Assessing the acute oncology
patient
Who, why, where and how!
Clare Warnock, Practice Development Sister, WPH
Kam Singh, Specialist nurse, WPH
Cherie Rushton, sister, ward 2, WPH
Stacey Spenser, BSc health and social care student
Sue Shepley, WPH
Aim 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 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
Triage
Practitioner
Triage and log
Sheet
Attend for
assessment
WPH or A&E
Follow assessment guidelines advice on appropriate care
location/service. e.g. pharmacy,
GP, self monitor
Advice/reassurance
Who is using the service?
How many calls do we 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
on
tu 1
es
w 2
ed
th 3
ur
s
4
fri
5
sa
t6
su
n
m 7
on
tu 8
es
w 9
ed
th 1 0
ur
s
11
fri
1
sa 2
t1
su 3
n
m 14
on
tu 15
es
w 16
ed
th 1 7
ur
s
18
fri
1
sa 9
t2
su 0
n
m 21
on
w 22
ed
th 2 3
ur
s
24
fri
2
sa 5
t2
su 6
n
m 27
on
tu 28
es
w 29
ed
th 3 0
ur
s
31
m
number of calls
Number of calls per day (July 2013)
30
25
20
15
10
5
0
Time of day of calls
160
140
120
100
80
60
40
20
0
00:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
Challenge of unpredictable demands
• 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
service
Where do patients live (2009)?
Primary diagnosis of patients
120
100
80
60
40
20
0
Breast
Lung
Colorectal
Gynae
Prostate
Upper GI Lymphoma
Brain
Kidney
Head and Melanoma
neck
Recent treatment (2013)
63, 12%
7, 1%
37, 7%
31, 6%
409, 74%
Chemotherapy
Radiotherapy
New pt/no treatment in past 6 weeks
Not documented
Other
In
f
tio
ec
n
tio
ec
PI
C
an
d
/fo
ot
xia
5
H
or
e
es
tio
n
7
An
h
as
h
ou
t
R
m
8
ig
te
10
In
d
re
si
le
m
s
a
pr
ob
ul
io
n
15
So
C
an
n
at
20
C
tip
on
s
30
C
ng
oe
a
itt
i
ia
rrh
om
/v
l
50
D
ea
au
s
70
N
te
m
p
60
re
xi
a
ap
y
wi
th
s,
n
m
pt
om
sy
In
f
Reason for ringing (2013)
Chemotherapy treatment related
80
70
59
49
40
29
18
15
4
0
1
Other common reasons for ringing (all
patients)
• Pain = 55
• Major illness = 45
– E.G. chest pain, deranged U&E, bowel obstruction, spinal
cord compression, sudden confusion
• Medicines advice = 33
• Minor ailments = 40
– E.G. Small bleed, infected toe, constipation, sore eye
• General query = 18
– E.G. DN fax, appointment query, dental advice
• Radiotherapy side effects = 10
• What happens when a patient or relative
rings for advice?
Triage pathway
Triage
Practitioner
Attend for
assessment
Cancer centre,
A&E
Follow assessment
guidelines - advice on
appropriate care
location/service. e.g.
pharmacy, GP, self
monitor
Advice/reassurance
How to decide assessment 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
• 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 37.5oc or more,
OR symptoms of infection OR
feels generally unwell
Assessment questions
1.What is the patients’
temperature?
2.How long have they had a
temperature?
3.Have they had any shivers or
shaking?
4.Do they have any other
symptoms?
5.Have they taken paracetamol
or NSAID that could mask a
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 bruising
Assessment questions
1.Is it is new problem?
2.Are they on anticoagulation or aspirin?
Severity level 1
Small volume
blood loss, self
limited,
controlled by
conservative
Bleeding
measures e.g.
1.Is it continuous? How long stops easily
for?
and quickly on
2.Volume of blood loss
applying
3. Where is it from?
pressure
4.Is there a cause or is it
Small bruise
spontaneous?
where cause of
bruise is
Bruising
known
1.Extent of bruising? Where
on the body?
2.has their been an injury?
Severity level 2
Moderate 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)
Severity level 3 and 4
Large volume blood loss
or continuous or
prolonged
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
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
Nausea
1.How long have they had
nausea?
2.Are they taking antiemetics as prescribed?
3.What is their oral intake?
4.Are there any signs of
dehydration e.g. decreased
urine output, thirst, dry
mucous membranes,
weakness, dizziness,
confusion?
