Advanced practice roles have existed within nursing for many years, some since the 1970s (Leary and MacLaine, 2019), under various titles such as advanced nurse practitioner, nurse consultant, advanced practitioner and nurse practitioner. The first official advanced nurse practice course was developed in 1990 at the Royal College of Nursing Institute (Leary and MacLaine, 2019). It was a common misconception that advanced practice roles were a substitute for a shortfall in medical roles (Coombes, 2008), however, the role is now becoming more recognised and the idea of collaborative working between nurses, allied health professionals and doctors is more accepted. Advanced clinical practitioners (ACPs) have been largely based within acute emergency areas such as emergency departments (EDs) and acute medical units. More recently, ACP roles have expanded to include a multitude of healthcare backgrounds—including nurses, physiotherapists and pharmacists—in a variety of specialties (Evans et al, 2020). This has allowed many professionals to expand their skills and knowledge, often taking on roles traditionally recognised as that of a doctor such as advanced clinical assessment and prescribing (Health Education England (HEE) et al, 2017; Hooks and Walker, 2020).
However, within the UK these roles still lack clear standardisation with wide variance across roles and settings in terms of knowledge, skills and competencies. Health Education England, in collaboration with other bodies, set out to define advanced clinical practice within health care in the ‘Multi-Professional Framework for Advanced Clinical Practice in England’ (HEE et al, 2017). The framework outlines the four pillars of advanced practice that ACPs should be competent in: clinical practice, leadership and management, education and research. ACP roles are underpinned by a master's level education, incorporating the four pillars and include competencies such as prescribing, advanced assessment and advanced clinical decision making, in contrast to traditional advanced nursing roles where no postgraduate level of education, set competencies or specific standards were requisite. It is vital that advanced practice roles are standardised and clear competencies are set in order for professionals to perform to a consistently high standard (Stanford, 2016).
Background to the ACP role
The acute oncology triage unit at The Royal Wolverhampton NHS Trust sees oncology and haematology patients presenting with various side effects of systemic anti-cancer therapy (SACT) and complications of disease. Until recently it was led solely by medical registrar trainees who are also required to manage clinics and cover inpatient ward areas in addition to other clinical commitments, resulting in a lack of consistency within the unit.
At the beginning of 2021 two trainee ACPs were employed in the oncology department with the aim of improving services and ultimately providing an ACP-led triage unit, ensuring consistency and continuity for patients, enhancing the patient experience and improving outcomes. The NHS Long Term Plan (NHS England/NHS Improvement, 2019) advocates expanding multiprofessional credentialing to include ACPs within various specialties, including within cancer services.
Both the trainee ACPs within the acute oncology triage unit are Nursing and Midwifery Council-registered nurses with extensive oncological knowledge and experience. The trainee ACPs primarily see patients presenting with a variety of oncological emergencies such as neutropenic sepsis, metastatic spinal cord compression and malignant hypercalcaemia, as well side effects of treatment. They take a comprehensive history, undertake physical examinations, develop differential diagnoses, refer to other specialties and formulate treatment plans.
The trainee ACPs are undertaking masters degrees in advanced clinical practice while developing their role within the service. ACPs should hold the knowledge and ability necessary for recognising areas requiring improvement and be able to implement strategies for change (Hill and Mitchell, 2021). As set out in the Multi-Professional Framework (HEE et al, 2017), the pillars of leadership and education are pivotal in the role of an ACP. The trainee ACPs therefore led on a service improvement project incorporating an educational initiative surrounding neutropenic sepsis for junior nursing staff within the department.
Service improvement
Issues identified
Shortly after starting on the acute oncology triage unit, the trainee ACPs identified several areas requiring change, the most important of which was the sepsis pathway and the poor compliance with door-to-needle times for intravenous (IV) antibiotics within the unit. Neutropenic sepsis is a life-threatening complication and occurs commonly following SACT, it is the cause of death in 1:500 oncology patients (National Institute for Health and Care Excellence (NICE), 2012). Neutropenic sepsis is defined as an absolute neutrophil count of 0.5 x 10 g/litre or less, pyrexia greater than 38C and/or other signs or symptoms of sepsis such as hypotension and tachycardia (NICE, 2012). According to the NICE (2012) guidelines, patients with suspected neutropenic sepsis should receive IV empirical (broad-spectrum) antibiotic therapy immediately. This is echoed in the wider-scope NICE guidance for sepsis recognition, diagnosis and early management (NICE, 2017a), which advocates giving antibiotics within 1 hour of identifying sepsis in high-risk groups such as cancer patients.
