Assessing the acute oncology Assessing the acute oncology patient patient

Who, why, where and how!Who, why, where and how!

Clare Warnock, Practice Development Sister, WPH Clare Warnock, Practice Development Sister, WPH Kam Singh, Specialist nurse, WPH Kam Singh, Specialist nurse, WPH

Cherie Rushton, sister, ward 2, WPHCherie Rushton, sister, ward 2, WPHStacey Spenser, BSc health and social care student Stacey Spenser, BSc health and social care student

Sue Shepley, WPH Sue Shepley, WPH

Aim of this sessionAim of this session

•Provide insight into the AOS needs of patients within the NT cancer network – How many patients seek AOS support – Which patients seek advice– Why do they need help– What type of support do they need– How do we currently provided AOS support – What tools do we have to help

Triage assessmentTriage assessment• Triage = the process of determining the priority of

patients' treatments based on the severity of their condition

• UKONS standards for triage - what do we have in place?

• The triage practitioner has the right of admission √

• There should be an identified assessment area √

• There should be a clearly identified triage practitioner for each span of duty √

• There should be a process for each step of the triage pathway √

• Each step provides insights into the AOS service

Triage pathway

Attend for assessmentWPH or A&E

Follow assessment guidelines - advice on appropriate care location/service. e.g. pharmacy, GP, self monitor

Advice/reassurance

TriagePractitioner

Triage and log Sheet

Who is using the service? Who is using the service?

How many calls do we How many calls do we receive?receive?• 4 reviews have been carried out at WPH

– October 2009 = 129 calls – October 2010 = 291 calls– April 2012 = 483– April 2013 = 544– July 2013 = 562

• The number of calls per month and per day vary widely

Number of calls per day (July 2013)Number of calls per day (July 2013)

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Challenge of unpredictable Challenge of unpredictable

demandsdemands • There was a wide variation in volume of

telephone calls each month and each day– We did not find a pattern

• The service need to meet a highly unpredictable workload

• This presents a challenge faced when trying to plan and deliver oncology telephone triage services

Which patients use the phone Which patients use the phone serviceservice

Where do patients live Where do patients live (2009)?(2009)?

Primary diagnosis of Primary diagnosis of patientspatients

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Breast Lung Colorectal Gynae Prostate Upper GI Lymphoma Brain Kidney Head andneck

Melanoma

Recent treatment (2013)Recent treatment (2013)

409, 74%

31, 6%

37, 7%

63, 12% 7, 1%

Chemotherapy Radiotherapy New pt/no treatment in past 6 weeks Not documented Other

Reason for ringing (2013)Reason for ringing (2013)

Chemotherapy treatment relatedChemotherapy treatment related

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Other common reasons for ringing Other common reasons for ringing (all patients)(all patients)

• Pain = 55Pain = 55

• Major illness = 45Major illness = 45– E.G. chest pain, deranged U&E, bowel obstruction, E.G. chest pain, deranged U&E, bowel obstruction,

spinal cord compression, sudden confusionspinal cord compression, sudden confusion

• Medicines advice = 33Medicines advice = 33

• Minor ailments = 40Minor ailments = 40– E.G. Small bleed, infected toe, constipation, sore eyeE.G. Small bleed, infected toe, constipation, sore eye

• General query = 18General query = 18– E.G. DN fax, appointment query, dental adviceE.G. DN fax, appointment query, dental advice

• Radiotherapy side effects = 10Radiotherapy side effects = 10

• What happens when a patient or What happens when a patient or relative rings for advice? relative rings for advice?

Triage pathway

Attend for assessmentCancer centre, A&E

Advice/reassurance

TriagePractitioner

Follow assessment guidelines - advice on appropriate care location/service. e.g. pharmacy, GP, self monitor

How to decide assessment How to decide assessment outcomes?outcomes? • Tools for triage

– Telephone triage – based on UKONS triage guidelines

– AOS guidelines

• Based on assessment of symptom severity and clinical signs – With elements of experience, intuition and hunches

• Colour coded grading of – Minor (green) – Moderate (amber) – Severe (red)

Action following assessment Action following assessment • Green – follow advice on guidelines. • 1 amber – follow advice in guidelines. • Ask patient to ring back if symptoms do

not improve or worsen• 2 or more amber – organise appropriate

medical review– WAU, GP, local A&E, next OPA

• Red – medical review at WPH unless alternative appropriate – e.g. A&E for cardiac chest pain, conditions that

might require surgical intervention

Temperature 37.5Temperature 37.5ooc or more, c or more, OR symptoms of infection OR OR symptoms of infection OR feels generally unwell feels generally unwell Assessment questionsAssessment questions1.1.What is the patients’ What is the patients’ temperature?temperature?2.2.How long have they had a How long have they had a temperature?temperature?3.3.Have they had any shivers or Have they had any shivers or shaking?shaking?4.4.Do they have any other Do they have any other symptoms? symptoms? 5.5.Have they taken paracetamol Have they taken paracetamol or NSAID that could mask a or NSAID that could mask a pyrexia?pyrexia?

