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Managing neuropenic sepsis My role as an acute oncology CNS is to improve cancer services. Part of my role is the treatment and management of neutropenic sepsis. Neutropenic sepsis is an oncological emergency following chemotherapy, whereby the patient’s immune system has been depleted by the treatment for their cancer. The body’s natural defense system has been wiped out from the cytotoxic drug, making the patient more susceptible to infections and, therefore, sepsis. The national standards for treatment of neutropenic sepsis are: Early warning symptoms: call the chemotherapy 24-hour hotline, manned during the day by the chemotherapy nurses and out of hours by the oncology ward nurses who are trained in giving advice to patients on chemotherapy. A high or low temperature is normally the worrying symptom. The UKONS 24 Hour Triage Tool: an algorithm used to support the nurses' advice. The patient is then advised to attend A&E or, if acutely unwell, call an ambulance. Once the patient arrives in the emergency department, the national standard 'door-to-needle time' is to receive antibiotics for suspected infection within 1 hour. How we improved cancer patient safety Monthly audits showed that for 65% of all patient's suspected to have neutropenic sepsis, none received appropriate treatment. This was usually because of contra-indicating admission i.e., came in with left flank pain, or poor triage. An alert card is given to every patient receiving cancer treatment for them to present to the emergency department, alerting everyone that the patient is receiving cytotoxic drugs and advice on how to manage this. The audits I performed highlighted that the patients who presented to the emergency department out of hours did not receive appropriate antibiotics in time. This correlated to no acute oncology nurse present. These findings led to us changing our practice to a nurse-led service. We asked the chemotherapy hotline to alert us to anyone they had advised to attend the emergency department. This allowed us to meet the patient at the front door, and to support and arrange for doctors and nursing staff to give the correct management in time, expediting and eliminating error. The errors I speak of were never incompetence; they were human error. One nurse to 20 unwell patients in the emergency department is unsafe. The emergency department is the frontline in all acute trusts. In the trenches, fantastically skilled but overworked and under-valued. This was noticed by the acute oncology team. I derived that we as a team needed to change our working hours. 10 hours days, 4 days a week. Excluding weekends, where the oncology registration would stand in for the acute oncology service. This worked on days where neutropenic sepsis admissions were many, but still did not support the out of hours admissions. Teaching and training were my next focus. I set up a trust-wide acute oncology conference where I invited all trust staff to attend, inviting guest speakers, experts in their field, to teach and train nurses, doctors, the receptionist, anyone who would meet a patient on cancer treatment. We trained emergency department nurses to be able to prescribe and administer the first dose of antibiotics to ensure the door-to-needle time less than 1 hour was adhered to. Training empowered the emergency staff. Training is investing not scolding. Following these changes, our monthly audit numbers went from 65% to 80–90% over the course of 3 months, which showed a huge success. However, then January came, ambulances queuing down the hill from the emergency department. 345 admissions with only two beds within the trust. 25 staff shortage. Door-to-needle times became 3 hour rather than 1 hour. Our team consisted of three CNS to cover the acute hospitals with emergency departments. 50 referrals a day predominately for new diagnosis of cancer. Door-to-needle times on audit were at an all-time low of 25%. The worst I had seen it. Look at the contributing factors: 25 staff nurses down, huge demand on admissions and beds, limited capacity to review patients. During this month, acute oncology CNS predominantly lived in the emergency department, prescribing and administering the antibiotics ourselves to ensure safe practice. This did not come at a cost to the rest of our service and ensured patient safety. It dramatically improved our door-to-needle times. Acute oncology CNS are a necessity and, I personally think, the unsung heroes of an acute trust. We can prevent hospital admissions and avoid delayed discharges, freeing up beds and supporting and advising doctors to investigate patients appropriately and safely. Why I love my role I enjoy my role. It is a rewarding role. I have had the privilege to meet and work with the most beautiful people in the most harrowing of times. The worst times. But it is worth it. Meeting someone who has been in pain and suffering for 3 months at home who has come into hospital because the pain had got to much. They are aware something is wrong but isn’t sure what. Breaking the bad news that this is a cancer and having the time and resources to support that patient and their family. Knowing I am making a difference. Even when the outcome is that this person is not fit enough for further investigations or would not be safe enough to have chemotherapy, but advising them that the main focus of care should be symptom management and palliative care to ensure quality of life. To feel that I have made a difference and, more importantly, to hear that I have. Ensuring patient safety through diagnosis to treatment and to the end of life care. Something we must not overlook the importance of. Although acute oncology CNS is not as well-known as critical outreach nurses or heart failure nurse specialists, it is equally important and necessary. A case study I would like to end this blog with a case study of a patient named Brendan*. Brendan was a 24-year-old man who presented with a 3-day history of right upper quadrant pain. Clinically jaundice. 10/10 pain. Unable to move. He had an ultrasound in the emergency department on Wednesday pm. He was referred to acute oncology in light of suspicious radiological diagnosis of cancer. Within 48 hours, acute oncology had reviewed him and broken the bad news to him that he had cancer. Cancer of unknown primary. The young man was discharged from hospital. We ensured a support service in system (given him our CNS number), managed his pain, arranged further investigations and discussed in a multidisciplinary meeting the best site for biopsy. We booked the biopsy and arranged a clinical appointment 1 week later with our acute oncology consultants. We called this young man every day for symptom reviews and holistic support for him and his family. He received chemotherapy within 3 weeks of diagnosis and is alive to this day, with a cancer that is rare and difficult to treat. Having only had six hospital admissions. This is why acute oncology are a necessity to any hospital and community service. *Name has been change to ensure confidentiality.

