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National Collaborating Centre for Cancer (UK). Neutropenic Sepsis: Prevention and Management of Neutropenic Sepsis in Cancer Patients. London: National Institute for Health and Clinical Excellence (NICE); 2012 Sep. (NICE Clinical Guidelines, No. 151.)
Neutropenic Sepsis: Prevention and Management of Neutropenic Sepsis in Cancer Patients.
Show detailsPatients who are receiving anti-cancer treatment and their carers can be given confusing and inconsistent information in different ways by different people. The training of healthcare professionals in this area is variable.
The objectives of this chapter are to identify:
- What information should be given to patients and carers?
- How this information should be given?
- What is the best way of training healthcare professionals?
3.1. Information and support for patients and carers
3.1.1. Content of information and support
The complications of anticancer treatment are unknown to many patients and carers. At this stressful time of initiating treatment and at all subsequent stages there is a lot of information to take in.
Patients and carers are informed about the nature of anticancer treatment, the potential complications (including neutropenic sepsis), the actions to be taken and the support offered should any problems arise.
A failure to recognise relevant symptoms could lead to a delayed diagnosis of infection and an increased risk of adverse clinical outcomes.
These issues have been widely acknowledged in the National Cancer Action Team, Manual of Cancer Services (NCAT 2011) and National Chemotherapy Advisory Group report (NCAG 2009).
Clinical question: What information and support for patients receiving anticancer treatment, and their carers, reduces the adverse effects of neutropenic sepsis?
Clinical evidence (see also full evidence review)
The literature searches identified no published evidence for this question.
Cost-effectiveness evidence
A literature review of published cost-effectiveness analyses did not identify any relevant papers. Further health economic analysis was not undertaken as the topic did not lend itself to economic evaluation as there was no comparative analysis of cost and outcomes.
Recommendation
- Provide patients having anticancer treatment and their carers with written and oral information, both before starting and throughout their anticancer treatment, on:
- -
neutropenic sepsis
- -
how and when to contact 24-hour specialist oncology advice
- -
how and when to seek emergency care.
Linking Evidence to Recommendations
The aim of this topic was to see what information and support reduce the adverse effects of neutropenic sepsis for patients receiving anticancer treatment and their carers.
The GDG considered the outcomes of mortality, ICU admissions, door to needle time, length of stay and patient knowledge to be the most clinically relevant to the topic. No evidence was identified that was relevant to this question and therefore none of these outcomes were reported.
The GDG noted that there was a lack of evidence on what information and support patients needed to reduce the adverse effects of neutropenic sepsis. The GDG agreed that despite this lack of evidence it was essential to recommend that information on neutropenic sepsis was provided to patients receiving anticancer treatment. The GDG noted a recommendation should represent best practice, and also be in line with existing Department of Health (NCAT 2011) and national guidelines (NCAG 2009). However the GDG decided that due to the lack of evidence it would not be possible to make definitive recommendations on exactly what information should be provided.
The GDG noted that the NCEPOD report (2008) had highlighted the lack of immediate 24 hour access to specialist oncology advice and appropriate emergency care. They believed it was important to recommend such access for patients with potential neutropenic sepsis to improve patient care and outcomes.
The GDG noted that no relevant, published economic evaluations had been identified and no additional economic analysis had been undertaken in this area. The opinion of the GDG was that there were potential cost implications for providing immediate 24hour access to specialist oncology advice and appropriate emergency care. However they were uncertain what these implications would be since some centres may already have resources in place to provide this service. The GDG also agreed based on their clinical expertise that providing this service could potentially result in cost savings at some centres by preventing unnecessary admissions and patients presenting earlier preventing later complications.
Therefore the GDG recommended that patients and carers be provided with information on how and when to contact 24-hour specialist oncology advice and access emergency care, together with written and verbal information on neutropenic sepsis before starting and throughout anticancer treatment.
3.1.2. Delivery of information and support for patients and carers
Patients with cancer and their carers receive many pieces of information regarding their treatment, the intended benefits, the potential harms, and support to meet the challenges of being treated for cancer. Information and support on neutropenic sepsis is provided as part of this process.
A range of different methods and formats are used to deliver information about neutropenic sepsis. These include pre-printed leaflets, personalised written information, verbal communication, video and other multi-media presentations. The methods may be delivered by various healthcare professionals. There is no clear consensus on which of these formats, methods or type of healthcare professional supplying the information and support is most beneficial.
Clinical question: What types of information and support have patients with neutropenic sepsis (and their carers) found useful or requested?
Clinical evidence (see also full evidence review)
Study quality and results
The literature search identified one qualitative study (Higgins, 2008) designed to evaluate an alert card containing information for patients and healthcare professionals.
The overall quality of evidence was low, because it only included a single study of one intervention. This study was not designed to explore which types of information and support patients with neutropenic sepsis (and their carers) find useful.
Evidence statements
Higgins, et al., (2008) reported recurring themes from patient responses to their alert card intervention. These included ‘Made me feel safe’, ‘Gave me assurance that if I needed help there was someone to give it to me at the earliest possible moment’, ‘Symptoms clearly explained’, ‘Great to have contact numbers’. The authors state that “Overall, the results showed a high level of patient satisfaction.”
Cost-effectiveness evidence
A literature review of published cost-effectiveness analyses did not identify any relevant papers. Further health economic analysis was not undertaken as the topic did not lend itself to economic evaluation as there was no comparative analysis of cost and outcomes.
Research recommendation
- A descriptive study involving patients who have had neutropenic sepsis and their carers should be undertaken to find out what types of support and information patients and carers were given, which of these they found helpful or unhelpful, and whether they think additional or different types of support or information are needed.
Linking Evidence to Recommendations
The aim of this topic was to see what type of information and support patients with neutropenic sepsis and their carers required or found helpful.
