Leading change

A senior staff nurse in the Cancer and Associated Specialties Unit at Nottingham University Hospitals NHS Trust identified unwarranted variation in the pathway of care of suspected neutropenic sepsis patients and led on changes to address these.

Where to look

Before the change, all patients suspected of having neutropenic sepsis were admitted for intravenous antibiotics on arrival to the Cancer and Associated Specialise Unit. A senior staff nurse however, identified unwarranted variation in the form of higher levels of short inpatient stays and use of antibiotics. The nurse identified that these patients could be nursed more effectively through the development of a neutropenic sepsis clinical pathway to support appropriate decision making before admission. The nurse, with the support of the wider nursing team led a review to identify where improvements could be made to the different elements of their clinical pathways in order to address the unwarranted variation.

What to change

In the Cancer and Associated Specialties Unit, before the nurse-led change, all patients suspected of having neutropenic sepsis were given intravenous antibiotics and admitted to the unit as an inpatient. As a part of the admission process, patients would each receive first line antibiotics within an hour, which adhered to the national and local guidelines (door to door needle time). They were allocated a bed on the Specialist Receiving Unit (SRU) for further tests and senior medical review.

The nurse led review involved collecting data over a three month period from patients admitted to the SRU and analysed to determine;

• What proportion were confirmed neutropenic;
• Length of stay; and
• Other co-morbidities.

Results showed that following further tests a large proportion of patients weren’t confirmed neutropenic septic and did not require antibiotics and half did not need admission to hospital.

The review also highlighted that depending on the time of admission, some patients were not receiving an initial review until the day following admission, which was in turn delaying a decision about ongoing appropriate treatment.

How to change

To address the need for change, the staff nurse with support of senior leadership introduced a new pathway for these patients. Its overarching aim was to streamline patient care, at the same time as ensuring it was evidence based and personalised to the need of the patient. The standardised approach on arrival into the SRU was:

• Full patient observations and blood tests to be undertaken;
• All bloods are then taken to Haematology day case for analysis;
• This means that a neutrophil blood count to identify Neutropenic Sepsis (NS) is available within ten minutes;
• If the patient do not have NS they are held in day case and appropriate treatment provided there;
• If the patient is identified as having NS, intravenous antibiotics are given; and admitted to the SRU.

The pathway was supported by the wider multi-disciplinary team and implemented within the unit as agreed practice.

Adding value

• Better outcomes –The new pathway maintained the high levels of care provided and continued to ensure patients were treated as per national standards as well as ensuring that all patients suspected of having neutropenic sepsis were triaged in the Oncology Day Case in the first instance to confirm the diagnosis. Those who were not neutropenic weren’t admitted unnecessarily and were discharged home as soon as they have been assessed and treated appropriately. This in turn has improved patient flow, capacity, patient experience and cost savings – the better outcomes centre around streamlining and personalising the care pathway. Due to its success the nurse lead and the SRU have now made the changes to the pathway permanent.
• Better experience – Friends and family feedback cards have shown patients are overwhelmingly in favour of the pathway changes.
• Better use of resources – In the four months following the implementation of the project: 34 of 73 patients were discharged home resulting in a saving of £10,200 for one night stay on SRU (based on £300 per night). A total of 56 out of 73 did not receive unnecessary antibiotics on arrival saving £840 (based on £15.00 per dose of Azocin). The total cost saving was £11,040 over the period.

Challenges and lessons learnt for implementation

The staff nurse who led this implementation suggested:

• Key learning from the project supported clinical based leadership skills and the confidence to challenge practice to improve patient care.
• It was important to work with the wider multi-disciplinary team to enable them to understand and support the evidence-base for the pathway change. This ensured full staff engagement to implement the change to allow for measurement of its success.
• Ensure that you collect data prior to and after the change to prove the intervention has had a positive impact.

A publication of the project is currently underway (August 2018). Sharing this knowledge through publication has the potential to address unwarranted variation in the care and management of neutropenic sepsis across a wider audience.

Find out more

For more information contact:

Sharon Leighton

Sharon.leighton@nuh.nhs.uk

Band 5 Nurse

Nottingham University Hospital NHS Trust