The Challenges and Benefits!
Ruth Topolnicky, Hospice Palliative Care Clinical Nurse Specialist Fraser Health
Elizabeth Beddard – Huber, Advance Practice Nurse Pain and Symptom Management/ Palliative Care, BCCA
Vancouver
Ingrid See, Clinical Practice Leader, Vancouver Home Hospice Palliative Care Service
Nicole Wikjord, Hospice Palliative Care Clinical Nurse Specialist, Vancouver General Hospital (transitioned to
Fraser Health)
Sarah Cobb, Clinical Nurse Leader Palliative Care Unit St. Paul’s Hospital

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Ruth Topolnicky, Hospice Palliative Care
CNS Hospice Residences, Fraser Health
Elizabeth Beddard Huber, Advanced
Practice Nurse, Pain and Symptom
Management BCCA Vancouver
Nicole Wikjord, Hospice Palliative Care
Clinical Nurse Specialist, Vancouver
General Hospital (transitioned to Fraser
Health)
Ingrid See, Clinical Practice Leader,
Vancouver Home Hospice Palliative Care
Service

 Supplies used in QI Project provided by MedQuest Medical
 Goal of the QI Project is to select the product that works best for patients, nurses and
Interventional Radiology independent of vendor support
 Evaluation not yet complete

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Identify common symptoms associated with malignancy related ascites
Briefly review the evidence base supporting the use of tunneled peritoneal catheters
Describe how 3 Health Authorities came together to design and implement a quality improvement project

 Ascites that develops with advanced or recurrent cancer
 Due to blockage of lymphatic channels and increased permeability (ovarian)
 Due to obstruction/compression of portal veins (i.e breast, colon, gastric, pancreatic and lung)

Symptoms can include:
 Shortness of Breath
 Early satiety
 Abdominal Pain (distention)
 Gastric Reflux
 Nausea and vomiting
 Fatigue
 Difficulty mobilizing

 Paracentesis:
 Done in hospital
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May need repeat taps more frequently
Large volume drains (tolerated by some patients, not well with others)
Travel becomes a burden over time as disease progresses
 Indwelling peritoneal catheter:
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Drainage can be done at home in smaller volumes
Smaller volumes better tolerated
No need for travel for drains
Patients/families can learn to do their own

Lack of a standardized catheter makes patient flow difficult!
 Several different devices are in use in Lower
Mainland (Pigtails, PleurX ™, Tenckhoff ™)
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Supplies are not always readily available when needed or they outdate before use. Funding for multiple products becomes a problem!
A clinical pathway clarifies criteria and referral process
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Staff education is challenging when multiple devices are used, often with little notice
The lack of approved procedures within each
Authority to guide practice and clinical decisionmaking poses a barrier to care
++ Stress for patients/families when interventions that are initiated in one Health Authority are not familiar to staff in another

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2013: Malignancy Related Ascites
Practices and Resources
BC Cancer Agency (PHSA)
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Ambulatory clients come to clinic for regular paracentesis
Insert ~ 8 PleurX ™ catheters per year and refer to
Vancouver Coastal Health community program to manage.
No business case.
A clinical pathway clarifies criteria and referral process.
Vancouver Coastal Health
 Provide drainage supplies for PleurX ™ Catheter
( VCH funding)
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Nephrologists inserts peritoneal catheters for ascites
Provide Home Care Nursing to manage the drainage.
Fraser Health
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Variation in access to catheter insertion
Estimate 20 peritoneal catheters inserted/year
No designated funding for catheter supplies (No business case).
Provide support for family to manage drainage.

 An overview (summary) of the body of evidence related to malignancy related ascites management was done by Fleming et al in 2009 1 .
 The state of the body of evidence was not sufficiently evolved to support a formal systematic review or meta-analysis 1

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 Early studies were retrospective in nature 1 often of low quality
and were
Multiple case series reports using:
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 various peritoneal catheters, off label use of IVAD devices, tunneled and non tunneled catheters designs included varying quality/rigor in assessing and measuring symptom efficacy (if at all)
Prospective multi center studies are emerging but:
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Validated measures of patient satisfaction are not always included measures of symptom efficacy are not standardized across studies

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 Focus of research has been on studying the impact of low volume drainage on serum albumin, electrolytes, blood volume with concerns re hemodynamics
Studies are becoming more sophisticated over time:
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One cluster analysis of ascites related symptoms was done with patients receiving repeat paracentesis 2
A similar study with patients with tunneled indwelling catheters would be welcome!

