Cancer Treatment in the Community – Options Appraisal Paper



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Audit of neutropenic sepsis in chemotherapy patients from North Wales

By Sue Armstrong

Audit Facilitator

Contents:

1) Executive Summary

2) Introduction and Context

2.1) What is neutropenic sepsis?

2.2) Background and guidance

3) Aims and Objectives

4) Methodology

4.1) Stage 1 – Establishing data collection form and audit duration

4.2) Stage 2 – Collection of data

4.3) Stage 3 – Clinical coding report

5) Results and analysis

5.1) Stage 1 & 2

5.2) Stage 3 Clinical coding report

6) Discussion

7) Conclusion and recommendations

8) Appendices

Appendix 1 Data Collection questionnaire

1. Executive Summary

Neutropenic sepsis is a potentially fatal complication of chemotherapy and recovery is reliant on rapid and appropriate treatment. Each cancer treatment facility will have its own procedures for identifying and treating neutropenic patients and this audit aims to test the robustness and effectiveness of these policies, especially where they apply to different admission routes within the organisation.

This audit proposes to assess all patients presenting in North Wales, between January to March 2009, with signs of neutropenic sepsis analysing:

• Timeliness of treatment

• Potential differences in treatment timescales at different hospitals

• Performance between different entry points

Upon analysis of all the data collated, the Cancer Network findings are as follows;

• Out of the 32 patients presenting with symptoms, 63% were treated within one hour and 13% were treated within 2 hours.

• 92% of patients who presented to the Oncology Day units were treated within 1 hour.

• Treatment timescales were lower for patients who presented via another route.

• 65% of patients were self referrals.

• Glan Clwyd hospital had the most cases of neutropenic sepsis between January to March.

2. Introduction and context

2.1) What is neutropenic sepsis?

The treatment of cancer patients using chemotherapy can leave the patient vulnerable to the risk of infection which, if not recognised in time, can be fatal. Neutropenic sepsis can be a complication of chemotherapy resulting from the patients’ low white blood cells (neutrophils), which fight bacterial infections. For a patient to be designated neutropenic they must have a neutrophil count less than 1.0 x 10 9/L. Unfortunately, this deficit does not exhibit any symptoms until an infection develops. With neutropenic sepsis, the prognosis for recovery is dependent on fast and appropriate treatment, as delay can result in the patient’s rapid deterioration into shock and potentially death.

2.2) Background and guidance

As a result of the national initiatives to promote awareness of cancer and highlighted in the National Cancer Standards 2005 which must be fully complied with by 2009, there is increased scrutiny of cancer and it’s treatment pathways. The Standards combined with reports like NCEPOD 2008 and the National Chemotherapy Advisory Group 2008 have raised the profile of the management of cancer patients. Neutropenic Sepsis has been identified as a side effect which is readily treatable and should not pose an irreversible threat to a patient’s life. Awareness of this condition has been raised and hospitals have developed their own internal protocols to remedy this, but there is still the potential for error and so this audit has been developed to attempt to measure this.

3. Aims and Objectives

The aim of the project is to analyse the details around chemotherapy patients presenting to the 3 district general hospitals in North Wales exhibiting signs of neutropenic sepsis. While symptoms of this would be easily recognisable to experienced cancer staff, this audit aims to measure whether patients presenting out of hours and to non-cancer departments/wards are getting the same level of expertise and treatment.

Objectives are:

• To assess the timeliness of treatment provided to patients attending hospital with signs of infection during chemotherapy treatment.

• To identify potential differences in treatment timescales provided at the 3 north Wales hospitals.

• To compare performance between different entry points within the hospitals.

Intended Outcome

Project should help identify practice in Cancer and other wards towards potentially Neutropenic patients and identify the speed with which they are treated.

4. Methodology

As stated previously this project aims to identify any potential problems with treating patients presenting with signs of neutropenic sepsis. In order to test this, a data collection form (see appendix 1) was devised to collect the relevant information, this was then filled in whenever a patient presented.

4.1) Stage 1 – Establishing data collection form and audit duration

As mentioned above the first step was to decide on the data to be collected and create a form to capture it (see appendix 1). After consultation with the cancer managers and relevant nursing staff at the 3 hospitals, it was decided to collect the following:

• Hospital attending

• Route of entry into hospital

• Referrer

• Symptoms upon arrival

• Blood tests performed on arrival

• Treatment provided

• Timescale for initial treatment commenced

It was also decided that the form would be printed out and filled in manually each time a patient presented with signs of neutropenic sepsis over the 3 month period of Jan 1st 2009 to March 31st 2009, and that batches of forms would be left with the following departments:

• Accident & emergency

• Admissions unit

• Oncology day unit

• Outpatients

The completed forms would then be returned to the Cancer Network for analysis.