An audit conducted before the introduction of the trainee ACPs by the trust's acute oncology service found that only 17% of patients presenting to the acute oncology triage unit with suspected neutropenic sepsis during December 2020 received antibiotics within 1 hour of arrival. It was also observed that the nursing staff were lacking in confidence in identifying patients presenting with potential neutropenic sepsis as well as use of the patient group direction (PGD) already in place.
PGDs have been used within health care for many years. They are usually written instructions to help non-prescribers to administer certain medications to a specific patient group meeting a set criteria (NICE, 2017b). The PGD for empirical antibiotics for suspected neutropenic sepsis had previously been introduced within the department to aid compliance with NICE guidelines and Commissioning for Quality and Innovation (CQUIN) measures for suspected sepsis (NHS England, 2018). Informal feedback from staff suggested that the nursing staff were not confident in identifying in which circumstances to use the PGD and in documenting its administration.
In addition to the use of the PGD, another important element that the trainee ACPs identified as requiring change was the trust sepsis screening tool. This tool identifies any patient with a National Early Warning Score 2 (NEWS2) of 3 in a single parameter or a total of 5 as being at risk of sepsis (Daniels and Nutbeam, 2019); however, it was observed that it was not sensitive enough for patients presenting with suspected neutropenic sepsis.
Leading change
It was clear that change was required within the acute oncology triage unit, however, sustainable change can be difficult to achieve, especially in environments where staff are accustomed to working in certain ways and the individual attempting to make that change is new to the area. Sustainable change can be brought about if effective leadership along with a recognised model of change is used (Lumbers, 2018). The trainee ACPs looked at the NHS England Change Model (NHS England Sustainable Improvement Team, 2018) to enable the necessary changes within the acute oncology triage unit. This model aims to support practitioners in bringing about transformational, sustainable change in practice. As well as a model of change, leadership styles were also considered. Authoritarian leadership is very effective in acute high-stakes situations such as cardiac arrests (Lumbers, 2018) but this style is considered inappropriate for long-term leadership such as the trainee ACPs were aiming for. Transformational leadership, on the other hand, was considered a useful style in this circumstance as it encourages leadership through shared outcomes and goals based on trust, admiration and respect (Bass, 1985). It was therefore important that the trainee ACPs led by example and encouraged the staff on the unit during the change as it was implemented alongside the ongoing COVID-19 pressures facing the team.
Changes introduced
A new neutropenic sepsis screening tool was developed and trialled for use on the acute oncology triage unit, including a decision algorithm (Figure 1). This tool enabled the nursing staff to feel more confident to identify patients presenting with neutropenic sepsis, assessing them holistically, rather than being focused on the NEWS2 score only. For example, a patient presenting with a temperature of 38C and a heart rate of 102 beats per minute would not trigger the traditional sepsis pathway as the NEWS2 score would not total 5, or 3 in a single parameter. However, by using the new neutropenic sepsis screening tool, this patient would now trigger action for sepsis (Table 1) and be flagged for empirical antibiotics within the hour. By ensuring these patients are now identified early as being at risk of neutropenic sepsis and treated accordingly, the risks of further deterioration and mortality are reduced. A study by Kumar et al (2006)—although not specifically on neutropenic sepsis—supports this theory as they found each 1 hour in delay in antibiotic administration for patients showing septic shock increased mortality rates by 7.6%.
Table 1. Sepsis Six actions for adults with suspected or confirmed sepsis, all to be completed within 1 hour
| Action | Further instructions |
|---|---|
| Administer oxygen | Aim to keep saturations >94% (88–92% if at risk of CO2 retention eg COPD) |
| Take blood cultures | At least a peripheral set, cultures from all CVAD lumensConsider other cultures eg CSF, urine, stool, sputum. Think source control!Chest X-ray and urinalysis for all patients |
| Give IV antibiotics | According to trust protocolPGD for post SACT—think neutropenic sepsis!Consider allergies before administration |
| Give IV fluids | If hypotensive or lactate >2 mmol/litre, give 500 ml immediatelyMay be repeated if clinically indicated—do not exceed 30 ml/kg |
| Check serial lactate | Corroborate high VBG lactate with arterial sampleIf lactate >4 mmol/litre, call critical care and recheck after each 10 ml/kg challenge |
| Measure urine output | May require urinary catheterEnsure fluid balance chart commenced and updated hourly |
If after delivering the ‘Sepsis Six’ the patient still has
|
|
COPD=chronic obstructive pulmonary disease; CSF=cerebrospinal fluid; CVAD=central venous access device; IV=intravenous; PGD=patient group direction; SACT=systemic anti-cancer therapy; VBG=venous blood gas sampling
In addition to the introduction of the neutropenic sepsis screening tool, training on the use of the PGD for the administration of first-dose empirical antibiotics was delivered to all qualified nursing staff by the trainee ACPs during June 2021. Taking into account varying working patterns, several educational sessions were delivered, to ensure all staff were able to take part. The aim was to educate and instil confidence in how and when to use the PGD as well as how to document its administration. The neutropenic sepsis screening tool was incorporated into this training as well as the introduction of pre-printed stickers for use on medication charts to enable nursing staff to easily document the administration of antibiotics given using the PGD. These were formatted to match the chart layout with the relevant information on drug, dose and administration route filled in, as well as indicating it was under the PGD, leaving spaces for date and time of entry, person giving medication and time of administration (Table 2).