 Some patients like the marked change in girth with a high volume paracentesis
 RISK for some patients: hepato-renal failure!
 Low volume drains with intraperitoneal catheter drains result in less change in girth, so a change in pt expectations may be needed

Tunneled Peritoneal Catheters:
The State of the Evidence
 To date accumulative evidence dating back from the 1980 ’ s suggests:
 Low volume (2 litres or less ) drains several times a week are not associated with significant changes in lab values or blood volume depletion
 Some patients may need to drain larger volumes for comfort 3,4,5

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The goal of intermittent drains is improved symptom management
Patients need to adjust the volume and frequency of drains to achieve comfort while also maintaining hydration
Monitor for thirst, dizziness – as may be a sign of hypovolemia 3
Check point – is the patient already on diuretics? Are they necessary?
Women with ovarian cancer can drain large volumes with intermittent paracentesis without hemodynamic effects: 5-10 litres or more 4 Subject to individual tolerance!

 Individualize the frequency and volume of drains
 Patients often experience fatigue after drains: moderate drain volume to reduce this while balancing ascites symptoms control
 The goal is NOT a flat abdomen or to drain all the fluid !

Non- tunneled :
 Pigtails: Risk of infection increases after 42 days (low level evidence). Reserve use for last days to weeks
Tunneled :
 Pleurx® Catheter
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Self sealing one way valve and protective cap
Drainage line set is connected to a foley bag necessitating modification of equipment
Tenchkoff ®
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Peritoneal dialysis catheter
Cook connector to a urinary drainage bag
No self sealing valve on the catheter
 Asept Catheter ®
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Self sealing valve that will facilitate prn irrigation
Closed drainage system with leur lock
Drainage bag prevents reflux of drainage from bag to drainage tubing

 Frustration on the part of providers, and patients
 Serendipity: new ascites management system coincided with comment from Intervention
Radiology stakeholder “ Just tell us what you want us to do!
”

Getting Started: Engagement within each Health Authority
(September 2011):
 Stakeholders:
 Infection control
 Interventional Radiology
 Home Health Leadership,
 Palliative Care MDs
 Health Shared Services BC
(HSSBC)
 Nurses in Hospice, Home Health, and Palliative Care Units

Standardize on a product that all stakeholders find acceptable
 Patients:* the VIPs!
 Interventional Radiologists
 Nurses in Home Health,
Hospice and TPCU

 Inter- Authority Stakeholder meeting to develop starting points:
 Checking for Health Canada approvals
 Invited stakeholder from Health Shared
Services BC (HSSBC) to ensure compliance with policies for new products
 Work began on common Clinical
Decision Support Tools to support practice to be tweaked in each area to meet agency formats, processes

 Decision Support tools developed (lots of time needed for this!)
 Working on project methodology, evaluation plan, education plan (lots of paper!)
 Seeking funding for supplies

 Funding tight within each Health
Authority
 Exploring other options including
Vendor Support with HSSBC assistance

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 Research Ethics Board (REB) support sought so we could present and/or publish
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Acknowledgement from REB UBC of the intent to do a Quality
Improvement Project (Vancouver
Coastal and PHSA)
UBC Letter of Acknowledgement supported in Fraser Health

 Process through HSSBC to obtain
Vendor support for trial product
 Med Quest Medical support received in December 2012 to provide supplies for 15 patients between
Vancouver Coastal, BCCA
Vancouver and Fraser Health.

