door to needle neutropenic sepsis audit (macmillan chemotherapy unit ) may 11– october 11 baleseng...
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Door to Needle Neutropenic Sepsis Audit(Macmillan Chemotherapy Unit )
May 11– October 11
Baleseng Nkolobe
NWLH NHS Trust Chemotherapy Lead Nurse/Matron
Auditors
• Audit lead: Baleseng Nkolobe
• Other staff carrying out the audit:• L. James
• Lead Consultant: Oncologist and Haematologist
Scope of the Audit
• Trust site specific: – Patients treated at NPH Macmillan Chemotherapy
Unit
• Following NCAG report • 6 monthly audit since January 2009
Speciality Adults only– Haematology – Solid tumour
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
• Patient Safety – Diagnoses of neutropenic sepsis to 1st dose of IV antibiotics
• Effectiveness of the action taken after the last audit (October 10-April 11)
Aims
• To measure time from diagnoses of neutropenic sepsis to first dose of intravenous antibiotics comparing it to Oct10-Apr 11 auditActions from Oct 10- Apr 11 audit
• No of patients decreased compared to September10 audit only 1 patient was admitted with diagnoses of neutropenis sepsis
• The IAVB`s were administered in 7 hours (100% failure)• E-mail sent to A+E matron and CCSG informed of results
Method
• Retrospective audit using formulated criteria for collecting data
• Data collected from information from medical notes and EPR timeline viewer
Findings/Results
• 11 patients episodes for 10 different patients compared to 1 episode in April 11
(1 patient attended A+E 2 times)
• 1 Patient from the 10 audited refused IVAB`s when offered within an hour, this patient was audited as he had neutropenic sepsis
• 1 excluded as not neutropenic
Only 10 patient episodes audited
Tumour site & Regimen
Tumour site Regimen Number of episodes
Colorectal Capecitabine 1
Urology Docetaxel+Pred 1 declined IVAB`s within the 1 hr
Breast FEC-T 4
Colorectal FOLFOX 2
Lung Gem/ Carbo 1
Colorectal Irinotecan 1
GCSF & Central line
Tumour site Central venous access
On GCSF
Colorectal Yes 2 patients Hickman Line
no
Urology no no
Breast Yes 2 patients Implantable Port
4
Lung No no
Age RangeN
o o
f p
atie
nts
0
2
4
6
8
10
18-24 25-34 35-44 45-54 55-64 65 & above
Age Range
Arrival Point
0
2
4
6
8
10
12
A&E MAU
Arrival Point
No
of
pat
ien
t ep
iso
des
10 patients
Time To IVABS
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
1 hr 2hrs 3-4hrs 6hrs 7hrs
Oct10-Apr11
may11-oct11
No
of
pat
ien
ts
40%
100%
20%20%
10%
40%
10%
Results/Findings
IVABs given• 1 x Augmentin+ Clarithromycin• 1 x Clarithromycin + Co-amoxiclav• 2 x Meropenem • 1 x Piperacillin+ Tazobactam• 4 x Tazocin (+ 1 patient was also given G-CSF and 1
patient declined the IVABS)• 1 x Tazocin + Vancomycin
(Paracetamol *2)
Time To Admission
0
1
2
3
4
5
6
2-3 hrs 3-4 hrs 4-5 hrs 6-7 hrs 8-9 Hrs
Apr-11
Oct-11
No
of
pat
ien
ts
epis
od
es
10 patients
Discussions & Recommendations
Regimen Cycle no Day of cycle G-CSF CVADGemlcarbo 1 8 No NoFolfox 3 1 No YesFolfox 3 8 No YesIrinotecan IV 2 15 No No
FEC-T 1 15 Yes NoDocetaxel + Pred 7 6 No NoFEC-T 1 2 Yes NoCapecitabine 3 17 No NoFEC-T 1 22 Yes Yes FEC-T 2 21 Yes Yes
• Number of solid tumour patients admitted in the last six months have increased from 1 to 10.• However, 40% of patients were treated within an hour of diagnoses/assessment in A+E.• The FEC-T regimen patients 2/4 had central venous access device (3/4patients were on first cycle of
treatment) • The FOLFOX regimen is a regimen that requires patients to have a CVAD which is a contributing factor• The average length of stay for the 4 patients who were treated within an hour of diagnoses was 5 days,
however; the longest admission was 13 days. This was a patient who also had a CVAD.
• But for the 6 other patients who were treated after an hour of diagnoses an average stay in hospital of 7 days. The longest hospital stay in this group was also 13 days. The patient who stayed the longest in hospital in this group declined the IVAB`s when they were offered within an hour of admission.
• Recommendations: TO BE DISCUSSED AT CCS Group meeting1. Patients starting chemotherapy to watch neutropenic sepsis DVD from the NWL Cancer Network
to re-iterate the importance of treatment for neutropenic sepsis
Feedback
•Head of Service (Clinical Chemotherapy Services)
•Clinical Chemotherapy Services Meeting
•NWLH NHS Trust Audit•A+E Matron and Lead Consultant
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
B
FEB 12 date changed TBC
Introduction of neutropenic sepsis DVD for patients who are starting chemotherapy
Baleseng Nkolobe – Chemotherapy Lead Nurse
April 2012
Re-audit required Baleseng 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/