Forde Caroline, Scullin Paula
Belfast Health and Social Care Trust, Northern Ireland, UK.
BMJ Qual Improv Rep. 2017 Mar 31;6(1). doi: 10.1136/bmjquality.u204420.w6531. eCollection 2017.
Neutropenic sepsis remains a time critical and potentially fatal complication of systemic anti-cancer therapy. A target 'door to needle' time of one hour for first dose empirical intravenous antibiotics continues to be promoted nationally. A baseline audit (June 2011) highlighted shortfalls in care in the Belfast Trust, with only 15% of patients receiving antibiotics within sixty minutes. A multi-professional group within the Trust was established to try and initiate the improvements in neutropenic sepsis recognition and initial management that were urgently required. A number of strategies have been developed over the last five years. Firstly an integrated care pathway was introduced, which is currently used by nursing and medical staff for patients presenting with suspected neutropenic sepsis, through acute cancer centre assessment areas and emergency departments, as well as inpatients developing neutropenic sepsis. An initial reaudit June 2012 demonstrated improvement (62% meeting 1hour target), but a subsequent audit, January 2013, was disappointing (only 50% meeting 1hour target). In response, a new compact, user-friendly care pathway was introduced. A range of other measures have also been subsequently introduced. Patients' care is continually monitored through simple ward based documentation, completed after initial treatment of each neutropenic sepsis episode. A patient group direction facilitates nurse led prescribing and administration of first dose antibiotics. Regular multidisciplinary education sessions and improved access to regional guidelines have also been prioritised. From November 2013, consistently greater than 80% of patients have met the one hour target. Recent data continues to be encouraging; in July 2016 100% of patients received first doses within sixty minutes, in October 95% of patients. Significant sustained improvements in meeting the sixty minute target have been demonstrated. The combination of measures ensures neutropenic sepsis is considered and basic clinical care delivered quickly and safely, through a co-ordinated standardised approach, to avoid complications.
中性粒细胞减少性脓毒症仍然是全身抗癌治疗中一个时间紧迫且可能致命的并发症。全国范围内仍在推行首剂经验性静脉使用抗生素的目标“门到针”时间为一小时。一项基线审计（2011年6月）凸显了贝尔法斯特信托基金在护理方面的不足，只有15%的患者在60分钟内接受了抗生素治疗。信托基金内部成立了一个多专业小组，试图启动急需的中性粒细胞减少性脓毒症识别和初始管理方面的改进。在过去五年中制定了一些策略。首先引入了一条综合护理路径，目前护理和医务人员在疑似中性粒细胞减少性脓毒症患者通过急性癌症中心评估区域和急诊科就诊时，以及住院患者发生中性粒细胞减少性脓毒症时使用该路径。2012年6月的首次重新审计显示有所改善（62%达到1小时目标），但随后2013年1月的审计结果令人失望（只有50%达到1小时目标）。作为回应，引入了一条新的简洁、用户友好的护理路径。随后还引入了一系列其他措施。通过简单的病房记录持续监测患者护理情况，在每次中性粒细胞减少性脓毒症发作的初始治疗后完成记录。患者群体指导便于护士主导首剂抗生素的处方和给药。还优先安排了定期的多学科教育课程并改善了获取区域指南的途径。从2013年11月起，一直有超过80%的患者达到1小时目标。近期数据仍然令人鼓舞；2016年7月，100%的患者在60分钟内接受了首剂治疗，10月为95%的患者。已证明在达到60分钟目标方面有显著的持续改善。这些措施的结合确保通过协调一致的标准化方法快速、安全地考虑中性粒细胞减少性脓毒症并提供基本临床护理，以避免并发症。
