intravesical bcg clinical care pathway

Intravesical BCG clinical care pathway

AcknowledgmentsThe WA Cancer and Palliative care Network wish to recognise Fremantle Hospital for their collaboration in the development of this document.

Disclaimer

All information and content in this material is provided in good faith by the Department of Health, Western Australia and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the Department of Health, Western Australia and their respective officers, employees and agents, do not accept legal liability or responsibility for the material, or any consequences arising from its use.

The Local implementation, training and evaluation of clinical staff remains the responsibility of the employee authority.

1

Intravesical BCG clinical care pathway explanatory notes

Intravesical therapies are the mainstay of treatment for non-muscle invasive bladder cancer. BCG, including maintenance treatment is the current gold standard for high risk disease, though optimal regimes remain undefined. This care pathway was developed to assist in the delivery of intravesical BCG induction and maintenance treatment by providing clinicians and nursing staff with a clear framework for treatment delivery utilising best practice principles.1, 2

The diagram below is a 12 month schedule for BCG induction and maintenance with suggested cystoscopic surveillance. It fulfills current guidelines for BCG and maintenance administration though other maintenance schedules exist. 3, 4

Induction BCG treatment

Week 1 2 3 4 5 6 7 8 9

Maintenance

Month 3 4 5 6 7 8 9 10 11 12

GA cystoscopy and biopsy

Flexible cystoscopy

Flexible cystoscopy

GA cystoscopy and biopsy

Patients should be screened to exclude urinary tract infection prior to commencing each cycle of BCG, as per shown in the algorithm on page 3. Once clearance to proceed has been obtained, regular surveillance cystoscopies should be undertaken during maintenance regimes, and this should be documented in the scheduling chart shown on page 4.

2

Surname UMRN

Given names Birthdate Sex

Address

Patient label

Intravesical Bladder CancerConsultant ____________________________

Ward ____________________________

Aims of Intravesical BCG clinical are pathway

The patient will receive Intravesical therapy at weekly intervals with managed side-effects and a cystoscopy performed at defined intervals

Risk factors

Any urinary bladder operation (eg. TURBT), cystoscopy +/- biopsy performed within last 2 weeks

Using the Clinical Pathway

The Clinical Pathway is a guide that should be altered to meet the patient’s needs as required

Record and code variations from the pathway on the variance page. If required, variance documentation may be expanded further in the integrated notes

Complete the signature register only on the FIRST occasion of caring for the patient

Signature register

Print Name Initial Desig Print Name Initial Desig

© Fremantle Hospital & Health Service – Permission to use

Surname UMRN


Address

Algorithm

Consultant ____________________________

Ward ____________________________

Patient label

3

Algorithm

Consultant ____________________________

Ward ____________________________

Surname UMRN


Address

Patient label

Medical Officer to review MSU growth results & sensitivities, and contact Microbiologist or Infectious Diseases physician for further clarification of urine culture and susceptibility results if required. Contact GP to organise antibiotic therapy and repeat MSU.

* LUTS – Lower Urinary Tract Symptoms

No

Yes

Yes

Yes

No

No

Urine M/C/S (MSU) form given by nurses for collection at hospital pathology on the Monday prior to intravesical commencing.

Treatment area nurse to review MSU results day prior to intravesical treatment day.

MSU - Scanty, Light Growth or Mixed organism.

Leukocytes less than 100 x 10^6/L.

Is this result following a repeat MSU?

Treatment cannot proceed Repeat MSU Inform patient Record variance.

Contact Urology Registrar to consider dose reduction or repeat MSU.

Treatment may proceed at reduced dose.

Severe LUTS*.

MSU - no growth & may include:

Isolated pyuria Contaminants.

No symptoms to mild/moderate LUTS*.

Treatment can proceed.

MSU - moderate to heavy growth.

Treatment cannot proceed.

Inform patient to see GP for antibiotic therapy and not to come in for the intravesical treatment.

Arrange a repeat MSU 3 days post completion of antibiotics. Record variance.

Inform booking clerk of treatment delay.

Is this 3rd positive MSU?