Table 2. Pre-flilled sticker information for medicine chart
| Drug | Dose | Route | Duration |
|---|---|---|---|
| Piperacillin/tazobactam (diluted in 50–100 ml 0.9% saline) | 4.5 g | IVI | 30 minutes |
| Meropenem | 1 g | IV | Bolus |
IV=intravenous injection; IVI=intravenous infusion
In addition to this training, a sepsis trolley containing all the necessary equipment was implemented as well as a timer to act a visual reminder for nursing staff of the 1-hour target for empirical antibiotic administration.
Impact
The data in Figure 2 were collated over a 6-month period on the acute oncology triage unit. The percentage of patients receiving antibiotics within 1 hour increased exponentially following the introduction of trainee ACPs within the department, increasing from 17% in December 2020 to 100% in February 2021 and remaining at 100% up to the completion of data collection in July 2021. The trainee ACP-led training on PGD use was conducted during June 2021. The impact of this training is apparent, as the use of the PGD increased significantly following delivery of the educational sessions. The PGD was used in 30% of patients presenting with suspected neutropenic sepsis in February 2021, this rose to 93% in June 2021 meaning patients were receiving antibiotics faster due to nurses being able to administer first-dose antibiotics ahead of medical assessment and prescription.
Antibiotic administration within 1 hour has remained at 100% and PGD use has averaged 72% since the data was collected up to May 2022, with 100% PGD use in the last 3 months.
Conclusion
The introduction of trainee ACPs to the acute oncology triage unit has resulted in significant improvements in sepsis outcomes for patients presenting with suspected neutropenic sepsis, with door-to-needle times consistently hitting full compliance with the 1-hour target.
Implementation of educational training sessions on neutropenic sepsis and the use of the PGD, as well as an updated, more sensitive screening tool and easier documentation using pre-printed stickers has meant that 100% of patients presenting at the acute oncology triage unit with suspected neutropenic sepsis are now receiving antibiotics within 1 hour, mainly given using a PGD. This means patients at risk of significant deterioration are recognised and treated earlier, reducing the risks of mortality and morbidity associated with neutropenic sepsis.
The role of oncology ACPs will continue to evolve and develop as the specialty requires, including undertaking advanced procedures such as paracentesis, central venous access device placement and removal, and the introduction of an ACP-led rapid access clinic for low-risk reviews and early supportive discharge follow-up for patients, with the aim of avoiding unnecessary hospital admissions. In the future, the aim is for the acute oncology triage unit to become completely ACP-led, therefore further changes such as non-medical prescribing and non-medical radiology requesting protocols are required to achieve this. These are currently in progress to enable an autonomous ACP-led service. Regarding the sepsis pathway, data collection on door-to-needle times will continue to ensure compliance and yearly educational updates will continue for the nursing staff on the unit. In the future, it would be beneficial to look at how improvements in compliance with door-to-needle times have impacted on length of stay for patients.
KEY POINTS
- Advanced clinical practitioners (ACPs) and trainee ACPs are in an ideal position to influence services and practice within both nursing and medical teams
- Recognised models of change can be used alongside effective leadership approaches to bring about sustainable change
- Neutropenic sepsis remains one of the most common oncological emergencies and timely recognition and management is vital
CPD reflective questions
- How do we ensure nursing staff are confident in recognising neutropenic sepsis?
- How can advanced clinical practitioners (ACPs) influence, support and educate junior staff members?
- In what ways can the introduction of an ACP-led service benefit both the medical and the nursing profession?