Standards › Standard 51 › Standard operating procedures (SOPs)
SOP · ONC-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 51.3
At a glance
- A patient with suspected neutropenic fever is identified at triage and treated as an emergency.
- First-dose antibiotics are given within the time target set by current guidance, and the time is recorded (ONC-REG-002).
- Staff are trained to recognise the urgency of neutropenic fever.
- The time target is reviewed each year against current guidance.
- Stop and get help straight away if: a patient with suspected neutropenic fever waits for antibiotics beyond the target without a recorded reason.
1. Purpose
To make sure a patient with neutropenic fever gets first-dose antibiotics quickly, and that the delay is recorded when it happens (51.3).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Chemotherapy lowers the white cells that fight infection. A patient with fever in that state can die within hours. Giving antibiotics within a set time is what saves them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Oncology physician | Sets the time target and reviews each case over the target | Clinical lead |
| Triage nurse | Identifies suspected neutropenic fever and starts the response | Oncology physician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Identify.
- Identify suspected neutropenic fever at triage and flag the patient as urgent.
Key point: Identified.
Step 2. Treat.
- Give the first-dose antibiotics within the time target.
Key point: Treated.
Step 3. Record.
- Record the times of presentation and antibiotics (ONC-REG-002). Record any reason for a delay.
Key point: Recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Cases with antibiotics within the time target | 100% | Monthly | Oncology physician | Review each case over the target |
| Times recorded for every case | 100% | Monthly | Oncology physician | Escalate to the clinical lead |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| ONC-REG-002 | Neutropenic fever time register | Register |
| HOS-SOP-003 | Sepsis recognition and antibiotic timing (existing, reused) | SOP |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)