Febrile Neutropenia Patient Group Direction: Improving treatment and sepsis management in paediatric oncology patients in Wales

Aim:

• To ensure compliancy of febrile neutropenic sepsis treatment in line with NICE guidelines.

Objectives:

• Improve treatment times and antibiotic therapy in line with NICE guidelines following initial audit results.
• Ensure future treatment of febrile neutropenic sepsis stays in line with recommendations.
• Improving standards of care, treatment and outcomes for children and young people with febrile neutropenia.

It is well recognised that febrile neutropenia can be a serious complication of anti-cancer treatments, putting children and young people having such treatments at great risk of sepsis with potentially fatal consequences.

With many reports highlighting problems in adequate treatment for this group of patients, it was clear that solutions and key areas for improvement needed to be identified. Since the introduction of the NICE guidance: Neutropenic sepsis: prevention and management in people with cancer in 2012, prompt recognition and treatment have been key in ensuring positive patient outcomes and reduction of complications.

As the CCLG principal treatment centre for Wales, we cover a large geographical area, providing anti-cancer treatment and supportive care for children and young people. It was important to ensure this large group of vulnerable children were receiving the highest standards of care and treatment that they should expect from a specialist centre. With febrile neutropenia being one of the most frequent side effects seen within our patient groups, strict local policies were already in place detailing recommended treatment in line with NICE guidelines.

With a highly experienced nursing staff, it was felt that febrile neutropenic patients were easily recognised and treatment within the unit was well executed. When local audits were conducted looking at guidelines compliance and antibiotic therapy times, it was of great shock that the results were less than complimentary.

Reasons for the results were discussed and it felt that a significant factor was the lack of medical cover to support nursing staff particularly out of normal working hours. A working group was set-up to discuss and develop a Patient Group Direction for Febrile Neutropenia. This would enable the experienced nursing staff to administer the first dose of IV antibiotics, thought to be the most important intervention in the prevention of sepsis, without the need for medical assessment and prescription.

A working group was put together consisting of healthcare professionals across multiple disciplinary specialities, with the sole aim of creating and developing a Patient Group Direction to meet the needs.

This included allocated leads from Medicine, nursing, pharmacy and microbiology directorates including representations from the Health board and directors for medicine and nursing. The pathway was required to identify strict patient inclusion and exclusion criteria to eliminate those deemed high risk and protect non-medical nursing staff that would be doing the initial patient assessment and delivering the antibiotic treatment.

The PGD allowed for trained and competent nursing staff to deliver the first dose of IV antibiotic without waiting for initial medical assessment. Medical staff would then have 4 hours in which to assess the patient should they remain in the low risk criteria. High risk patients were identified following initial assessment using common clinical indicators and observations.

These patients would then need urgent review by medical staff within 30 minutes. Implementation consisted of two main stages:

1). Teaching on the PGD

2). A competency assessment for all staff who met the eligibility criteria for training.

Stage one had many hurdles due to staff shortages and clinical responsibilities preventing release for formal training. Thus, stage one was done ad-hoc during working hours over a period of a months.

Stage two relied on the staff dedication to complete the competency workbooks and return them in a timely manner which could have proved problematic. Despite this, staff were well motivated to complete the assessment process. It was more difficult to introduce the PGD within the medical disciplinary due to the constant movement and rotation needs. Teaching boards were constructed and the PGD was introduced onto the Medical induction programme for those who would be likely to rotate to the unit. A letter was distributed to all patients currently on treatment outlining the PGD and what this meant for the patient when admitted febrile neutropenic.

On average, implementation of all stages was completed over approximately 6 months due to all the pressures and restrictions detailed previously. User questionnaires were distributed after 6 months to identify any problems with documentation. Following this, a second version went into use with some minor changes and additions.

The implementation of a Patient Group Direction for managing Febrile Neutropenic Sepsis met and exceeded its aims and objectives.

Initial Audit: A baseline audit showed that only in 38% of cases were targets being met of administering antibiotics within 1 hour.

Possible Causes:

• Paucity of junior doctor cover out of hours.

• Lack of the utilisation of the skills of the experienced senior nursing staff working that could help towards improving the care standards, safety and efficiency of care delivery.

Solution: A multi-disciplinary work group to initiate and devise a strategy to improve ward targets.

A PGD was created that would be nurse led and provide the ability for senior nursing staff to assess the patient and deliver the first dose of intravenous antibiotics in a safe and controlled manner. There needed to be a systematic and logistical pathway that would provide points for when high risks were met and immediate action was needed.

The PGD provided a step by step approach for clinical assessment and a comprehensive proforma that each patient had to meet to determine if it was safe for first dose antibiotic to be prescribed and administered by skilled senior nursing staff, or if the immediate attention was required by a doctor. Follow Up Audit: This was conducted retrospectively looking at the first 9 months of implementation of the PGD.

It would be measured against the standard review in accordance with NICE guidelines CG151.

Data collected for the audit included:

1. Time of Initial phone call from parent

2. Time patient arrived on the ward

3. Time of initial nurse assessment

4. Time doctor was informed of patient arrival

5. Time doctor conducted their assessment

6. Time of first antibiotic administration

73 participants were included in the audit of which 6% of these participants didn’t qualify for the use of the PGD, and so were consequently excluded from the audit.

This was due to the following:

1. No central venous access device

2. Not neutropenic

3. Not febrile on arrival to the unit

4. Central venous device needed reviewing by a medical professional before it could be used.

The findings revealed 100% guideline compliance with meeting targeted time of 1 hour of antibiotic treatment due to the implementation of the PGD. Consequently, this improved care standards and outcomes for patients, utilised the skills of senior nursing staff and minimise the impact of paucity of medical staff.

The creation and implementation of the Patient Group Direction for Febrile Neutropenic Sepsis was complex and challenging. It involved the co-ordination and motivation of individuals across multi-disciplinary specialties.

It took a number of years to be able to devise and then approve the document to ensure the safety of healthcare professionals to deliver the PGD and also minimise any risk factors to patients. There needed to be measures in place that would allow strict guidelines for safe assessment and high-risk criteria to be identified resulting in escalation to immediate medical attention.

It was time consuming to have the proforma approved by Quality and Safety and then following this to train sufficient number of skilled senior staff to safely use the PGD. There were some difficulties being able to train nursing staff in using the PGD as detailed previously. This was partly down to the availability and activity accumulating on ward.

To overcome this, it would be beneficial to have the training for using the PGD online rather than face to face. However, it was advantageous having the training face to face when possible as it allowed for feedback, discussion and areas for improving the proforma for usability.