chemotherapy out of hours triage: neutopenic fever jeanette ribton oncology cns project no: 26 08/09...
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Chemotherapy Out of Hours Triage:Neutopenic Fever
Jeanette Ribton
Oncology CNS
Project No: 26 08/09 Produced by: J Anders C-GARRDPresented: September 2008
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Why we needed to change: Case Study
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•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
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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
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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
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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
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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
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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
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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
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Conclusions
Pathway still not perfect but has improved the care for patients
It encourages better communication and awareness of A&E staff
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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
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Thank you