MAK So-Shan Suzanne, Nurse Consultant (Oncology), NTEC

Member, SAG (Oncology) of HA

Exponentially increasing chemotherapy delivered in ambulatory setting

Fatal toxicities from chemotherapy

• Neutropenic sepsis (中性粒细胞减少败血症) is a well-known and life-threatening complication of bone marrow dysfunction and cytotoxic chemotherapy. Associated mortality rates range from 2% to 21%.

Smith et al, (2006) Update of recommendations for the use of white blood cell

growth factors: an evidence-based clinical practice guideline. Journal of Clinical Oncology, 24, 3187–3205.

Herbst et al, (2009) Prophylactic antibiotics or G-CSF for the prevention of infections and improvement of survival in cancer patients undergoing chemotherapy. Cochrane Database of Systematic Reviews, CD007107.

Need for prompt identification & treatment

• Neutropenic sepsis is a time-dependent medical emergency in which early, goal-directed resuscitation and the urgent administration of broad-spectrum antibiotics have proven benefits on outcome.

Dellinger et al (2008) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine, 36, 296–327.

Gaieski et al (2010) Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department *. Critical Care Medicine, 38, 1045– 1053 doi:1010.1097/ CCM.1040b1013e3181cc4824.

【on.cc東網專訊】 患血癌的士司機宋海洲化療後出院，但因白血球指數極低受感染翌日再入院，但他先後到過伊利沙伯及瑪嘉烈兩醫院，都未獲即時處方抗生素，4個多小時後因敗血症死亡，死因庭經過連日聆訊後，裁定宋海洲死於自然。死者妻子與兒子聞判後表現失落，妻子留在庭內哭泣，不願意離開。

51歲男死者宋海洲，2011年中因白血病在瑪嘉烈醫院接受化療，同年10月24日因化療導管傷口發炎入院，直至31日出院。裁判官建議，醫管局應全面檢討及實施白血球缺乏症病人的出院決定及指引，公立醫院亦應全面檢討，以及實施急症室就此類病人治療發燒的方案，如施用抗生素，冀將來有更好醫療體制，減少不幸事件。

Corporate Overseas Scholarship Training 15/11/2010-11/12/2010

Corporate Overseas Scholarship Training 15/11/2010-11/12/2010

Corporate Overseas Scholarship Training 28/2/2011-25/3/2011

Corporate Overseas Scholarship Training 5/3/2012-30/3/2012

Corporate Overseas Scholarship Training 26/3/2012-20/4/2012

Nurses from the six Oncology Centers to champion QI efforts &

empower staff to engage in and move QI initiatives forward

Corporate Overseas Scholarship Training 25/10/2010-21/11/2010

Objectives

1) To analyze and identify problems in the management of patients presenting with post-chemotherapy febrile neutropenia (FN) in the emergency access as well as its impact on patient outcomes;

2) To develop solutions and streamline pathway;

3) To evaluate the impact after implementation of a clinical pathway for post-chemotherapy FN.

Methodology/ Process • Design:

• Pre- and post- study of the QI impact, case series with comparison • Quality improvement process

• Setting: • HA Oncology Centers in HK

• Patients: • Being admitted in oncology wards due to FN and receiving chemo

within 1 month of presenting to emergency department or oncology clinics between November 2012 and September 2013 in the 1st survey, which served as historical referents and provided data for problem identification

• Similar cases between May and October 2016 in the 2nd survey after implementation of improvement.

• Data collection: • Retrospective chart reviews

Outcome Measures

Primary outcome

Secondary outcome

2012 4Q

2013 3Q

10

Timeline of QI

Patients identified being admitted for chemotherapy induced FN in all oncology centers of HA in the 1st survey

65

206 patients identified in 6 oncology centers, Nov 2012 - Sep 2013

62 4

30

15

30

Door-to-Antibiotic Time in 1st Survey, n=206 Median = 221 minutes Mean = 265.5 minutes 47 patients (23%) within 120 mins

M=106 (13-904) mins

M=321 (104-1340) mins

M=281 (177-992) mins

M=194 (35-346) mins

M=302 (106-701) mins

M=324 (125-1500) mins

22 patients (11%) within 60 mins

Detail of investigation/treatment given in the 3 major routes when patient accessed with suspected FN before admission