4.2) Stage 2 – Collection of data

A spreadsheet was designed to capture all the information on the forms and begin to pull out any themes.

4.3) Stage 3 – Clinical coding report

The next step was to contact the information departments at each of the 3 hospitals in order to obtain a report of all coded occurrences of Neutropenic sepsis over the 3 month period to act as a double check and ensure there was no non-reporting of any negative incidents.

5. Results and analysis

5.1) Stage 1 & 2

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The chart above shows the overall timescales for treatment, clearly 63% of the 32 patients audited were treated within one hour and 13% were treated within 2. Therefore, cumulatively 82% were treated rapidly. Below shows the number of cases per hospital. Clearly, Glan Clwyd hospital had the highest number of cases.

|Number of cases per hospital | |

|Hospital |%age |Number |

|Glan Clwyd |56% |18 |

|Wrexham Maelor |31% |10 |

|Bangor |13% |4 |

|Total |100% |32 |

The following tables show each hospital’s individual timescales for treatment, below Wrexham Maelor treated 60% of patients within 2 hours. This figure could be higher though as the 40% that represents the ‘unknown’ category relates to data that is unobtainable.

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Glan Clwyd performed better with 84% treated within 2 hours and 95% treated within 3, but 6% did have to wait 5 hours before their initial treatment commenced.

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Lastly, Bangor treated 75% within 1 hour and 100% within 3 hours.

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The chart below combines the 3 tables above. As illustrated in the table previously though there was a big difference in numbers of cases at each hospital. There were 4 cases at Bangor, 18 at YGC and 10 at Wrexham.

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The chart below illustrates the timescales for the various points of entry; unmistakably the route of entry for the speediest treatment is via the Oncology Day Unit. The other routes show a significantly longer wait. The longest a patient had to wait for treatment was 5 hours. The cases where the treatment timescale was unknown all relate to Wrexham Maelor hospital.

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|Table of treatments provided | | | | |

|Hospital attending|Antibiotics Only |Antibiotics & Growth |Antibiotics, Growth |Antibiotics & |Unknown |Total |

| | |Factors |Factors & Anti-Fungal |Anti-Fungal | | |

|YGC |16 |2 |0 |0 |0 |18 |

|Bangor |4 |0 |0 |0 |0 |4 |

|Total |22 |7 |1 |1 |1 |32 |

The table above shows the types of treatment provided to Neutropenic patients, plainly all patients were given Antibiotics, but patients in Wrexham Maelor were also treated with other medication.

The table below shows the type of symptoms the patients presented with at each hospital, clearly most exhibited fever combined with other symptoms, but some presented with fever only which could be indicative of a variety of things. Of the 3 patients in the ‘other’ category, 1 patient felt ‘generally unwell’, another had ‘shortness of breath’ and 1 presented with a ‘sore mouth’.

|Table of symptoms patients presented with | | | |

|Hospital attending |Fever only |Fever and other symptoms |Other |Unknown |Total |

|Bangor |1 |3 |0 |0 |4 |

|WM |3 |3 |3 |1 |10 |

|YGC |7 |11 |0 |0 |18 |

|Total |11 |17 |3 |1 |32 |

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The table above shows the types of tests performed on the 32 patients to determine whether they were neutropenic, obviously all were given a full blood count, and 31 were also given a Urea & Electrolytes. Most were given more than one type of test.

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The pie chart above shows the types of referral, clearly at 65% most were self-referrals with the patient presenting straight to the hospital, but there were a small number of GP referrals.

5.2) Stage 3 Clinical coding report

To act as a cross check, the information departments in each hospital were contacted to provide a report of all coded occurrences of neutropenic sepsis over the 3 month period January to March 2009. This was to give an idea of how many episodes it would be reasonable to expect and to reduce the risk of non-reporting of any negative incidents.

|Clinical coding comparison | |

| |Information Dept |Forms returned for audit |

|YGC |15 |18 |

|NWWT |6 |4 |

|WM |10 |10 |

|Total |31 |32 |

As per the table above, overall there was only 1 difference in the number of cases, individually there was only Wrexham Maelor whose number of forms returned for the audit matched the report from their information department. It is not apparent if the differences for Glan Clwyd and Bangor are due to incorrect coding of data or under reporting on the audit forms, but this is not being considered an issue as the differences are minimal.