Following a review of the events that led up to Amy’s death Great Ormond Street Hospital have already made changes to practice: They have improved the way clinical information is shared between different specialist teams, to make sure staff have as comprehensive a picture as possible when making complex decisions about a patient’s treatment. They now use a single log-in electronic patient record system which means staff can quickly access clinical information about a patient and have the right information at the right time, rather than routinely having to use multiple systems. They have improved consultant availability. This means there is more consultant time for each patient being looked after in our paediatric intensive care unit. They have introduced a new process to make sure the care of patients, like Amy, who have both complex spinal and heart conditions is routinely considered by the hospital’s specialist joint cardiology committee.

The following safety issues were identified during the HSIB’s initial investigation and will form the basis for the ongoing investigation: referral from the emergency department into early pregnancy services provision of early pregnancy assessment services that allow for the timely diagnosis and optimum management of ectopic pregnancies.

The video supports the Patient Safety Alert 'Confirming removal or flushing of lines and cannulae after procedures' issued by NHS Improvement in November 2017.

In this report the CQC have seen much good and outstanding care, in particular around: responsiveness staff interactions with patients effective treatment leadership and engagement with staff and patients. However, there were a number of areas where services needed to make substantial improvements: governance clinical audit safety culture.

This issue (episode 2) focuses on: the most common safety issues associated with measuring patient weight steps to eliminate drug concentration confusion understanding Patient Care Analgesia (PCA) by proxy.

In this talk, Rob Hackett, director of The PatientSafeNetwork, takes a look at the medical error problem, why it exists, why it persists, what we can do through working together to overcome it and create the best environment for patient care.

