jeanette ribton oncology cns l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Jeanette Ribton Oncology CNS PowerPoint Presentation
Download Presentation
Jeanette Ribton Oncology CNS

Loading in 2 Seconds...

play fullscreen
1 / 15

Jeanette Ribton Oncology CNS - PowerPoint PPT Presentation


  • 120 Views
  • Uploaded on

Jeanette Ribton Oncology CNS . Chemotherapy Out of Hours Triage: Neutopenic Fever. St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09. Project No: 26 08/09 Produced by: J Anders C-GARRD Presented: September 2008 . Why we needed to change: Case Study.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

Jeanette Ribton Oncology CNS


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
jeanette ribton oncology cns
Jeanette Ribton

Oncology CNS

Chemotherapy Out of Hours Triage:

Neutopenic Fever

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

Project No: 26 08/09

Produced by: J Anders C-GARRD

Presented: September 2008

why we needed to change case study
Why we needed to change: Case Study
  • 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

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

background
Background
  • 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

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

background4
Background

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

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

initial actions
Initial actions
  • 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

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

slide7

Refer to unwell adult flowchart

YELLOW ORANGE

Inform senior Dr and coordinator

At presentation

If 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 admission

Prioritize for G5

background8
Background
  • 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

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

further audit
Further audit

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

  • 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
determining high low risk groups
Determining high/low risk groups

Risk determined through MASCC score

(Multinational Association of Supportive Care in Cancer)

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

methodology
Methodology

Retrospective audit of patients >18 yrs

Time period ~ January 2008 ~ August 2008

Neutropenic fever secondary to chemotherapy (neutrophils <1.0 x 10⁹/l)

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 Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

results
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 Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

conclusions
Conclusions

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

Pathway still not perfect but has improved the care for patients

It encourages better communication and awareness of A&E staff

recommendations the future
Recommendations:The Future

St Helens & Knowsley Teaching Hospital NHS Trust ~ CGARRD 2008-09

  • 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