6. Discussion

This audit was devised to gain an insight into how rapidly cancer patients with neutropenic sepsis are treated, especially when they present to non-cancer wards. If a patient presents to a cancer ward within its operating hours, it is likely that the condition will be correctly identified and treated speedily within the guidelines and this may be for a variety of reasons that include the patient and their chemotherapy history being familiar to the ward and its staff. But where a patient presents out of hours at A&E or through the Admissions Unit there is a risk that the true nature of the condition and its potential seriousness may not be recognised in time.

This audit aims to measure whether or not this is the case. It can be argued from the findings that the initial supposition is correct; clearly from the results obtained the route of entry for the quickest treatment was via the available Oncology facilities, other routes of entry into hospital showed a significantly longer wait. Patients presenting via A&E were treated within 3 hours overall, but the spread of patients over this time was fairly even, with the same number of patients waiting 3 hours as being treated in 1 hour. One patient who came in an unknown route waited 5 hours before their initial treatment was commenced. A delay such as this could, potentially be fatal and it is unfortunate that their admission route was not specified and only recorded as ‘other’.

As the initial supposition was validated, it seems feasible to ask the question of why this should be. Obviously, the patients are more familiar to the staff on cancer wards, but each hospital will have its own policies and procedures for dealing with patients and what to prescribe for various symptoms whatever the admission route. However presenting to A&E rather than a cancer ward should not compromise speed of treatment especially when would expect there to be protocols in place and the attendee identified at risk through being a known oncology patient.

One reason for a delay in treatment could be the approach and resources within the different wards and environments; the nurses within oncology will be familiar with the patients and possibly more vigilant when it comes to the expectation of neutropaenia and the risk of infection. When faced with this patient group they would probably not only be pro-active in obtaining antibiotics for the patient by acting as a conduit to the consultant but actually be expected to do so as part of their role. The practice via A&E though can be expected to be different as the patient would have to wait to be seen by a doctor which could take longer depending on the time or day.

Overall, combining all the hospitals, 85% of patients were treated within 3 hours, with 63% treated within 1 hour. 87% were definitely treated within the same day; although this figure is likely to be higher as for 13% of patients the treatment timescale was unknown. Bangor Hospital had the highest number of cases treated within 1 hour at 75%, closely followed by Glan Clwyd with 67%. Wrexham treated 50% of cases within an hour and 10% within 2, but for 40% of Wrexham patients the data was unavailable so the timescale is unknown. Wrexham Maelor was the only hospital with missing data and as this related to 4 out of their 10 patients, this is quite substantial and is of concern.

It should be noted that there was a big difference in the number of cases; Bangor only reported 4 cases of neutropenic sepsis during January to March, while Glan Clwyd had 18 and Wrexham Maelor reported 10, it is unclear as to why Bangor’s number is so low. It would seem logical to expect that the spread of cases would be fairly even; this disparity could be due to a combination of factors beginning with activity, the population served by Glan Clwyd and Wrexham Maelor being slightly larger than that of Bangor. Equally it could reflect timing and if the audit were repeated over a different or longer timescale the numbers would even out.

It could be theorised that perhaps awareness of the dangers of neutropenic sepsis are e emphasised more in Glan Clwyd and Wrexham so the patients are educated in being attentive to possible warning signs although the counter argument exists that patients are better educated in Bangor so as to avoid sepsis regardless of their blood count. Clinical practice must also be considered as a factor as the prescribing practices regarding chemotherapy may differ resulting in less or more patients becoming susceptible to the infection and this extends to the possibility that some chemotherapy regimens being more aggressive than others and used locally leading to the unusual result.

The types of treatment provided also differed slightly, in all cases antibiotics were administered, but while Bangor only used this method of treatment, Glan Clwyd also used growth factors and Wrexham Maelor used a combination of antibiotics, growth factors and anti-fungal treatments (although it is recognised that the latter is likely to have been for a very specific indication). There may be some merit in exploring this further to see if there should, perhaps, be more consistency between the hospitals in terms of the immediate treatment they provide, especially as the evidence may support a more cost effective approach.