Q: Why was the training needed? A: A trust audit found that mortality for NIV was higher than the national average. We looked at previous training for nurses and there was no clear record for most ward areas using NIV. Some nurses had training, but this was several years old. The trust had also upgraded all the NIV machines as the previous machines were no longer serviceable. This gave a great opportunity to ‘rebrand’ NIV and provide current and appropriate training for all those using NIV. Q: What inspired you to take on this project? A: I work in an amazing team of highly skilled and resourceful nurses. We each have areas or ‘projects’ that we work on, looking to develop knowledge and skills among other nurses and to support unwell or deteriorating patients in ward areas. Since joining the critical care outreach team, I have been inspired by my colleagues to look at situations with the aim of ‘how can we improve this?’ and look at practical solutions to issues that may arise. Training ward nurses is an excellent way of passing on knowledge and skills, increasing safety and improving patient care. Q: What did you do? A: I began by gathering current training records and speaking to ward nurses about how they practice currently and the NIV care given. I found that many nurses did not have an up to date record of training, had gaps in their knowledge and lacked confidence in using NIV. We asked the reps supplying the new machines to carry out machine updates, including how to operate the machine, cleaning, storage and maintenance. I then planned a pilot training day for nurses working in the acute medical unit, which included indications for starting NIV, assessing and recognising a deteriorating patient, analysing arterial blood gases and using the machines in practice. From the pilot training day and the feedback from the nurses, I adapted the training to include more simulation and patient scenario training, as well as a troubleshooting workshop for everyone to have a chance to use the machine. Following this I set up monthly study days, working with the practical development nurses in the areas using NIV, and invited all nurses from these areas to sign up and attend the day, whether they had previous NIV experience or not. Ten nurses attend each of these days and an up-to-date database is kept for the whole trust. I gathered information at each day, asking the candidates to score their confidence out of 10 before and after training. I also worked with the NIV steering group during this time to update the trust NIV policy to reflect the most recent British Thoracic Society standards for NIV care in acute wards. Q: You work full-time, how did you find the time to complete the project? A: A lot of the initial background work, planning teaching sessions and administrating the study days was done in my own time. My manager has been very supportive from the beginning and since the first few months I have had some protected management time to continue planning, administrating and improving the training. Q: What challenges did you face? A: The administration has been really challenging: booking rooms, updating the online booking form, contacting candidates and managers about non-attendees or issues that arise. It has also been a huge undertaking, we have identified 230 nurses that need training, some of whom only work nights! There has been a varied response from ward areas, some being very supportive and others taking a lot longer to engage with the training. Nurses attend who have no prior experience of NIV right through to those who have been using NIV for over 10 years, this can be difficult to pitch the training at the right level. Q: How did you overcome these challenges? A: I have now got a more robust system for administration, this mainly involves a lot of forward planning, organisation and writing everything down! I have kept going and kept going with trying to engage all ward areas and managers, we are getting there – but it remains a work in progress. I have had to develop the teaching from scratch and have learnt as I’ve gone along! Feedback from the candidates after each day has been invaluable to ensuring the training is relevant and interesting for everyone there. I have also used the KSS e-learning NIV package to provide some pre-reading, especially for those with no prior experience. Q: Has the project made a difference? A: Yes! We asked candidates to score their confidence before and after training, with on average this improving from 3/10 to 8/10 following training. We have improved nursing training records from unrecorded to 49% across the trust and competency from unrecorded to 20% in just over a year of training sessions. We are aiming for 80% so we have a bit more work to do. We are currently doing the national NIV audit in the trust and I hope this will reflect some of the improvements in training to patient care and outcomes. Q: How have you ensured that this project is sustainable? A: We have recently asked some senior nurses on the wards using NIV to take on additional responsibility as ‘link nurses’ for NIV. They will help to deliver bedside support on clinical shifts and assess competency for nurses in their ward areas. I have completed a standardised template for the days, so in theory any one of my critical care outreach team colleagues could pick up the training folder and run a training day. I am also looking at working with the senior respiratory physios to deliver ‘update training’ for nurses who have attended training to keep up with any recent policy changes and have a chance to refresh their NIV knowledge if needed. Q: Do you have any advice for anyone starting a quality improvement project? Or top tips? A: Evidence is essential. Have a clear standard that you are working towards, make sure you have gathered some evidence as to why your project is needed, and have a measure that you can look at to show how you are improving things. Not only does this help continued motivation and interest in your project, but it also helps with securing more support from managers and those you are trying to engage with. Look at sustainability right from the beginning. It’s easier to start something first time then have to go back and re-do things later down the line. Stay positive! It’s easy to feel disheartened in an under-resourced and challenging environment, sometimes it feels like no one else is aware of what you are doing and the difference it can make, but keep talking about it, and keep being positive, and eventually others will get on board! Q: What are your future plans? I will continue the training until we reach our goal of 80% competency. I am working with physio colleagues to develop ‘update sessions’ so that competency can be maintained. I will continue to inform and update ward leaders and managers to keep the momentum going. As a team we have used the database structure I created to help track other areas of competency such as tracheostomy training. I have created a poster to represent the work I have done over the last 12 months and will look to do this yearly to show how far we have come. Please contact me if you are planning or implementing a similar project, I would love to hear about it and share resources and ideas.

ECRI Institute's Top 10 Patient Safety Concerns for 2019 names diagnostic errors and improper management of test results in electronic health records (EHRs) among the most serious patient safety challenges facing healthcare leaders. Other items address systemic issues facing health systems, such as behavioural health concerns, clinician burnout and skills development. Mobile health technology, number four on the list, opens up a world of opportunities by transporting healthcare to the home, but also presents potential risks.