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.

Solution

The Whittington Health acute oncology lead met the LAS senior medical and administrative staff to understand the existing protocols. Together they process mapped the pathway for patients and they conducted a survey involving 153 paramedics to understand their current level of knowledge. They also needed to ensure that the alert system would send an electronic alert to the acute oncology team within an hour of a high risk patient arriving at hospital.

All emergency department staff were trained to recognise the significance of these alerts once they had been triggered and were taught, via a protocol that was accessible and understood, how to manage patients who present with suspected FN. All patients assessed to have a risk of FN greater than 20 per cent (either from the specific regimen or other line of treatment) had a PSP completed, which was sent via e-mail to LAS through a secure system. 

All high risk patients were asked to call 999 if they felt or became unwell during chemotherapy and the ambulance service sent all patients a copy of the PSP to their home address. High risk alerts and the PSP were removed six weeks after the patient completed SACT.

The pilot project ran for a year and data collection included door to needle times and the patient’s experience of the process.

Results

Information was collated on all patients beginning a new programme of chemotherapy at any time in the calendar year 2012 who had a patient specific protocol completed because they were considered to be at high risk of FN, and collected data on all those who presented with FN in the pilot period. 

In addition, the team cross-correlated all patients on chemotherapy who presented to the emergency department and who triggered an acute oncology alert. The team met with representatives from LAS to collect feedback on their experience of the project and the extra burden it added to their daily duties. Auditing was also carried out on the administration of antibiotics for each patient against an approved FN algorithm.

This project optimised the unique skills of LAS paramedics in assessment and emergency management of a specific group of patients. Combining these specialist skills, along with ringing ahead to the ‘blue phone’ in the emergency department meant that the emergency team was prepared for the patient with probable FN. Educating patients about their individual risk, along with the selective use of high risk alert flags and personalised patient specific protocols has not added an excessive workload to existing pathways.

Building the pilot project into existing pathways at both LAS and Whittington Health made it easier for staff to ensure that this new step in the pathway was readily incorporated into their daily workload.

Evaluation

The project did not incur any financial costs and demonstrated that existing staff with key specialist knowledge can collaborate by sharing their unique skills to improve patient care. 

By giving patients on SACT greater confidence in recognising the warnings signs of FN, and an emergency pathway to use when they become, or are at risk of becoming unwell, serious delays in the prompt management of their symptoms can be reduced and their experience of care significantly improved.

Because patients develop greater confidence about the way in which they will be managed when they are unwell, the chances that they will complete the full course of chemotherapy are significantly increased.

Patients on SACT need to know that it is appropriate for them to use emergency services. Many of those on our PSP pilot previously chose not to do so, believing other patients deserved LAS more, or that they were ‘less worthy’.

Collaboration between emergency services and specialist oncology staff can ensure that the generic aspects of managing FN can be understood, giving greater confidence to paramedics who may rarely encounter a patient on chemotherapy who becomes unwell.

Impact

After the year-long pilot the data and experience of staff and admitted patients was reviewed. The number of people predicted to be high risk was about a third of all newly treated patients. Of this cohort, less than a third used the service and in half the correctly identified patients antibiotics were administered within 60 minutes of arriving at hospital.

The patients reported a very good experience of care – in particular saying how reassuring it was to have ‘experts waiting for their arrival.’ LAS felt the initiative was a natural extension of the PSPs they currently operate throughout the city and would like to roll it out London-wide.

The patient specific protocol we developed has proven itself to be a useful tool in ensuring that FN patients receive appropriate pre-hospital care. It highlights a potential training opportunity for paramedics and we intend to introduce an e-learning package that will be nationally available to paramedics, and feature in the Journal of Paramedic Practice.