Low compliance in blood culture & antibiotic administration

Time pattern & breakdown from presentation at A&E or Oncology Odd/FU clinics to 1st dose of antibiotics given after admitted to ward,

n=174

256

99 136

Door-to-1st Dose of

Needle Time

Door-to-Ward Admission

Time

Ward Admitted-to-1st Dose of Needle Time

admission process to be affected by factors e.g. transportation issue, administrative procedure involved, etc;

prolonged time between arrival & clinical assessment;

no stock of antibiotic in ward due to hospital policy about drug supply & storage

Problem Identified

• The delay in antibiotic administration in the oncology centers is found associated with – lack of a fast-track mechanism to be in place for emergency

management of post-chemotherapy febrile patients with cancers between oncology centers and A&E.

– lack of policies for managing neutropenic sepsis in some emergency & oncology departments.

– lack of staff awareness of the natural history of neutropenic fever syndrome and its evolution to severe sepsis & shock

– lack of patient knowledge & alertness to monitor symptoms and seek treatment earlier

2012 4Q

2013 3Q 2014 2015

1Q 2015 2Q

16

• Work out materials & system to facilitate emergency triage

• collaborate with key parties

Timeline of QI

• Report presented in forum/ COC for wider support & comment

• Consolidate FN care pathway & guideline

• Staff training & briefing for manage-ment of FN

Consultation for stakeholders Collaboration with A&E

Admitted for treatment

New Practice Streamline care for patient at risk of FN

Patient at risk of FN Improvement strategies

Stage 1

Patient Education on FN

FN Alert Card

Stage 2

Electronic Patient Alert

No improvement

Attend A&E or Oncology centers clinics

When patient feels unwell (e.g. fever, sore throat, flu-like symptoms)

Undergoing chemotherapy

Driven triage workflow

Admitted for treatment

Care plan to guide staff for FN patient

Admitted for treatment

Proactive assessment & education to patients at risk of FN by nurse clinic or nurse-led service

TMH PYNEH PWH

QMH PMH QEH

Clinical Pathway for Management of Patient at-Risk for Post-Chemotherapy Febrile Neutropenia

Patient Education

Nursing Assessment

Alert Card given upon discharge with information

Accessible Emergency Service after discharge

Refer to Nurse Clinic 1. Identified as problem case 2. further reinforcement required

Proactive Chemotherapy Education 1. Management of post-chemo complication 2. Preventive measures of infection & SE

• Patient understanding & competency on self-care & awareness

• Discharge care plan

Office Hours - Odd Case Clinic or Day Ward 1. Alert card +/- electronic alert 2. Fast track follow up in clinic or day ward 3. Direct admission to oncology ward after

septic work up for antiobiotics

Office or Non-Office Hours – AED Service 1. Alert card +/- electronic alert 2. Fast track triage & management with work up & antibiotics 3. Admission to ward

2012 4Q

2013 3Q 2014 2015

1Q 2015 2Q

2016 2Q

20

• Work out materials & system to facilitate emergency triage

• collaborate with key parties

• Staff briefing & training for manage-ment of FN

• 2nd cross-cluster survey on FN manage-ment

Consultation for stakeholders Collaboration with A&E

Timeline of QI

• Report presented in Forum/COC for wider support & comment

• Consolidate FN care pathway & guideline

Patients identified being admitted for chemotherapy induced FN in all oncology centers of HA in the 2 surveys

65

206 patients identified in 6 oncology centers, Nov 2012 - Sep 2013

62 4

30

15

30

30

40

18

28

7

8 13

144 patients identified in 7 oncology centers, May - Oct 2016

Baseline characteristics of study patients Referent (n=206) Pathway (n=144) P value

Age (years) 53 (19-78) 56 (21-88) 0.06 Male 57 (28%) 40 (28%) 1.00 Co-morbidities COPD 2 1 Cardiac disease 21 22 Diabetes 7 11 Surgery within 6 weeks 24 6 Others 8 1 Total No. of patients with co-morbidities 51 (25%) 35 (24%) 1.00 Characteristics of malignancy 0.51 Solid Tumour 174 (85%) 125 (87%) Lymphoma 23 (11%) 16 (11%) Haematological malignancy 9 (4%) 3 (2%) Last chemo dose to emergency visit at A&E or Onc Clinic (days)

11.7 (1-35) 10.7 (2-30) 0.07

ANC ≤ 1x109/L † 195 (95%) 137 (95%) 1.00 Sepsis criteria y 71 (34%) 54 (38%) 0.57

ANC = absolute neutrophil count; Onc Clinic = Oncology ODD or Follow-up Clinics Data are shown as mean (range) or number (%) † Based on blood result at index visit in A&E or Onc Clinic y According to Bone criteria (i.e. >2 out of 4 of the following: leukocyte count <4 or >12 x 10-9 /L, respiratory rate >20/min, oral temperature >38°C or <35°C, pulse >90 beats/min).