January 2013 Pulling it together and Rolling it Out: Going Faster!
 Target Population
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English speaking
PPS 50%, life expectancy 6 weeks to 6 months goal of care is palliative
Refractory symptomatic ascites: 2 episodes of recurrence in 30 days or less
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Symptomatic improvement post paracentesis
No coagulopathy that cannot be managed for the time of insertion

Medical Considerations:
 Curative interventions have ceased, focus is on palliative care plan
 Prognosis > 6 weeks and requiring frequent paracentesis for symptom relief
 Patient is transitioning to EOL

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This protocol is not intended for patients: with non-malignant ascites i.e. cirrhotic patients (more prone to hemodynamic instability, infection) who are receiving active treatment aimed at cure with infection in the peritoneal cavity, significant coagulopathy, or when the ascites is multi-loculated

 Exclusion Criteria:
 Non English speaking
 Pt desiring acute chemo for cure
 Patient Screening: HPC MDs in collaboration with CNSs

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Education Plan
Processes for roll out within each
Health Authority
 Education for Interventional Radiologists and Nurse Leaders in IR re catheter and post insertion care
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Connecting with HPC Teams and MDs for case finding
Just in time teaching for nurses in Home
Health and Hospice and Tertiary
Palliative Care Units

WHO
Intervention
Radiologist
Nurses who perform the drain (acute, community)
Patient:
WHAT WHEN Number of times
1 Ease and Use
5 point scale
After insertion of
ASEPT™ catheter
Ease and Use
5 point scale
After using the product 1 per patient
ESAS, modified 1. Prior to insertion
2. After 1 st Drain
3. Weekly
What I Think of my ASEPT: 5 point scale
1.
Before discharge 1 from hospital
2.
4 weeks post
insertion
1
1
1

 First patient receives a catheter
 Mid May: a total of 5 patients have received catheters

The Hurdles…Internal Challenges
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Guidelines
 Developing a clinical pathway to support patients for in patients and community patients
Education
 Educating nurses across settings
Clinical
 Changes in patient status
 Revising our inclusion criteria: PPS 50% too low as these patients can deteriorate quickly!

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Many questions!
CLPNBC practice consultant advises:
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RN establishes the care plan and works collaboratively with the LPN
LPN can assess the catheter exit site, drain the catheter for stable patients whose drainage schedule (volume/frequency) has been established and the outcome is predictable
Must have education and know the indicators of changing predictability and stability
Cannot irrigate the catheter

The Hurdles…Across Systems
 Working across 3
Health Authorities to develop standardized clinical protocols
 Ethics approval or acknowledgement for a QI Project:
Malignancy Related
Ascites Management

 PPS 50% was too low to be an effective criterion for a tunneled catheter
 Patients with advanced malignant disease may have a higher PPS post drain (mobility is a target symptom)
 Patient/family caregivers must be included in the evaluation plan (we forgot!)

 Each patient has different needs in terms of drainage frequency and amount
 Start low, go slow is a good principle

 Analysis of evaluations
 Decision re further direction for
QI project re further product trial
 IN THE END: business case that can be adapted for all participating Health Authorities

1.
Fleming, N. et al. (2009). Indwelling catheters for the management of refractory malignant ascites: A systematic literature overview and retrospective chart review. Journal of
Pain and Symptom Management. 38 (3), 341-349.
2.
Husain, A., Bezjak, A., Easson, A. Malignant Ascites
Symptom Cluster in Patients Referred for Paracentesis Ann
Surg Oncol; 2007. (Internet) Published online October 2009.
Cited Nov 11, 2009. Available from: Springer Science
3 . Courtney, A., Nemcek, A. et al. (2008). Prospective evaluation of the Pleurx ™ catheter when used to treat recurrent ascites associated with malignancy. Journal of Vascular Interventional Radiology. 19 (12), 1723-
1731.

4. O ’ Neill, M.J., Weissleder, R., Gervais,
D.A., Hahn, P.F., Mueller, P.R. (2001).
Tunnelled peritoneal catheter placed under sonographic and fluoroscopic guidance in the palliative treatment of malignant ascites. AJR:177, September
2001
5. Decruze, S.B., Macdonald, R., Smith, G.,
Herod, J.J. (2010). Paracentesis in ovarian cancer: A study of the physiology during free drainage. Journal of Palliative
Medicine, Vol 13, No. 3, 2010. pp 251-
617.