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

2. 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

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

4. 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.

5. 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

6. 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

7. 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

8. City Hospitals Sunderland
Time period – Oct 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)

9. 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

10. South Tees NHS Foundation Trust
Time period – June 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

11. 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

12. 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

13. 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

14. Serial Audits of Door to Needle Time - NUTH

15. 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

16. 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

17. 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.

18. 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 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

19. 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.

20. 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

21. 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

22. NECN Actions??

23. Thank - you