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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/