Using a patient specific protocol to improve the emergency management of suspected febrile neutropenia/neutropenic sepsis in patients on systemic anti-cancer chemotherapy

Summary

Neutropenic sepsis/febrile neutropenia (NS/FN) is a potentially fatal complication of chemotherapy. National guidance recommends that the first dose of antibiotics should be given within 60 minutes once they present with NS/FN. To improve the ‘door to needle’ time, Whittington Health, in conjunction with London Ambulance, developed a patient specific protocol (PSP) to rapidly identify all at risk patients. 

Patients included on the PSP register who became unwell while receiving chemotherapy were instructed to ring 999. The PSP dictated an automatic blue light response from the ambulance service and a pre-approved treatment plan, including the patient going immediately to a resuscitation room.

Overall just 3.8 per cent of all patients treated with SACT used the protocol (9.5 oer cent of high risk patients), which reduced the added burden to the ambulance service but offered huge benefit to patients receiving high risk regimens.

Challenge

The National Confidentiality Enquiry into Patient Outcomes and Deaths (NCEPOD) For Better or For Worse demonstrated that emergency care of people receiving systemic anti-cancer chemotherapy (SACT) was insufficient – more than half died within 30 days. Increasing numbers of patients, particularly with solid tumours, are receiving SACT but when they develop toxicities are often admitted to a district general hospital and almost half of all emergency admissions are under the care of acute medical physicians, not specialist haemato-oncologists.

Neutropenic sepsis/febrile neutropenia (NS/FN) is a potentially fatal complication of SACT but early recognition and prompt intravenous antibiotics can avoid a preventable death. A chemotherapy course where the risk of inducing NS is greater than 20 per cent is deemed high risk.

While a clear 60 minute ‘door to needle’ time has been mandated by national peer reviews, in many cases this target is not met and there are too few oncologists to ensure that each Trust’s emergency department has 24-hour oncology cover.

A survey of 153 paramedics across London Ambulance Service (LAS) demonstrated that just 43.8 per cent of paramedics recognised an at-risk patient and 92.8% under-triaged patients presenting with priority symptoms suggestive of FN. Furthermore, 93.5 per cent over-triaged the oncology patient presenting with no priority symptoms.

Objectives

Managing sepsis is an acute emergency competency so this project aimed to raise the level of training and awareness among paramedics by designing a patient-specific protocol (PSP) to recognise and emergency manage patients on SACT at high risk of developing FN. It was designed to establish whether early intervention by paramedics could ensure that patients who realised they had FN symptoms could receive their first dose of IV antibiotics within 60 minutes of presentation to an emergency department.  

The objective was to: Identify all patients deemed at high risk of developing FN at the start of any new programme of SACT. The team wanted to achieve this by educating patients about their risk of FN and take part in a pilot study offering rapid assessment and transfer to hospital. It needed to complete a patient-specific protocol for each patient deemed high risk, communicate with the ambulance service to ensure prompt admission and removal of alerts and gather data about the patient experience of care. This required the team to ascertain the feasibility of this approach, including patients’ confidence in using it.

In addition we wanted to measure the door to needle time of all patients admitted with FN who were collected by ambulance and compare this to those treated pre-pilot in 2011.

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QiC Oncology 2016 partner:
Bristol-Myers Squibb
Supported by: