Transcript Slide 1

JUST GIVE IT: a 2 phase study
to audit
the Immediate Management of Patients with Proven or
Suspected Neutropenic Sepsis
by Ally Gruber
Acute Oncology Clinical Nurse Specialist
March 2012
Background
 Neuts below 0.5 with temp above 38 c
 Highest cause of death in patients within
30 days of chemo
 Mortality and morbidity could be reduced
by timely treatment
 National Guidelines
 Previous audits – we fell short
 Anectdotal evidence – we still do!
O
Aims and Objectives
To audit the door to needle time for the
administration of IV antibiotics in
neutropenic sepsis
and to identify the reasons for any delays
so as to implement strategies to minimise
delays
and then to evaluate the impact of these
strategies
Target
100% of patients to have antibiotics
administered within 1hour of presentation
(NCAG, 2009)
Design
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Phase 1: Patients were identified using discharge codes
for neutropenia and sepsis for all patients hospitalised
between October 2010 and March 2011 and the list was
checked against Rosewood Ward records. The case
notes were requested and retrospective data was
collected from them using the audit tool.
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Phase 2: For all patients presenting between October
2011 and February 2012 data was collected
prospectively as patients were flagged to the Acute
Oncology Team on presentation or admission. (Patients
found not to be neutropenic (previously excluded) were
included in this phase)
Phase 1 Results
 33 patients were identified as having been
hospitalised with neutropenic sepsis on 37
occasions.
 12 of these were excluded due to being the
wrong time period, no recording of time in case
notes, the drug chart or other crucial parts of the
notes missing, the case notes were unclear or
patients were found not to have been
neutropenic on admission. This left 18 cases
which met the audit criteria.
Phase 1 Results

The time from presentation to administration of
IV antibiotics ranged from 10 minutes to 15
hours and 26 minutes.
 Only 2 patients (11%) received their antibiotics
within 60 minutes and thus met the standard of 1
hour door to needle time. A total of 4 (22%)
received them within 90 minutes and a total of 6
(33%) within 120 minutes.
Phase 1 Results – reasons for
delay
 delay in being seen by A+E doctor or a
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medic
neutropenic sepsis not being considered
as a possible diagnosis
waiting for blood results prior to treatment
not treating due to absence of pyrexia
tazocin not being in stock
PTU being unable to contact a doctor to
review the patient.
Phase 1 Conclusion
Unacceptable delays remain in the
administration of antibiotics to patients
with potential neutropenic sepsis. This
delay is associated with the potential risk
of morbidity. Service improvement
activities should focus on the reasons for
delay
ICE 1
Recommendations
1. Chemo Alert Cards
Recommendations
1. Chemo Alert Cards
2. Pathway
Recommendations
1. Chemo Alert Cards
2. Pathway
3. CAS Card question
4. Teaching sessions / education
5. Prompt referral to AOS
6. Sepsis trolley
7. ‘Time seen’ in notes
8. Coding
9. Chemo referrals
10. KOMS
Other influences
 ‘Just Give It’ poster campaign
Other influences
 ‘Just Give It’ poster campaign
 Surviving Sepsis Campaign
Other influences
 Just Give It’ poster campaign
 Surviving Sepsis Campaign
 Development of the Acute Oncology
Service
Phase 2 Results
 64 patient episodes were identified and
only 1 was excluded as the time of
presentation was not documented in the
notes – therefore 63 episodes were
audited.
Phase 2 Results
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The time from presentation to administration of IV
antibiotics ranged from 17 minutes to 5 hours and 21
minutes.
35 patients (55%) received their antibiotics within 60
minutes. A total of 49 (78%) received them within 90
minutes and a total of 57 (90%) within 120 minutes.
In cases where patients waited over 2 hours for
antibiotics the reason was that neutropenic sepsis was
not considered as a differential diagnosis.
21 patients treated as per neutropenic sepsis protocol
were found not to be neutropenic; however all of these
patients remained on intravenous antibiotics due to
presence of infection.
Graph to show the improvement in care between phase 1 and
phase 2 of the audit
100%
90%
% of Patients treated
90%
80%
95%
84%
91%
82%
73%
70%
60%
50%
Treated in 1hr
50%
40%
40%
30%
91%
33%
Treated in 2hr
38%
20%
10%
11%
0%
Baseline Oct '11
Nov '11 Dec '11
Jan '12
Feb '12
Phase 2 Conclusion
These results show the vast improvement in
care that has resulted from actions taken
to date and it is hoped that further
improvement will be made during the
coming months.
ICE 2
Recommendations
1. Continue teaching sessions
2. Competency criteria
3. Implement NICE Guidance when
finalised
4. ‘Time seen’ in notes
5. Review coding
6. Nurse prescribing
Recommendations
7. Continue prospective audit but also evaluate:
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Patients’ view of information relating to neutropenic
sepsis and the actions they should take
Length of stay of patients admitted with neutropenic
sepsis
Management of patients treated as neutropenic
sepsis but who are not neutropenic
Adherence to other aspects of the pathway such as
sepsis screening, review by senior clinician and
antibiotic prescription
Adherence to NICE guidance
Thank You
 A+E staff – for commitment and hard work
 Dylan Jenkins – for help with pathway
 Dr Gonzales – for encouragement
 Jan Murphy – for artistic advice
 Jane Beadle – for ongoing audit support
 You – for listening!
Any questions?
Just Ask Them!!