chemotherapy out of hours triage: neutopenic fever jeanette ribton oncology cns project no: 26 08/09...

Chemotherapy Out of Hours Triage:Neutopenic Fever

Jeanette Ribton

Oncology CNS

Project No: 26 08/09 Produced by: J Anders C-GARRDPresented: September 2008

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

Why we needed to change: Case Study

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

•Lung cancer – early SCLC Potential remission 2 yrs + with treatment

•Co-morbidity – Eaton Lambert (poor mobility)

•Pt given 1 cycle – discharged home

•On day 8 - diarrhoea, unwell, low grade pyrexia

•Attended A&E 1am - Hypotensive, Neuts 0.1, fluids administered

•Transferred to a ward

•Transferred on again Antibiotics given at 1 pm

•Patient died at 4 pm

Background

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

Snap shot Audit (randomly selected patients 2005-07)

Pre-pathway audit identified:

Lack of inpatient beds Lack of awareness of care pathways in A&E Poor communication across inpatient ward and A&E Absence of IV antibiotics (for Neut sepsis) in A&E Negative impact of 4 hour targets with patients moved off A&E prior to treatment Delays in first antibiotic that exceeded 12 hours in several cases Delayed first antibiotic on cancer day unit due to lack of medical staff

Background

St

Hel

en

s &

Kn

ow

sle

y T

each

ing

Ho

spit

al N

HS

Tru

st ~

CG

AR

RD

2

008-

09S

t H

ele

ns

& K

no

ws

ley

Tea

chin

g H

osp

ital

NH

S T

rust

~ C

GA

RR

D

200

8-09

A snap shot analysis illustrated: Time for a patient to see a Doctor ranged from; 53mins to 3hrs 8mins from arrival at A&E

Time to first administration of antibiotics ranged from; 3hrs 5mins to 12hrs from arrival at A&E

Initial actions

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

The process involved multi-professional collaboration through the oncology and A&E departments to enable:

The development of an alert card The development of an A&E triage neutropenic sepsis pathway (integrated into the standard A&E generic pathway)

Immediate Full Blood Count

First antibiotic administration in A&E

Broad spectrum antibiotics stored on A&E

Educational meetings to inform staff/patients of the process

Pilot period to ensure that it is patient friendly and usable

Nurse led admission (working hours)

Development of Patient Group Directives

Admission pathway

Refer to unwell adult flowchart

YELLOW ORANGE

Inform senior Dr and coordinator

At presentationIf TEMP > 37.5

BP, Pulse, Resp rate

IMMEDIATE FBC, U&E

If clinical signs of shock – pallor, mottled skin, tachycardia, hypotension, ^resp rate, altered GCS

Pts on steroids /analgesics or dehydrated may not present with pyrexia but may still have infection

If Neutrophil count < 1.0

Commence IV antibiotics ASAP before pt leaves A&E

Commence IV antibiotics

IMMEDIATELY

Without FBC result

Tazocin & Gentamicin (4.5g tds) (5mg/kg od)Gentamicin should not be given with cisplatin chemotherapy

If allergic to penicillin (skin rash)Gentamicin & Ceftazidime(5mg/kg od) (2g tds)If allergic reaction is anaphylaxis, uticaria, or rash immediately after penicillin must discuss management with microbiologist

If Neutrophil count > 1.0:If no focus of bacterial infection and no signs of systemic infection oral antibiotics may be considered

Requires medical admissionPrioritize for G5

Background

St

Hel

en

s &

Kn

ow

sle

y T

each

ing

Ho

spit

al N

HS

Tru

st ~

CG

AR

RD

2

008-

09S

t H

ele

ns

& K

no

ws

ley

Tea

chin

g H

osp

ital

NH

S T

rust

~ C

GA

RR

D

200

8-09

Post pathway results:

The preliminary results are favorable after the implementation of the alert card and neutropenic pathway

Shortened time to first medical assessment; Ranged from 11mins to 1 hr 9mins

Reduced time to first antibiotic administration; Ranged from 1hr 38mins to 2hrs 22mins

First antibiotic dose administered in A&E

Greater understanding and enthusiasm of A&E staff

Further audit To undertake a more robust audit

To determine if the initial changes following the snap shot audit have improved the patient journey

To identify any problems with the new pathway

To measure patient outcomes High Risk/Low risk using the MASCC tool Length of stay Length of antibiotics Mortality

To identify future potential changes to improve the inpatient experience

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

Determining high/low risk groups Risk determined through MASCC score

(Multinational Association of Supportive Care in Cancer)

Characteristic Score

No symptoms 5Mild symptoms Not accumulative 5Moderate symptoms 3

No hypotension (systolic<90mmHg) 5

No COPD 4

Solid tumour or no fungal infection 4

No dehydration 3

Outpatient at onset 3

Age < 60 yrs 2

Score > 21 = low risk Score < 21 = high risk

Methodology

Retrospective audit of patients >18 yrs

Time period ~ January 2008 ~ August 2008

Neutropenic fever secondary to chemotherapy (neutrophils <1.0

x 10 /l)⁹

The study group included patients with solid tumours only

Relevant data collection tool devised

Data extracted from health records

Data analysed using Microsoft Access

Total sample size N21

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

Results 58% of patients classified as high risk

42% of patients low risk

The majority of patients - lung (38%) and breast (42%)

primary

Carbo/gem (23%), taxotere (14%), AC (23%)

Length of stay ↑ high risk (6days compared to 4days)

76% a/b’s given within 4hr target

Length of antibiotics – equal for high and low risk

Less IV days for low risk

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

Conclusions

Pathway still not perfect but has improved the care for patients

It encourages better communication and awareness of A&E staff

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

Recommendations: The Future Re-audit in 1 year

Reduce length of stay for low risk patients by facilitating early oncology referral / safe early discharge Thorough education to ensure safety Use of tools Responsibility

Link nurse with A&E

Chemo alert

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

St

Hel

ens

& K

now

sley

Tea

chin

g H

ospi

tal N

HS

Tru

st ~

CG

AR

RD

2

008-

09

Thank you