1. Chemotherapy Out of Hours Triage: Neutopenic Fever Jeanette Ribton Oncology CNS Project No: 26 08/09 Produced by: J Anders C-GARRD Presented: September 2008 St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

2. Why we needed to change: Case Study St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09 Lung cancer – early SCLC Potential remission 2 yrs + with treatment Co-morbidity – Eaton Lambert (poor mobility) Pt given 1 cycle – discharged home On day 8 - diarrhoea, unwell, low grade pyrexia Attended A&E 1am - Hypotensive, Neuts 0.1, fluids administered Transferred to a ward Transferred on again Antibiotics given at 1 pm Patient died at 4 pm

3. Background St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09 Snap shot Audit (randomly selected patients 2005-07) Pre-pathway audit identified:  Lack of inpatient beds  Lack of awareness of care pathways in A&E  Poor communication across inpatient ward and A&E  Absence of IV antibiotics (for Neut sepsis) in A&E  Negative impact of 4 hour targets with patients moved off A&E prior to treatment  Delays in first antibiotic that exceeded 12 hours in several cases  Delayed first antibiotic on cancer day unit due to lack of medical staff

4. Background St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09 A snap shot analysis illustrated:  Time for a patient to see a Doctor ranged from; 53mins to 3hrs 8mins from arrival at A&E  Time to first administration of antibiotics ranged from; 3hrs 5mins to 12hrs from arrival at A&E

5. Initial actions St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09 The process involved multi-professional collaboration through the oncology and A&E departments to enable:  The development of an alert card  The development of an A&E triage neutropenic sepsis pathway (integrated into the standard A&E generic pathway)  Immediate Full Blood Count  First antibiotic administration in A&E  Broad spectrum antibiotics stored on A&E  Educational meetings to inform staff/patients of the process  Pilot period to ensure that it is patient friendly and usable  Nurse led admission (working hours)  Development of Patient Group Directives  Admission pathway

7. Refer to unwell adult flowchart YELLOW ORANGE Inform senior Dr and coordinator At presentation If TEMP > 37.5 BP, Pulse, Resp rate IMMEDIATE FBC, U&E If clinical signs of shock – pallor, mottled skin, tachycardia, hypotension, ^resp rate, altered GCS Pts on steroids /analgesics or dehydrated may not present with pyrexia but may still have infection If Neutrophil count < 1.0 Commence IV antibiotics ASAP before pt leaves A&E Commence IV antibiotics IMMEDIATELY Without FBC result Tazocin & Gentamicin (4.5g tds) (5mg/kg od) Gentamicin should not be given with cisplatin chemotherapy If allergic to penicillin (skin rash) Gentamicin & Ceftazidime (5mg/kg od) (2g tds) If allergic reaction is anaphylaxis, uticaria, or rash immediately after penicillin must discuss management with microbiologist If Neutrophil count > 1.0: If no focus of bacterial infection and no signs of systemic infection oral antibiotics may be considered Requires medical admission Prioritize for G5

8. Background St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09 Post pathway results: The preliminary results are favorable after the implementation of the alert card and neutropenic pathway  Shortened time to first medical assessment; Ranged from 11mins to 1 hr 9mins  Reduced time to first antibiotic administration; Ranged from 1hr 38mins to 2hrs 22mins  First antibiotic dose administered in A&E  Greater understanding and enthusiasm of A&E staff

9. Further audit  To undertake a more robust audit  To determine if the initial changes following the snap shot audit have improved the patient journey  To identify any problems with the new pathway  To measure patient outcomes  High Risk/Low risk using the MASCC tool  Length of stay  Length of antibiotics  Mortality  To identify future potential changes to improve the inpatient experience St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

10. Determining high/low risk groups Risk determined through MASCC score  (Multinational Association of Supportive Care in Cancer) CharacteristicScore No symptoms 5 Mild symptoms Not accumulative 5 Moderate symptoms 3 No hypotension (systolic<90mmHg)5 No COPD4 Solid tumour or no fungal infection4 No dehydration3 Outpatient at onset3 Age < 60 yrs2 Score > 21 = low risk Score < 21 = high risk

11. Methodology  Retrospective audit of patients >18 yrs  Time period ~ January 2008 ~ August 2008  Neutropenic fever secondary to chemotherapy (neutrophils <1.0 x 10 ⁹ /l)  The study group included patients with solid tumours only  Relevant data collection tool devised  Data extracted from health records  Data analysed using Microsoft Access  Total sample size N21 St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

12. Results  58% of patients classified as high risk  42% of patients low risk  The majority of patients - lung (38%) and breast (42%) primary  Carbo/gem (23%), taxotere (14%), AC (23%)  Length of stay ↑ high risk (6days compared to 4days)  76% a/b’s given within 4hr target  Length of antibiotics – equal for high and low risk  Less IV days for low risk St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

13. Conclusions Pathway still not perfect but has improved the care for patients It encourages better communication and awareness of A&E staff St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

14. Recommendations: The Future Re-audit in 1 year Reduce length of stay for low risk patients by facilitating early oncology referral / safe early discharge  Thorough education to ensure safety  Use of tools  Responsibility Link nurse with A&E Chemo alert St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

15. Thank you