The evidence reported one qualitative study of patient satisfaction of an alert card containing information for patients and healthcare professionals. However the GDG felt that there was potential bias as this study only covered a small limited group of patients experience satisfaction. The GDG noted that the evidence was of ‘low’ quality.
The GDG noted that no relevant, published economic evaluations had been identified and no additional economic analysis had been undertaken in this area.
The GDG felt that due to the limited evidence available they were unable to make a recommendation for clinical practice. They agreed that further research needs to be undertaken to identify what type of support and information have been offered to patients and their carers, and what were felt to be helpful or unhelpful, and what other types of support and information is felt to be needed.
3.2. Training for healthcare professionals
Patients with suspected neutropenic sepsis may present to a variety of healthcare settings including primary care, emergency departments and hospital wards.
Healthcare professionals within these settings are often unfamiliar with the management and potentially life threatening complications of neutropenic sepsis and have varying levels of expertise within this field.
Some healthcare professionals may receive training in this topic as part of their continued professional development. The methods used vary widely and include lectures, workshops and bedside teaching as well as the use of teaching aids such as DVDs or simulators which allow healthcare professionals to role-play the practical treatment of patients. There is no clear consensus on whether training by these methods is effective, which of the methods is most efficient and whether training delivery should differ by healthcare profession.
Clinical question: Does training healthcare professionals on the identification and management of neutropenic sepsis improve outcomes for patients receiving anticancer treatment?
Clinical evidence (see also full evidence review)
Evidence statements
Door to needle time
There was very low quality evidence from two observational studies about the effect of training on door to needle time (Table 3.1). Lim, et al., (2010) reported a shorter time from triage to first antibiotic in hospitals which used an electronic clinical practice guideline for febrile neutropenia. Sastry, et al., (2009) evaluated staff re-education about febrile neutropenia and found that the proportion of patients receiving antibiotics within 30 minutes of their first assessment did not differ significantly before and after re-education.
Table 3.1
GRADE profile: Does training healthcare professionals on the identification and management of neutropenic sepsis improve outcomes for patients receiving anticancer treatment?
Mortality, ICU admissions, length of stay, patient satisfaction and healthcare professionals' knowledge of neutropenic sepsis management
Literature searches identified no evidence about the impact of training healthcare professionals on the identification and management of neutropenic sepsis on these outcomes.
Cost-effectiveness evidence
A literature review of published cost-effectiveness analyses did not identify any relevant papers. The potential health benefits from this intervention were likely to be small and difficult to attribute to the training of healthcare professionals, therefore further health economic analysis was not considered appropriate.
Recommendation
- Healthcare professionals and staff who come into contact with patients having anticancer treatment should be provided with training on neutropenic sepsis. The training should be tailored according to the type of contact.
Linking Evidence to Recommendations
The aim of this topic was to see if training of healthcare professionals on the identification and management of neutropenic sepsis could improve outcomes for patients receiving anticancer treatment.
The GDG considered the outcomes of mortality, ICU admissions, door to needle time, length of stay, patient satisfaction, and healthcare professionals knowledge of neutropenic sepsis management, were the most relevant to the question. Evidence was only available for door to needle time. The overall quality of the evidence classified by GRADE was ‘very low’.
Despite this limited evidence, the GDG agreed it was essential to recommend training was provided on the identification and management of neutropenic sepsis because this represents best practice, and is in line with existing Department of Health guidance (NCAT, 2011; NCAG, 2009). In addition, it was the opinion of the GDG that providing this training would improve the patient experience. However, the GDG did not feel able to make definitive recommendations on what specific training should be provided due to the lack of evidence. They noted that patients might benefit from receiving better care because healthcare professionals would be trained in the early identification of patients with neutropenic sepsis leading to earlier treatment, more appropriate ongoing management, and reducing complications.
The GDG noted that no relevant, published economic evaluations had been identified and no additional economic analysis had been undertaken in this area. The GDG agreed based on their clinical experience that there may be additional costs or cost savings of recommending training, though it was not possible to quantify these.
Therefore the GDG agreed to recommend that training on the identification and management of neutropenic sepsis for healthcare professionals who come into contact with patients at risk of neutropenic sepsis should be provided.
References
- Higgins A. Raising awareness of neutropenic sepsis risk in ambulatory patients. Cancer Nursing Practice. 2008 Nov;9(7):34–8.
- National Cancer Action Team (NCAT); National Cancer Peer Review Programme. Manual of Cancer Services. Apr, 2011. Available at: www
.dh.gov.uk/prod_consum_dh /groups/dh_digitalassets /documents /digitalasset/dh_125889.pdf. - National Chemotherapy Advisory Group (NCAG) report on Chemotherapy Services in England: Ensuring quality and safety. Aug, 2011. Available at- www
.dh.gov.uk/prod_consum_dh /groups/dh_digitalassets /documents /digitalasset/dh_104501.pdf. - National Confidential Enquiry into Patient Outcome and Death (NCEPOD). For better, for worse? A review of the care of patients who died within 30 days of receiving systemic anti-cancer therapy. 2008. Available at- www
.ncepod.org.uk/2008report3 /Downloads/SACT_report.pdf. - Lim C, Bawden J, Wing A, Villa-Roel C, Meurer DP, Bullard MJ, Rowe BH. Febrile neutropenia in EDs: the role of an electronic clinical practice guideline. American Journal of Emergency Medicine. 2010 [PubMed: 21030183]
- Sastry J, Harrison D, Taylor J, Ronghe M, Gibson B, Murphy D, McIntosh D. Re-education works! re-audit shows improved compliance to febrile neutropenia protocol in a principle treatment centre. Pediatric Blood and Cancer. 2009;53:866.
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