Chasing the Golden Hour – Lessons learned from improving initial neutropenic sepsis management.

Abstract

Neutropenic sepsis remains a time critical and potentially fatal complication of systemic anti-cancer therapy. A target ‘door to needle’ time of one hour for first dose empirical intravenous antibiotics continues to be promoted nationally. A baseline audit (June 2011) highlighted shortfalls in care in the Belfast Trust, with only 15% of patients receiving antibiotics within sixty minutes. A multi-professional group within the Trust was established to try and initiate the improvements in neutropenic sepsis recognition and initial management that were urgently required. A number of strategies have been developed over the last five years. Firstly an integrated care pathway was introduced, which is currently used by nursing and medical staff for patients presenting with suspected neutropenic sepsis, through acute cancer centre assessment areas and emergency departments, as well as inpatients developing neutropenic sepsis. An initial reaudit June 2012 demonstrated improvement (62% meeting 1hour target), but a subsequent audit, January 2013, was disappointing (only 50% meeting 1hour target). In response, a new compact, user-friendly care pathway was introduced. A range of other measures have also been subsequently introduced. Patients' care is continually monitored through simple ward based documentation, completed after initial treatment of each neutropenic sepsis episode. A patient group direction facilitates nurse led prescribing and administration of first dose antibiotics. Regular multidisciplinary education sessions and improved access to regional guidelines have also been prioritised. From November 2013, consistently greater than 80% of patients have met the one hour target. Recent data continues to be encouraging; in July 2016 100% of patients received first doses within sixty minutes, in October 95% of patients. Significant sustained improvements in meeting the sixty minute target have been demonstrated. The combination of measures ensures neutropenic sepsis is considered and basic clinical care delivered quickly and safely, through a co-ordinated standardised approach, to avoid complications.

Improving management of fever in neutropenic children with cancer across multiple sites

“…Highly successful quality improvement measures involve a high level of multidisciplinary team engagement, multiple audit and intervention cycles to overcome site‐specific barriers and significant investment of healthcare provider time (Dandoy et al, 2016; Forde & Scullin, 2017; Salstrom et al, 2015). Other studies report that in order to achieve 95% of patients achieving target time, standardised processes, a dedicated oncology contact to streamline communication and the implementation of a rapid response team with a vascular access healthcare provider were necessary (Dandoy et al, 2016).…”

“…Other studies report that in order to achieve 95% of patients achieving target time, standardised processes, a dedicated oncology contact to streamline communication and the implementation of a rapid response team with a vascular access healthcare provider were necessary (Dandoy et al, 2016). In addition to care plans, education and audit, specialist nurse led antibiotic prescribing and electronic guidelines were needed before Forde and Scullin (2017) achieved >80% TTA. Novel initiatives are often resource intense and not always applicable at multiple sites.…”

Neutropenia Incidence: A Retrospective Analysis of Clinical Data of Cancer Patients Receiving Systemic Anti-Cancer Therapy to Assess the Impact on Treatment Pathways

“…A facilitator in expediting administration of empirical intravenous antibiotics is the implementation of a patient group direction (PGD), whereby nurses in the UK can administer the first dose of antibiotics to any patient with suspected neutropenic sepsis without a prescription [19]. This, as part of an evidence based, robust clinical pathway, has been pivotal in reducing the door to needle time of first dose antibiotic [20]. The development of ambulatory emergency care pathways for oncology patients in the UK has been recognized as a key tenet in promoting patient safety, whilst reducing pressures on Emergency Departments [21,22].…”

Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs

“…It is important to recognise that 30% of patients with severe sepsis do not have fever, and patients with neutropaenia may meet sepsis criteria without being febrile, leading to delays in administration of appropriate antimicrobial therapy. 12 …”