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 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
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
o
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 inpatients 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
Azacitidine+AML16
Number of Episodes
Rituximab+ Fludarabine and
Cyclophosphamide
2
1
1
R-CHOP
BEACOPP
1
Cyclophosphamide and
Dexamethasone
1 excluded as no script
to analyse time for
IVABS
Age Range
10
9
8
7
6
No of patients
5
4
3
2
2
2
1
1
0
0
1
0
0
20-30
30-40
40-50
50-60
Age Range
60-70
70-80
80+
Arrival Point
12
11
6 patient episodes but CMH patient only
included in arrival point not in time to
IVABs
10
9
No of patient episodes
8
7
6
5
4
50%
3
33%
2
17%
1
0
A&E NPH
Byrd Ward A/Room
Arrival Point
A&E CMH
Time To IVABS
6
5
Byrd day care
NPH A&E
4
CMH A&E
No of patient
episodes
3
100%
67%
2
33%
1
0
0
0
0
<1hr- 1hr
2hrs
Time to IVABS
3hrs
Results/Findings
IVABs given
•
•
•
2 x Tazocin
1 x Tazocin+ Amikacin + Metronidazole
1x Tazocin and Metronidazole
Time To Admission
7
6
5
No of patient
4
3
3
2
1
1
1
0
0
3-4 hrs
5-6 hrs
6-7 hrs
Time to Admission
8-9 hrs
Length of Stay
Average length of stay 19.5 days
7
6
No of patient
episodes
5
4
3
2
2
1
1
1
1
0
4 days
6 days
11 days
Length of Stay
71days
Discussions & Recommendations
Regimen
Cycle no
Day of cycle
On oral antibiotics
CVAD
Azacitidine
6
15
Yes
No
Rituximab+ Fludarabine +Cyclophos
8
6
Yes
No
8
12
Yes
No
3
17
No
No
2
9
No info
Yes
Rituximab+ Fludarabine +Cyclophos
BeaCOPP
R-CHOP
•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 inpatients
Haematology ward
manager/matron
April 12
Introduction of
neutropenic sepsis DVD
for patients who are
starting chemotherapy
Haematology ward
manager/matron
April 12
Re-audit required
B. Nkolobe; Chemotherapy Lead Nurse
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/