Unsurprisingly there was also some diversity in the types of symptoms patients presented with which could obscure the diagnosis. Most complained of fever combined with other symptoms, but a few reported fever only and a limited number of patients complained of only vague symptoms, such as shortness of breath, a sore mouth or feeling generally unwell. With symptoms as seemingly vague and unthreatening as these, it is perhaps, not unreasonable, to expect non-cancer wards to be slower than cancer wards at picking up on the potentially fatal implications on a chemo patient.

7. Conclusion and recommendations

The results achieved show that although treatment is provided fairly quickly the initial hypotheses, that the route of entry is a factor in the speed of treatment, was supported.

Upon reflection of the findings of this audit and the comments provided, the following recommendations are made;

▪ The collation of such data should be collected permanently and rolling audits of performance should be performed and outcomes addressed.

▪ Future audits should be expanded to encompass the outcome for the patient and provide greater detail on clinical management.

▪ Policies followed provided by each of the hospitals and their respective admitting departments should be audited to look at developing some consistency.

▪ There needs to be greater confidence that where patients are not treated in oncology departments they are still treated as oncology patients and as such the recommendation of 24hr acute oncology teams needs to be investigated further if only to ensure a solution to the issue is put in place.

Appendix 1.

|  |  |  |  |  |  |

|Questionnaire - Patients attending hospital with signs of infection during Chemotherapy treatment |  |

|  |  |  |  |  |  |

|Q1) |Hospital attending |Please choose one from the following by ticking the relevant box: |  |  |

|  |  |  |  |  |  |

|  |  |Ysbyty Maelor, Wrexham |  |  |  |

|  |  |Ysbyty Gwynedd, Bangor |  |  |  |

|  |  |Ysbyty Glan Clwyd, Bodelwyddan |  |  |  |

|  |  |  |  |  |  |

|Q2) |Route of entry into |Please choose one from the following by ticking the relevant box: |  |  |

|  |hospital |  |  |  |  |

|  |  |Accident & Emergency |  |  |  |

|  |  |Admissions Unit |  |  |  |

|  |  |Oncology Day Unit |  |  |  |

|  |  |Outpatients |  |  |  |

|  |  |Other |  |  |  |

|  |  |  |  |  |  |

|Q3) |Referrer |Please choose one from the following by ticking the relevant box: |  |  |

|  |  |  |  |  |  |

|  |  |Outpatients Clinician |  |  |  |

|  |  |GP |  |  |  |

|  |  |Self-Referral |  |  |  |

|  |  |Other |  |  |  |

|  |  |  |  |  |  |

|Q4) |Symptoms upon |Please choose one from the following by ticking the relevant box: |  |  |

|  |arrival |  |  |  |  |

|  |  |Pyrexia/fever only (temp 37.5oC or above) |  |  |  |

|  |  |Pyrexia/fever and other symptoms |  |  |  |

|  |  |Coma |  |  |  |

|  |  |Other (please specify) |  |  |  |

|  |  |  |  |  |  |

|Q5) |Blood test performed |Please choose one or more from the following by ticking the relevant |  |  |

| | |box: | | |

|  |on arrival |  |  |  |  |

|  |  |Full blood count |  |  |  |

|  |  |Urea and Electrolytes |  |  |  |

|  |  |Blood Cultures - Peripheral |  |  |  |

|  |  |Blood Cultures - Central |  |  |  |

|  |  |CRP |  |  |  |

|  |  |  |  |  |  |

|Q6) |Treatment provided |Please choose one or more from the following by ticking the relevant |  |  |

| | |box: | | |

|  |  |  |  |  |  |

|  |  |Antibiotics |  |  |  |

|  |  |Growth Factors |  |  |  |

|  |  |Anti-fungal treatment |  |  |  |

|  |  |Anti-Viral treatment |  |  |  |

|  |  |None |  |  |  |

|  |  |  |  |  |  |

|Q7) |Timescale for initial |Please choose one from the following by ticking the relevant box: |  |  |

|  |treatment commenced |  |  |  |  |

|  |  |Within 1 hour |  |  |  |

|  |  |Within 2 hours |  |  |  |

|  |  |Within 3 hours |  |  |  |

|  |  |Within 4 hours |  |  |  |

|  |  |Within 5 hours |  |  |  |

|  |  |Within 6 hours |  |  |  |

|  |  |Same day |  |  |  |

| |  |None |  |  |  |

|  |  |  |  |  |  |

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