Stop pathway. Contact Urology Registrar or Urology Consultant for management plan.

Contact Medical Officer.

Clearance to proceed algorithm

ME

DIC

AL

4

Surname UMRN


Address

Patient label

Cystoscopy Scheduling Chart

Cystoscopy Date Range Required Date Request Sent

Date Procedure Scheduled

Signature

GA cystoscopy/biopsy(Post Induction) Recorded on cystoscopy

booking form Patient informed

Flexible cystoscopy(First)

Recorded on cystoscopy booking form Patient informed

Flexible cystoscopy (Second)


Flexible cystoscopy (Third*)


GA cystoscopy/biopsy (Post maintenance completion)


High Grade Non-muscle Invasive Bladder Cancer patients require a follow up General Anaesthetic (GA) cystoscopy and bladder biopsy at a minimum of two weeks post therapy. These should take place following completion of the induction course and then following completion of the maintenance course.

High Grade Non-muscle Invasive Bladder Cancer patients on maintenance intravesical therapy require follow up flexible cystoscopy third monthly.

Ongoing cystoscopy surveillance thereafter is to be determined by the patient’s Urologist.

*Determined by length of time of the maintenance course.

5

Surname UMRN


Address

Patient label

Induction treatmentConsultant ____________________________

Ward ____________________________

Category Pre Admission

Date:

Var

ian

ce Week 1 of 6 Date:

Var

ian

ce

1 Education & Discharge Planning

Procedure explained and patient understands UTI symptoms, MSU collections and GP follow up of abnormal results with antibiotics explained BCG patient handout Bladder cancer information booklet. Patient aware cystoscopy/biopsies will be carried out post induction; third monthly whilst receiving maintenance; and on completion of maintenance.

Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance

2 Consults Nursing admission complete Medical admission complete Consent signed

3 Investigations & Clearance to Proceed

Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted (pages 14 and 15)

4 Treatment & Assessment

TPR recorded TPR recorded

5 Medications & Pain Management

Usual medications Assess for analgesia requirements

BCG instillation as per protocolDate instillation givenUsual medicationsAssess for analgesia requirements

6 Diet & Hydration

Usual diet and fluids Usual diet Encourage oral fluids after treatment

7 Hygiene Education provided on Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination &

Safety Patient educated on safe voiding technique - sitting to void and double flush Patient educated on use of bleach tablet after toileting

No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sit to void and double flush)Patient educated on use of bleach tablet post toileting

Special Needs & Team Messages

Sig

nat

ure

s Medical

Allied Health

Nurse AM PM AM PM

This pathway is a guide and should be altered to meet the patients needs as required

6

Surname UMRN


Address

Patient label


Ward ____________________________

Category Week 2 of 6

Date:

Var

ian

ce Week 3 of 6

Date:

Var

ian

ce




2 Consults







BCG instillation as per protocolDate instillation given ________________

Usual medicationsAssess for analgesia requirements



6 Diet & Hydration

Usual diet Encourage oral fluids

Usual diet Encourage oral fluids

7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination

& SafetyNo voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting

No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting


Sig

nat

ure

s Medical

Allied Health

Nurse AM PM AM PM


7

Surname UMRN


Address

Patient label


Date:

Var

ian

ce Week 5 of 6

Date:

Var

ian

ce




2 Consults Refer to Pre-Admission Clinic for GA cystoscopy and biopsyBooking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway


Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted









6 Diet & Hydration

Usual diet Encourage oral fluids after treatment






Sig

nat

ure

s Medical

Allied Health

Nurse AM PM AM PM



Ward ____________________________

8

Surname UMRN


Address

Patient label


Date:

Var

ian

ce



2 Consults GA cystoscopy and biopsy booking date recorded on Cystoscopy Scheduling Chart of this pathway




TPR recorded




6 Diet & Hydration


7 Hygiene Pre procedure genital Chlorhex wash8 Elimination



Sig

nat

ure

s Medical

Allied Health

Nurse AM PM



Ward ____________________________

9

Surname UMRN


Address

Patient label

Category Maintenance treatment: 1 of 10

Date:

