blood Cultures to minimise delay waiting for technicians. Importance of 1hour A/B time relayed to all areas. Results discussed quarterly at local AOS meetings, disseminated monthly (traffic light system)

North Cumbria University Hospitals NHS Trust Time period – Nov 2011 – April 2012 Number of Patients treated with neutropenic sepsis – 46 Number of cases audited – 31 Places where patients with Neutropenic sepsis where treated (eg A&E, Haematology ward) Admission Units (CIC & WCH) Haem/Onc Inpatient Ward (CIC) Proportion that received antibiotics within one hour of arriving in hospital – 4 out of 31 Issues identified – Some patient notes lacks the time the patient arrived and/or the time the patient was seen, therefore more patients may have received the antibiotics within one hour Neutropenia not viewed by junior doctors as an emergency, or difficulty getting a doctor to see the patient Difficulty accessing antibiotics in clinical areas Local action Develop an admission pathway for all clinical areas (CIC/WCH) - done Update the antibiotics prescribing guidelines – in development Neutropenic sepsis boxes in all appropriate clinical areas – ordered Education events linked with the organisations sepsis team Alter audit tool and review audit practice

South Tees NHS Foundation Trust Time period – June 2011 - November 2011 – 6 months Number of Patients treated with neutropenic sepsis 60 Number of cases audited- 60 Places where patients with Neutropenic sepsis where treated A+E/MAU/AAU Chemotherapy/Haematology Day Units Haematology/Oncology Wards Non cancer wards Proportion that received antibiotics within one hour of arriving in hospital – 28% Issues identified no documented time that A/B were given but documented they were given, patients transferred from one area to another before A/B given, poor venous access Local action PGDs implemented onto all cancer areas and across both hospitals Training arranged for staff and close liaison with the specialist nurse for sepsis management Importance of 1hour A/B time relayed to all areas. Results discussed quarterly at all relevant meetings. A fully constituted AOS service will be across both sites from September 2012

North Tees and Hartlepool NHS Foundation Trust Time period October 2011 – April 2012 Number of Patients treated with suspected neutropenic sepsis 49 Number of cases audited Places where patients with Neutropenic sepsis where treated EAU, Ambulatory Care, Chemotherapy Day Unit, A&E, Haematology Proportion that received antibiotics within one hour of suspicion of neutropenic sepsis Average time 1 hour 25 minutes Issues identified Education, early warning scores, waiting for blood results, controversy regarding Cdiff risk, issues with local sepsis policy Local action Re address local policy, PGD,s, Education, Posters for staff and patients, microbiology and infection control support, 24 hour triage tool, IT alerts on electronic boards in A&E and EAU

Northumbria Healthcare Foundation trust Time period of 2 months :- February and March 2012 Number of patients treated with suspected neutropenic sepsis :- 27 Number of cases audited - 34 Places where patients with neutropenic sepsis where treated :- ODU / A&E across 3 hospitals Proportion that received antibiotics within one hour of suspicion of neutropenic sepsis – 16 patients ( 47% ) Issues identified : poor documentation of actual time anti-biotics given; poor record keeping of patient arrival time on Oncology Day unit; availability of a nurse to deal with emergencies outwith their clinical commitment on the ODU; length of time before actually seen in A&E Local action : development of the Acute Oncology Service will allow a dedicated nurse to be available to deal with emergencies more promptly ; update awareness of neutropenic sepsis policy which will be part of the new Acute Oncology Service education and training programme strengthen links between ODU and A&E

Newcastle upon Tyne Hospitals Time period 1st to 31st January 2012 (4th audit cycle to date, see next slide) Number of Patients treated for neutropenic sepsis 17 Number of cases audited Places where patients with Neutropenic sepsis were treated A+E: n=1 NCCC (haematology & oncology): n=16 Proportion receiving antibiotics within one hour of arriving in hospital door to needle <1hr: 14/17 patients (82%) mean time to antibiotics (n=17): 45 mins Issues identified transfers between wards before antibiotic delivery cause delay Local action highlighted at governance meetings and junior doctor induction 3x yearly nursing updates NCCC stock taz pre-mixed now on NCCC wards

Serial Audits of Door to Needle Time - NUTH

South Tyneside Hospital Time period 6 months October 2011 – March 2012 Number of Patients treated with neutropenic sepsis -7 Number of cases audited - 11 Patients with Neutropenic sepsis where treated in A&E. 0 received antibiotics within one hour of arriving in hospital Issues identified Lack of neutropenic sepsis policy awareness Need for training of medical and nursing teams in emergency/acute care. Awareness of AO CNS role No clear information resources for staff to access Local action Role out educational events Development PGDs and tool box for immediate administration of antibiotics Development of educational tools and accessible resources for staff Roll out the Triage tool Involvement of pharmacy and microbiology staff in development

County Durham and Darlington Time Period- 09/01/2012 to 10/05/2012 Number Treated 26 Number Audited 23 (3 incomplete data available) Treatment Areas A & E Specialist Chemo Area Ward 2 16 5 Proportion who received Antibiotics within one hour. 34.78% Average door to needle time in hours 2.11 hours Out of hours 5 hours A&E 42.5 mins

Neutropenic Sepsis Audit. Issues and Local Action. Staff waiting for results to confirm neutropenia. Doctor not available to take cultures and prescribe antibiotics. Lack of awareness of policy. Policy not followed. Lack of senior review. Local Action Targeted education in key areas. Patient group directives almost ready to roll out. Engagement with sepsis steering group. Sepsis Care Bundle developed to include management of neutropenic sepsis. High visibility of AOS nurses in key areas to assist and advise. Neutropenic sepsis kits being supplied to key areas. Audit ongoing.

QE Hospital Time period 4 months August 2011 – Nov 2011 Number of Patients treated for neutropenic sepsis 17 Number of cases audited 13 (the others developed neutropenic sepsis while already inpatients therefore not included in the audit which just looked at admissions) Places where patients with Neutropenic sepsis where treated (eg A&E, Haematology ward) Chemo day unit – 6 patients, A+E -6 patients, ward 14 -1 patient (gynae-onc) Proportion that received antibiotics within one hour of suspicion of neutropenic sepsis CDU 38 mins (using patient group directives) A+E 2 hours 22 mins

QEH Issues identified Local action – CDU very much better at identifying and treating neutropenic sepsis PGDs have been helpful to reduce time to treatment A+E nowhere near target – despite patient information, carrying red chemotherapy book, staff education See attached slides for some nice graphs Local action – under discussion how best to deal with this – would welcome ideas.

QE before and after PGDs introduced on CDU December 2010 – March 2011³ August 2011 – November 2011 Dec 2010 – March 2011 40% received antibiotics in less than one hour 20% received antibiotics between 1 – 2 hours 20% received antibiotics between 2 – 3 hours 20% received antibiotics between >3 hours Aug 2011 – Nov 2011 54% received antibiotics in less than one hour 8% received antibiotics between 1 – 2 hours 15% received antibiotics between 2 – 3 hours 23% received antibiotics between >3 hours 40% received antibiotics within 1 hour of the trigger 54% received antibiotics within 1 hour of the trigger 20

Only CDU are managing to follow the Neutropenic Sepsis Protocol. Time (in minutes) 1 Hour Only CDU are managing to follow the neutropenic sepsis protocol of antibiotics within 1 hour of a trigger. 6 patients admitted to CDU 6 patients admitted to A + E 1 patient admitted through ward 14 Only CDU are managing to follow the Neutropenic Sepsis Protocol. 4 out of the 6 doses of antibiotics administered on CDU were given by nurses under the new Patient Group Directive. 21

NECN Actions??

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