NWLH NHS Trust Chemotherapy Lead Nurse/Matron Chemotherapy Door to Needle Neutropenic Sepsis Audit (Haematology patients only) May 11 –Oct 11 Baleseng Nkolobe NWLH NHS Trust Chemotherapy Lead Nurse/Matron

Auditors Audit lead: Baleseng Nkolobe Other staff carrying out the audit: Mary Collins Caroline Kieley Vashti Ragoonanan Lead Consultant: N. Panoskaltsis

Scope of the Audit Trust site specific: Following NCAG report and N.S. Northwick Park Hospital and CMH Following NCAG report and N.S. 6 Monthly audit Speciality Haematology patients treated on the: Haematology Unit NPH Day-care Unit CMH Chemotherapy Out Patient Unit NPH

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 and Results from Last Audit Patient Safety – time from neutropenic sepsis diagnoses by medical / nursing staff to 1st dose of IV antibiotics Results from last audit 33% of patients were seen in the haematology assessment room.20% were treated within an hour of assessment by nurse/medical personnel compared to 40% in previous six months 60% were seen in NPH A+E and 33% of patients who attended A+E were treated within 1 hour 6% was seen in CMH A+E (1/15) and treatment within an hour was not achieved Overall there was an improvement of 5% from last audit as 27% of haematology patients were treated within an hour. The longest wait for antibiotics was 9 hours in A+E compared to 6 hours in haematology assessment room

Aims To measure time from diagnoses of neutropenic sepsis to first dose of IVABS comparing it to Sept 10 audit.

Actions Agreed and Dates Action Lead Target completion date N.S. DVD for haematology unit to improve teaching re-management of N.S. B. Nkolobe Chemotherapy Lead Nurse Dec 2010 done To discuss audit of in-patients developing N.S. K.Kyriakou Haematologist J.Lucas Haem unit Matron Outstanding May 12 Discussed at Cancer Board meeting B. Nkolobe 2011 Re-audit required B. Nkolobe;Chemotherapy Lead Nurse October 2011 Please note, this slide is to inform your areas that actions will be taking place and in the re-audit these actions may probably show a change. Note possible date/ month of the Re-audit.

Methodology Only 5 patients episodes were audited Retrospective audit using formulated criteria for collecting data and also PAM-T patients from October 11 Data collected from information from medical notes and EPR timeline viewer 15/15 patient episodes were audited across 14 different patients 11 patients through PAM-T were audited and 9 excluded as reason for admission was not neutropenic sepsis 1 patient from CMH A+E was also excluded in time to IVAB`s as prescription could not be located for time confirmation Only 5 patients episodes were audited

Regimen & Number of Episodes Azacitidine+AML16 1 Rituximab+ Fludarabine and Cyclophosphamide 2 R-CHOP BEACOPP Cyclophosphamide and Dexamethasone 1 excluded as no script to analyse time for IVABS

Age Range Indicate on this slide as to why this audit was carried out. No of patients Indicate on this slide as to why this audit was carried out. Example is it: National, regional, trust wide, Trust site specific, Nice Guidance,Patient involvement Essence of care (Essence of care standards). An audit should be carried out to ensure that there are no gaps between actual practice and Best practice

Arrival Point No of patient episodes 6 patient episodes but CMH patient only included in arrival point not in time to IVABs Indicate on this slide as to why this audit was carried out. Example is it: National, regional, trust wide, Trust site specific, Nice Guidance,Patient involvement Essence of care (Essence of care standards). An audit should be carried out to ensure that there are no gaps between actual practice and Best practice

Time To IVABS No of patient episodes Indicate on this slide as to why this audit was carried out. Example is it: National, regional, trust wide, Trust site specific, Nice Guidance,Patient involvement Essence of care (Essence of care standards). An audit should be carried out to ensure that there are no gaps between actual practice and Best practice

Results/Findings IVABs given 2 x Tazocin 1 x Tazocin+ Amikacin + Metronidazole 1x Tazocin and Metronidazole

Time To Admission No of patient Indicate on this slide as to why this audit was carried out. Example is it: National, regional, trust wide, Trust site specific, Nice Guidance,Patient involvement Essence of care (Essence of care standards). An audit should be carried out to ensure that there are no gaps between actual practice and Best practice

Length of Stay Average length of stay 19.5 days No of patient episodes Average length of stay 19.5 days Indicate in this slide, as to How did you select the audit sample… retrospective/ prospective?/ randomly/ shift patterns what was the total sample size were there any inclusion/exclusion criteria. Did you just audit NWP/ CMH or both sites

Discussions & Recommendations Regimen Cycle no Day of cycle On oral antibiotics CVAD Azacitidine 6 15 Yes No Rituximab+ Fludarabine +Cyclophos 8 12 BeaCOPP 3 17 R-CHOP 2 9 No info Number of haematology patients admitted with neutropenic sepsis decreased by 33% this is despite the inclusion of patient data from PaM-T for only one month October 11. 1000% of patients were treated within an hour of diagnoses/assessment in haematology unit 67% of patients seen in A+E were treated within an hour and the longest wait was 2 hours compared to 9 hours in last six months. Overall 80% of patients treated in NWLH-NHS Trust were treated within 1 hour of diagnoses/assessment this is an improvement from 27% in the last audit( April 11) The average length of stay for the 5 patients was 19.5 days the longest stay was 71 days for a patient who was treated in less than 1 hour. Recommendations: TO BE DISCUSSED AT CCS Group meeting

Feedback CCSG Meeting Feb 12 Haematology Clinical governance April 12 Cancer Board meeting A&E Matron and Lead Consultant NWLH NHS Trust Audit

Actions Agreed and Dates Action Lead Target completion date Teaching for A+E medical and nursing staff As part of Acute Oncology Services teaching FEB 12 date changed TBC Neutropenic audit for in-patients Haematology ward manager/matron April 12 Introduction of neutropenic sepsis DVD for patients who are starting chemotherapy Baleseng Nkolobe – Chemotherapy Lead Nurse Re-audit required B. Nkolobe; Chemotherapy Lead Nurse Please note, this slide is to inform your areas that actions will be taking place and in the re-audit these actions may probably show a change. Note possible date/ month of the Re-audit.

References http://www.macmillan.org.uk/ 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) http://www.macmillan.org.uk/