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: – Northwick Park Hospital and CMH

• Following NCAG report and N.S. 6 Monthly auditSpeciality

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

o 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

o Overall there was an improvement of 5% from last audit as 27% of haematology patients were treated within an hour.

o 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 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

Methodology

• 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

Regimen Number of Episodes

Azacitidine+AML16 1

Rituximab+ Fludarabine and Cyclophosphamide

2

R-CHOP1

BEACOPP 1

Cyclophosphamide and Dexamethasone

1 excluded as no script to analyse time for IVABS

Age Range

0

1

2

3

4

5

6

7

8

9

10

20-30 30-40 40-50 50-60 60-70 70-80 80+

Age Range

0 0 0

2

1

2

1No

of

pat

ien

ts

Arrival Point

50%

33%

17%

0

1

2

3

4

5

6

7

8

9

10

11

12

A&E NPH Byrd Ward A/Room A&E CMH

Arrival Point

No

of

pat

ien

t ep

iso

des

6 patient episodes but CMH patient only included in arrival point not in time to IVABs

Time To IVABS

100%

0 0

67%

33%

00

1

2

3

4

5

6

<1hr- 1hr 2hrs 3hrs

Time to IVABS

Byrd day care

NPH A&E

CMH A&E

No

of

pat

ien

t ep

iso

des

Results/Findings

IVABs given

• 2 x Tazocin• 1 x Tazocin+ Amikacin + Metronidazole• 1x Tazocin and Metronidazole

Time To Admission

1

0

1

3

0

1

2

3

4

5

6

7

3-4 hrs 5-6 hrs 6-7 hrs 8-9 hrs

Time to Admission

No

of

pat

ien

t

Length of Stay

0

1

2

3

4

5

6

7

4 days 6 days 11 days 71days

Length of Stay

2

1 1 1

No

of

pat

ien

t ep

iso

des

Average length of stay 19.5 days

Discussions & Recommendations

Regimen Cycle no Day of cycle On oral antibiotics CVAD

Azacitidine 6 15 Yes No

Rituximab+ Fludarabine +Cyclophos 8 6 Yes No

Rituximab+ Fludarabine +Cyclophos8 12 Yes No

BeaCOPP3 17 No No

R-CHOP 2 9 No info Yes

•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 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

Haematology ward manager/matron

Baleseng Nkolobe – Chemotherapy Lead Nurse

April 12

Re-audit required B. Nkolobe; Chemotherapy Lead Nurse April 12

References

• 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/