Arrange urgent medical review as risk of neutropaenic sepsis – follow neutropaenic sepsis pathway.

If no bed available at WPH send to local A&E. Phone A&E to inform staff of patients arrival and need to follow the neutropaenic sepsis protocol including urgent bloods and IV antibiotics within 1 hour if neutropenic sepsis suspected

ALERT patients on steroids/analgesics or dehydrated may not present with pyrexia but may still have an infection

Bleeding or bruisingBleeding or bruisingAssessment questionsAssessment questions1.1.Is it is new problem? Is it is new problem? 2.2.Are they on anti-Are they on anti-coagulation or aspirin? coagulation or aspirin?

BleedingBleeding1.1.Is it continuous? How long Is it continuous? How long for? for? 2.2.Volume of blood lossVolume of blood loss3.3. Where is it from?Where is it from?4.4.Is there a cause or is it Is there a cause or is it spontaneous? spontaneous?

Bruising Bruising 1.1.Extent of bruising? Where Extent of bruising? Where on the body? on the body? 2.2.has their been an injury? has their been an injury?

Severity level 1Small volume blood loss, self limited, controlled by conservative measures e.g. stops easily and quickly on applying pressureSmall bruise where cause of bruise is known

Severity level 2Moderate volume blood loss or bleeding on more than one occasion. Spontaneous bruising /large areas of bruising particularly where the cause is not known (need to check platelet count)

Arrange urgent medical review. Review may be at local A&E if appropriate or likely to require surgical or specialist intervention e.g. vaginal bleeding with gynaecology primary, haematemesis, resuscitation/ critical care team support

Severity level 3 and 4Large volume blood loss or continuous or prolonged

Arrange urgent medical review at local A&E via 999 ambulance as likely to require surgical or specialist intervention e.g. immediate resuscitation/critical care team support

NauseaNausea1.1.How long have they had How long have they had nausea?nausea?2.2.Are they taking anti-Are they taking anti-emetics as prescribed? emetics as prescribed? 3.3.What is their oral intake?What is their oral intake?4.4.Are there any signs of Are there any signs of dehydration e.g. decreased dehydration e.g. decreased urine output, thirst, dry urine output, thirst, dry mucous membranes, mucous membranes, weakness, dizziness, weakness, dizziness, confusion?confusion?5.5.Do they have any other Do they have any other symptoms e.g. stomach symptoms e.g. stomach pain, abdominal distension, pain, abdominal distension, diarrhoea? diarrhoea? (If yes, refer to (If yes, refer to appropriate guidelines)appropriate guidelines)

Able to eat and drink, managing a reasonable oral intake

Give advice on prescribed anti-emetics including regular use and compliance with prescription. Advise to take frequent sips of fluid and eat small amounts often. Teach patient to monitor for signs of dehydration.

Can eat/drink but intake reduced, no signs of dehydration

Arrange medical review of anti-emetics. May not need to attend WPH if appropriate to contact GP for new prescription of anti-emetics or S/C or IM anti-emetics If on capecitabine discuss dose reduction/ discontinuing with on call registrar/ patients medical team.

Patient symptomatic of dehydration /haemodynamic instability or patient unable to take adequate oral fluids

Arrange urgent medical review at WPH. If no bed available at WPH send to local A&E. Phone A&E to inform staff of chemotherapy related antiemetic protocol If on capecitabine or 5FU infusor discuss discontinuing with registrar/patients medical team.

Palmar- plantar Palmar- plantar (hand-foot) (hand-foot) syndrome (PPE)syndrome (PPE)1.1.How many days? How many days? 2.2.What areas are What areas are affected? affected? 3.3.Is there any pain? Is there any pain? 4.4.Is the skin broken? Is the skin broken? 5.5.Does it interfere with Does it interfere with mobility/normal mobility/normal activity?activity?6.6.Is the patient on oral Is the patient on oral medication likely to be medication likely to be causing this – i.e. causing this – i.e. capecitabine, capecitabine, Sunitinib, SorafenibSunitinib, Sorafenib

Numbness, tingling, painless erythema, swelling, not disrupting normal activity

Advise use of emollient cream.(e.g. Diprobase, or E45)

Painful erythema and swelling, discomfort that affects normal activity but still able to perform them

Advise use of emollient cream.If on capecitabine or other oral cancer treatment that can cause PPE discuss dose reduction/ discontinuing with registrar/patients medical team.

Moist desquamation, ulceration, blistering, severe pain, unable to perform normal activities

Organise admission and medical reviewIf on capecitabine or other medication that can cause PPE discontinue and discuss with registrar/patients medical team.

AOS assessment and AOS assessment and treatment guidelines treatment guidelines

• Local guidelines have been Local guidelines have been developeddeveloped

• WPH guidelines are accessible on th WPH guidelines are accessible on th intranet intranet

What are the outcomes of the calls? What are the outcomes of the calls?