Var

ian

ce Maintenance treatment: 2 of 10

Date:

Var

ian

ce




2 Consults Refer to Pre-Admission clinic for GA cystoscopy and biopsyBooking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway











6 Diet & Hydration







Sig

nat

ure

s Medical

Allied Health

Nurse AM PM AM PM


Maintenance treatmentConsultant ____________________________

Ward ____________________________

10

Surname UMRN


Address

Patient label


Date:

Var

ian


Date:

Var

ian

ce




2 Consults Flexible cystscopy booking date recorded on Cystoscopy Scheduling Chart of this pathway











6 Diet & Hydration




& SafetyPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on safe bleach tablet usage post toileting

Patient educated on safe voiding technique (sitting to void and double flush)Patient educated on safe bleach tablet usage post toileting


Sig

nat

ure

s Medical

Allied Health

Nurse AM PM AM PM



Ward ____________________________

11

Surname UMRN


Address

Patient label


Date:

Var

ian


Date:

Var

ian

ce




2 Consults Refer for flexible cystoscopyBooking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway

Proposed flexible cystoscopy Booking date recorded on Cystoscopy Scheduling Chart of this pathway











6 Diet & Hydration







Sig

nat

ure

s Medical

Allied Health

Nurse AM PM AM PM



Ward ____________________________

12

Surname UMRN


Address

Patient label


Date:

Var

ian


Date:

Var

ian

ce




2 Consults











6 Diet & Hydration







Sig

nat

ure

s Medical

Allied Health

Nurse AM PM AM PM



Ward ____________________________

13

Surname UMRN


Address

Patient label


Date:

Var

ian


Date:

Var

ian

ce




2 Consults Proposed GA cystoscopy and biopsy booking date recorded on Cystoscopy Scheduling Chart of this pathway

Refer to Pre-Admission clinic for GA cystoscopy and biopsyBooking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway











6 Diet & Hydration







Sig

nat

ure

s Medical

Allied Health

Nurse AM PM AM PM



Ward ____________________________

14

Surname UMRN


Address

Patient label

Integrated Variance Report

Date & Time

Pathway Day

Variance Description & Action Taken

Positive/ Negative

Variance Code

Signature

The variance report should record any unexpected variations to care.

Variances should be reviewed regularly as part of local clinical Governance process.

15

Surname UMRN


Address

Patient label

Integrated Variance Report

Date & Time

Pathway Day

Variance Description & Action Taken

Positive/ Negative

Variance Code

Signature

Code A Patient Code B Clinical Code C Hospital Code D Community

A1 Suspicion of bladder perforation

B1 Medical decision C1 Delay in test results D1 Delay in transport availability

A2 Allergic reaction B2 Altered dose of intravesical agent

C2 Delay in OR/Procedure

D2 Delay in home care/ community/ family support

A3 Poor tolerance of intravesical agent

B3 Altered frequency of intravesical agent

C3 Cancellation of procedure

D3 Equipment/ supplies not available

A4 Unable to catheterise B4 Other C4 Other D4 Other

A5 MSU positive growth delaying treatment

A6 Taken off pathway

A7 Pre treatment MSU not provided

A8 Other

16

Notes

References1. Department of Health, Western Australia. Guidelines for the administration of intravesical cytoxic

and immununotheapeutic drugs within the hosiplta setting. Perth: Healthnetworks Branch, Department of Health, Western Australia; 2010

2. British Association of Urological Nurses (BAUN) Section of Oncology (2005) Guidelines for the administration of Intravesical therapies. Bathgate, UK: Fitwise Management Ltd.

3. European Association of Urology (2010) Guidelines on Non Muscle Invasive Baldder Cancer. Accessed online 7/1/11 <http://www.uroweb.org/gls/pdf/TaT1%20(non-muscle%20invasive)%20bladder%20cancer%202010.pdf>

4. Lamm, D, et al. Clinical Practice recommendations for the management of non-muscle invasive bladder cancer. European urology supplements 7 (2008) 651-666: Elsevier

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intravesical bcg clinical care pathway

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