5.Do they have any other
symptoms e.g. stomach
pain, abdominal distension,
diarrhoea? (If yes, refer to
appropriate guidelines)
Able to eat and
drink, managing a
reasonable oral
intake
Can eat/drink but
intake reduced, no
signs of dehydration
Patient symptomatic of
dehydration /haemodynamic
instability or patient unable to
take adequate oral fluids
Give advice on
prescribed antiemetics 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.
Arrange medical
review of anti-emetics.
May not need to attend
WPH if appropriate to
contact GP for new
prescription of antiemetics or S/C or IM
anti-emetics
If on capecitabine
discuss dose
reduction/
discontinuing with on
call registrar/ patients
medical team.
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
(hand-foot)
syndrome (PPE)
1.How many days?
2.What areas are
affected?
3.Is there any pain?
4.Is the skin broken?
5.Does it interfere with
mobility/normal
activity?
6.Is the patient on oral
medication likely to be
causing this – i.e.
capecitabine,
Sunitinib, Sorafenib
Numbness,
tingling,
painless
erythema,
swelling, not
disrupting
normal activity
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
Advise use of
oral cancer treatment that
emollient
can cause PPE discuss
cream.
dose reduction/
(e.g. Diprobase, discontinuing with
or E45)
registrar/patients medical
team.
Moist desquamation, ulceration,
blistering, severe pain, unable to
perform normal activities
Organise admission and medical
review
If on capecitabine or other
medication that can cause PPE
discontinue and discuss with
registrar/patients medical team.
AOS assessment and treatment
guidelines
• Local guidelines have been developed
• WPH guidelines are accessible on th
intranet
What are the outcomes of the calls?
Outcomes of calls (2013)
Phone advice, 177,
34%
Other, 44, 8%
A&E, 46, 8%
GP, 121,
22%
WAU, 154, 28%
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 centre
for review?
Attending for review
• Patients attend WAU for medical review
– 8 bedded unit
• Figures for January to July 2011
– range 96 to 189 per month (mean 136)
• Review January 2013
– 206 patients
• September 2013
– 231 patients
Number of patients per day
(September 2013)
Time of day that patients arrived
(September 2013)
The num ber of em ergancy adm issions by area
Where
do patients
live (2013)
for January 2013
100
80
60
40
20
O
th
er
0
Ba
rn
sl
ey
C
he
st
er
fie
ld
D
on
ca
st
er
R
ot
he
rh
am
Sh
ef
fie
ld
W
or
ks
op
Patients Admitted
120
Reason for treatment related 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 patients
on active treatment in the past 6 weeks
Reason
Total
Pain and symptom management
8
Oncology emergency e.g. collapse, seizure,
haemoptysis, obstruction,
Disease related symptoms e.g. jaundice, confusion
6
End of life care
3
Pulmonary embolus
2
Problem with paracentesis drain site
1
Total
26
6
Patients who had not received active
treatment in the last 6 weeks
Reason
Total
Pain control
6
End of life care
4
Other
6
Total
16
What care do patients need on WAU?
– Medical and nursing assessment
– Cannulation, IV fluids, medicines administration (oral,
IV and IM), urinary catheterisation, phlebotomy
– Tests and investigations
– Information and support
• explanation of treatments/condition, updating on the
treatment plan
– Consultation with senior medical staff/patients own
consultant team
– Transfer to wards
How does the service measure up?
• Three key activities were identified
– observations, blood tests and cannulation.
• Time for admission to observations
– Range 3 minutes to 10 minutes, average 6.4 minutes
• Time from admission to blood tests
– Range 5 minutes to 30 minutes, average 15.2
minutes
• Time from admission to Cannulation
– Range 15 to 30 minutes, average 21.25 minutes
Where
dopatients
patients
goto during
next?
January
w ere discahrged
The location
2013
Number of patients
80
70
60
50
40
30
20
10
0
Home
Ward 2
Ward 3
TCU
Other
Location
Challenges of AOS and triage
• Workload is variable and unpredictable
• Can be a struggle to provide the service when busy
•
•
– Undermines effectiveness and safety if not managed
Example of challenges:
– Next call waiting while taking calls,
– No time for review for patient on the phone
• e.g. check ICE
– Fitting in other roles (e.g. managing WAU and triage)
Patient triage and assessment isn’t easy!
– requires skill and experience
Is it worth it?
• It IS proving to be a valuable resource for patients
– Provides timely access to specialist advice and
treatment
– Prevents inappropriate admissions
– Allays unnecessary patient anxiety
– Valuable safety net
• But it is a Challenging service to provide
– Triage has never been funded as a separate service
and has developed from existing resources
– Its success over time means this should be reviewed
as it is outgrowing the resources available