Comparison of outcomes of patients with post-chemotherapy fever between the pathway and referent group

Referent (n=206) Pathway (n=144) P value

Patient with alert Card 31 (15%) 99 (69%) <0.001

Blood culture in A&E or Onc Clinic 53 (26%) 108 (75%) <0.001

Antibiotic given at A&E or Onc Clinic 33 (16%) 98 (68%) <0.001

Door-to-antibiotic time (mins) 266 (13-1500) 103 (11-541) <0.001

Door-to-antibiotic time <1 hour 22 (11%) 91 (63%) <0.001

A&E or Onc Clinic LOS (mins) 129 (13-1237) 93 (7-439) 0.006

Hospital LOS (days) 7 (1-33) 7 (2-33) 0.85

Mortality 4 (2%) 2 (1.4%) 1.00

Adverse outcomes 10 (5%) 5 (3.5%) 0.60

A&E = Accident & Emergency Department; Onc clinic = Oncology ODD or Follow-up Clinics; LOS = Length of stay Data are shown as mean (range) or number (%)

Door-to-Antibiotic Time in All Oncology Centers Before & After New Care Pathway, n=350

Improved Outcomes

1. Sammut & Mazhar. Management of febrile neutropenia in an acute oncology service. QJM 2012;105:327-36. 2. Lim et al. Febrile neutropenia in Eds: the role of an electronic clinical practice guideline. Am J Emerg Med 2012;30:5-11. 3. Nirenberg et al. Emergency department waiting times for patients with cancer with febrile neutropenia: a pilot study.

Oncol Nurs Forum 2004;31:711-5. 4. Clarke et al. Improving the immediate management of neutropenic sepsis in the UK: lessons from a national audit. Br J

Haematol 2011;153:773-9.

• The new care pathway in the HK oncology centers and their affiliated hospitals could significantly reduce the mean Door-to-Antibiotic time from 266 minutes to 103 minutes (P<0.001).

• Patients who could achieve the target Door-to-Antibiotic time of <1 hour increase from 11% to 63% (P<0.001).

• The result was satisfactory when compared with similar studies conducted in Europe and North America where reported median DTA ranged from 154 minutes to 3.9 hours.1-3

• Audits from UK report that only 18% to 26% of patients receive initial antibiotic within the target DTA of 1 hour.4

Patient length of hospitalization & door-to-antibiotic Time, n=350

Median LOH= 6; Range: 1-33 days

P = 0.01; Correlation coefficient: 0.13

Pearson test

Patient final outcomes between groups with door-to-antibiotic time cut off at 3 hours, n= 350

95.2

3.2 4.8

96.7

0

20

40

60

80

100

120

< 3 hours >= 3 hours

Patie

nt p

opul

atio

n (%

)

Resolution without complicationSerious adverse events

p= 0.79,

Fisher exact test

serious complication

Impact on Patient Outcomes

• The survey revealed that – delayed antibiotic administration did translate

into increased length of hospital stay, and

– no impact was demonstrated on serious adverse outcome.

Limitations – small sample size

– heterogeneous nature of solid tumour and hematological malignancies

Conclusions

Implementation of the care pathway for cancer patients at risk of post-chemotherapy febrile neutropenia can significantly shorten the door-to-antibiotic time to meet the international standard of care in neutropenic sepsis patients.

The pathway compliance rate was also high.

Effective implementation of the care pathway is feasible across departments through excellent teamwork between oncology and emergency nurses, physicians, pharmacists, etc

Implications of Findings

Serve to inform HAHO Q&S for design of Alert Card that is currently being

rolled out in all related hospitals

Won the Champion of outstanding WISER CQI in PWH Q&S Forum in 2016

Acknowledgment