JUST GIVE IT: a 2 phase study to audit the Immediate Management of Patients with Proven or Suspected Neutropenic Sepsis by Ally Gruber Acute Oncology Clinical Nurse Specialist March 2012

Background  Neuts below 0.5 with temp above 38 O c  Highest cause of death in patients within 30 days of chemo  Mortality and morbidity could be reduced by timely treatment  National Guidelines  Previous audits – we fell short  Anectdotal evidence – we still do!

Aims and Objectives To audit the door to needle time for the administration of IV antibiotics in neutropenic sepsis and to identify the reasons for any delays so as to implement strategies to minimise delays and then to evaluate the impact of these strategies

Target 100% of patients to have antibiotics administered within 1hour of presentation (NCAG, 2009)

Design  Phase 1: Patients were identified using discharge codes for neutropenia and sepsis for all patients hospitalised between October 2010 and March 2011 and the list was checked against Rosewood Ward records. The case notes were requested and retrospective data was collected from them using the audit tool.  Phase 2: For all patients presenting between October 2011 and February 2012 data was collected prospectively as patients were flagged to the Acute Oncology Team on presentation or admission. (Patients found not to be neutropenic (previously excluded) were included in this phase)

Phase 1 Results  33 patients were identified as having been hospitalised with neutropenic sepsis on 37 occasions.  12 of these were excluded due to being the wrong time period, no recording of time in case notes, the drug chart or other crucial parts of the notes missing, the case notes were unclear or patients were found not to have been neutropenic on admission. This left 18 cases which met the audit criteria.

Phase 1 Results  The time from presentation to administration of IV antibiotics ranged from 10 minutes to 15 hours and 26 minutes.  Only 2 patients (11%) received their antibiotics within 60 minutes and thus met the standard of 1 hour door to needle time. A total of 4 (22%) received them within 90 minutes and a total of 6 (33%) within 120 minutes.

Phase 1 Results – reasons for delay  delay in being seen by A+E doctor or a medic  neutropenic sepsis not being considered as a possible diagnosis  waiting for blood results prior to treatment  not treating due to absence of pyrexia  tazocin not being in stock  PTU being unable to contact a doctor to review the patient.

Phase 1 Conclusion Unacceptable delays remain in the administration of antibiotics to patients with potential neutropenic sepsis. This delay is associated with the potential risk of morbidity. Service improvement activities should focus on the reasons for delay ICE 1

Recommendations 1. Chemo Alert Cards

Recommendations 1.Chemo Alert Cards 2.Pathway

Recommendations 1.Chemo Alert Cards 2.Pathway 3.CAS Card question 4.Teaching sessions / education 5.Prompt referral to AOS 6.Sepsis trolley 7.‘Time seen’ in notes 8.Coding 9.Chemo referrals 10.KOMS

Other influences  ‘Just Give It’ poster campaign

Other influences  ‘Just Give It’ poster campaign  Surviving Sepsis Campaign

Other influences  Just Give It’ poster campaign  Surviving Sepsis Campaign  Development of the Acute Oncology Service

Phase 2 Results  64 patient episodes were identified and only 1 was excluded as the time of presentation was not documented in the notes – therefore 63 episodes were audited.

Phase 2 Results  The time from presentation to administration of IV antibiotics ranged from 17 minutes to 5 hours and 21 minutes.  35 patients (55%) received their antibiotics within 60 minutes. A total of 49 (78%) received them within 90 minutes and a total of 57 (90%) within 120 minutes.  In cases where patients waited over 2 hours for antibiotics the reason was that neutropenic sepsis was not considered as a differential diagnosis.  21 patients treated as per neutropenic sepsis protocol were found not to be neutropenic; however all of these patients remained on intravenous antibiotics due to presence of infection.

Phase 2 Conclusion These results show the vast improvement in care that has resulted from actions taken to date and it is hoped that further improvement will be made during the coming months. ICE 2

Recommendations 1.Continue teaching sessions 2.Competency criteria 3.Implement NICE Guidance when finalised 4.‘Time seen’ in notes 5.Review coding 6.Nurse prescribing

Recommendations 7.Continue prospective audit but also evaluate: –Patients’ view of information relating to neutropenic sepsis and the actions they should take –Length of stay of patients admitted with neutropenic sepsis –Management of patients treated as neutropenic sepsis but who are not neutropenic –Adherence to other aspects of the pathway such as sepsis screening, review by senior clinician and antibiotic prescription –Adherence to NICE guidance

Thank You  A+E staff – for commitment and hard work  Dylan Jenkins – for help with pathway  Dr Gonzales – for encouragement  Jan Murphy – for artistic advice  Jane Beadle – for ongoing audit support  You – for listening!

Any questions? Just Ask Them!!