Outcomes of calls (2013) Outcomes of calls (2013)

A&E, 46, 8%Other, 44, 8%

GP, 121, 22%

Phone advice, 177, 34%

WAU, 154, 28%

Are we getting it right?Are we getting it right?• 3 reviews have evaluated whether phone advice

was appropriate

• 2009 = 84.4% appropriate– Incorrect advice = 7– Not enough information documented = 7

• 2010 = 87.2% appropriate– Incorrect advice = 17– Not enough information = 6

• 2012 = 92% appropriate– Incorrect advice = 12– Not enough information = 21

• Which patients attend the cancer Which patients attend the cancer centre for review? centre for review?

Attending for reviewAttending for review• Patients attend WAU for medical Patients attend WAU for medical

reviewreview– 8 bedded unit 8 bedded unit

• Figures for January to July 2011 Figures for January to July 2011 – range 96 to 189 per month (mean 136) range 96 to 189 per month (mean 136)

• Review January 2013Review January 2013– 206 patients 206 patients

• September 2013September 2013– 231 patients 231 patients

Number of patients per day Number of patients per day (September 2013)(September 2013)

Time of day that patients Time of day that patients arrivedarrived(September 2013)(September 2013)

Where do patients live Where do patients live (2013)(2013)

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Reason for treatment related Reason for treatment related admissions (June 2011)admissions (June 2011)

Reason Total

Suspected neutropenic sepsis 53

Nausea and vomiting 21

Infection not neutropenic 20

Diarrhoea 17

Electrolyte imbalance/dehydration 11

Head and neck radiotherapy symptom management 9

Pancytopenia/low platelets/symptomatic anaemia 6

Other (PICC problems, oesophagitis, extravasation) 4

Total 141

Non treatment related reasons for Non treatment related reasons for patients on active treatment in the patients on active treatment in the past 6 weekspast 6 weeksReason Total

Pain and symptom management 8

Oncology emergency e.g. collapse, seizure, haemoptysis, obstruction,

6

Disease related symptoms e.g. jaundice, confusion 6

End of life care 3

Pulmonary embolus 2

Problem with paracentesis drain site 1

Total 26

Patients who had not received Patients who had not received active active treatment in the last 6 treatment in the last 6 weeksweeks

Reason Total

Pain control 6

End of life care 4

Other 6

Total 16

What care do patients need on What care do patients need on

WAU?WAU? – Medical and nursing assessment Medical and nursing assessment – Cannulation, IV fluids, medicines administration Cannulation, IV fluids, medicines administration

(oral, IV and IM), urinary catheterisation, (oral, IV and IM), urinary catheterisation, phlebotomy phlebotomy

– Tests and investigationsTests and investigations– Information and support Information and support

• explanation of treatments/condition, updating on the explanation of treatments/condition, updating on the treatment plan treatment plan

– Consultation with senior medical staff/patients Consultation with senior medical staff/patients own consultant teamown consultant team

– Transfer to wards Transfer to wards

How does the service measure How does the service measure up?up?

• Three key activities were identified Three key activities were identified – observations, blood tests and cannulation. observations, blood tests and cannulation.

• Time for admission to observationsTime for admission to observations– Range 3 minutes to 10 minutes, average 6.4 Range 3 minutes to 10 minutes, average 6.4

minutesminutes

• Time from admission to blood testsTime from admission to blood tests– Range 5 minutes to 30 minutes, average 15.2 Range 5 minutes to 30 minutes, average 15.2

minutesminutes

• Time from admission to CannulationTime from admission to Cannulation– Range 15 to 30 minutes, average 21.25 minutes Range 15 to 30 minutes, average 21.25 minutes

Where do patients go next?Where do patients go next?

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Challenges of AOS and Challenges of AOS and triage triage • Workload is variable and unpredictableWorkload is variable and unpredictable

• Can be a struggle to provide the service when busy Can be a struggle to provide the service when busy – Undermines effectiveness and safety if not managedUndermines effectiveness and safety if not managed

• Example of challenges:Example of challenges:– Next call waiting while taking calls, Next call waiting while taking calls, – No time for review for patient on the phone No time for review for patient on the phone

• e.g. check ICEe.g. check ICE

– Fitting in other roles (e.g. managing WAU and triage) Fitting in other roles (e.g. managing WAU and triage)

• Patient triage and assessment isn’t easy! Patient triage and assessment isn’t easy! – requires skill and experience requires skill and experience

Is it worth it?Is it worth it?• It IS proving to be a valuable resource for patientsIt IS proving to be a valuable resource for patients

– Provides timely access to specialist advice and Provides timely access to specialist advice and treatmenttreatment

– Prevents inappropriate admissions Prevents inappropriate admissions – Allays unnecessary patient anxietyAllays unnecessary patient anxiety– Valuable safety net Valuable safety net

• But it is a Challenging service to provide But it is a Challenging service to provide – Triage has never been funded as a separate Triage has never been funded as a separate

service and has developed from existing resourcesservice and has developed from existing resources– Its success over time means this should be Its success over time means this should be

reviewed as it is outgrowing the resources reviewed as it is outgrowing the resources availableavailable