Philippa JonesChemotherapy Redesign Manager Chair UKONS Central West Chemotherapy GroupGreater Midlands Cancer NetworkEnglandUnited Kingdom

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DevelopmentAt the inaugural meeting of the UKONS

chemotherapy nurses forum in 2007 it was decided that the Central West Chemotherapy Nurses Group would review and develop 24 Hour Triage Services.

The group began work in December 2007.

Oncology and Haematology Nurses from within the central West Region were invited to attend a series of meetings to review current practice ,determine the project aims and objectives and develop a project plan.

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The triage process was discussed in depth, this coupled with a comprehensive review of current pathways and guidelines led us to the conclusion that there were a number of steps involved in triage and assessment and that we should look at the requirements for each individually.

The first step was identified as Helpline Triage

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The decision to concentrate on the development of guidelines for helpline services was reinforced in 2008 by the publication of two reports :-

1. National confidential enquiry into patient outcomes and death. “for better, for worse?”

2.Chemotherapy Services in England: ensuring quality and safety

These reports identified the need for support for patients receiving chemotherapy and early detection and treatment of chemotherapy toxicities/side effects.

They were produced in response to serious concerns about quality and safety, for patients receiving chemotherapy.

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A steering group of Central West and Wales members have over an two year period developed a

The core group was made up of experienced

oncology/haematology nurses working within chemotherapy services.

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Who else has been involved?Consultation with;Local teams; consultant haematologists and oncologists pharmacy leads chemotherapy nursesUKONS; Chemotherapy Leads and Board

Members National Patient Safety AgencyInformation and discussion;National Cancer Action TeamBOPA membersChemotherapy Redesign Group

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The group reviewed the telephone triage process and identified three clear steps:-

1.Contact 2.Assessment/definition of problem 3.Appropriate intervention/action

The tool kit has been developed to provide clear guidelines and support for the practitioner at each stage of this process.

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Aims and objectives

To develop an assessment tool/process that would;-improve quality and safetystandardise care deliverydefine the role of the helpline practitionersupport training for the staff managing helplinessupport the trainee and act as a reference point

for practice support auditprovide an explanation and rational for each step

of the process

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The Tool Kit contents;-Alert cardTool Kit manual with process mapLog sheetAssessment toolConcertina cardCompetency framework

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National alert cardWe would like to

promote the introduction of a national format for chemotherapy/oncology alert cards.

National card should be linked to promotional campaign to encourage primary and emergency care providers to contact the helpline for advice regarding patient care.

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Tool kit document A simple document

detailing;

How the tool was developed

How it should be usedWho should use itTraining required

It also contains examples of the documentation and assessment tools

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Assessment PathwayA process map that

details each step of the pathway

Helpline providers should have clear agreed assessment and admission pathways

There should be a clearly identified Helpline practitioner for each span of duty

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Communication and record keepingIt is vitally important that the data collection

process is methodical and thorough in order for it to be useful and provide an accurate record of the triage assessment and any actions .

The log sheet has been developed in a format that guides the practitioner through the process

A log sheet should be completed for all calls and unscheduled patient visits. This will facilitate audit of the helpline service

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Log sheet Data collected should be;-

C completeA accurateL legibleC concise U usefulT traceableA auditable

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Assessment toolPrompt the practitioner with

appropriate questions to ask in order to gain information from the patient

Provide a reliable guide to toxicity grading based on WHO toxicity assessment and The NCI Common Terminology Criteria for Adverse Events

Prioritise the level of urgency indicated by the presenting symptoms and will aid in identifying potential emergency situations

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Assessment toolRED any toxicities graded here take priority

and action should follow immediately.Two or more AMBER toxicities should be

escalated to red action.

Amber one toxicity in amber should be followed up within 24 hours. The caller should be instructed to call back if they continue to have concerns or their condition deteriorates

Green callers should be instructed to call back if they continue to have problems or their condition deteriorates.

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If in the triage practitioners clinical judgement the guideline is not appropriate to that individual situation the rationale for that decision should be clearly documented.

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Exceptions

Follow upAll Log sheets should be reviewed within 24 hours;-

Was this the correct adviceCall the patient to assess if they are improving or

notFollow the patient were they admitted or not? Admitted..find them and check treatment. Discharged.. call to see if they are improving.

Original log sheets should be filed in the patients treatment records.

Duplicates retained for helpline audit.

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Concertina card

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Competency FrameworkThis assessment should

be undertaken by all medical staff and chemotherapy qualified nurses working within cancer services who are expected to manage

24 hour triage helplines.Approved triage

practitioners will be assessed annually in line with chemotherapy annual assessment programme.

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AuditAll copies of Log sheets should be retained

safely for audit and clinical governance purposes.

Information may be entered onto a data base.

Possibility of electronic format in the future.

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Pilot And

Evaluation

Where are we now?

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NPSA funded pilot27 initial pilot sites in the UKAll pilot leads attended train the trainer days

prior to commencingAll helpline practitioners should receive

training and be assessed as competent prior to using the tool

Training packs supplied to each areaTool kits supplied to all areasPilot time line; 100 log sheets or two months use

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Evaluation processAnonomised copies of log sheets returned to

project lead.. 25 sites completed and returned

2 in the process of returning Information from all log sheets will be

entered onto a data base…approximately 2,500 to 2,700

User questionnaire

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Preliminary report……..Log sheets

Sample size 96 Timing of calls Night 19%

Day 81%

Day defined as 08.00 – 20.00hrs

Distribution at night;8pm - 12 midnight 33%............ 6

calls12 midnight – 6am 27%........... 5 calls6am -8am 40%.......... 7 calls

In a 2 month period

 TreatmentOn active treatment 68

71%Not on treatment 28

29% All patients receiving

treatment were on chemotherapy

 Treatment last given when phone call made

 1-7 days 32 47%8-14 days 19 28%15-28days 8 11%>28days 5 8%Other 4 4%

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Grade of staff receiving calls CNS 6%Sister 31%Staff nurse 58%Other 1% (doctor)Omitted 4%  Grade of staff making follow - up call CNS 3%Sister 51%Staff nurse 42%Omitted 4% Follow up time interval <12hrs 27%12 – 24hrs 41%24 – 36hrs 21%36 - 48hrs 5%48 – 72hrs 5% 

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Data recording on the forms and any omissions.

 Filling in the form34% had all the data requested recorded …………………………………………………………………..66% had data missing. of these the data missing related to;-48% medical history/clinical trial/current

medication.10% had not recorded temp/central line information. 8% had not filled in the toxicity scores.

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User QuestionnaireHow long have you been caring for oncology/haematology

patients? A. less than 12 month’s 5%B. between 1 year and 3 years 17% C. more than 3 years 78%  Prior to being involved in the pilot did your Trust have a 24 hour

helpline

Yes 86%No 14%

Prior to being involved in the pilot did you use any other tool for assessing patients contacting the helpline

 Always 26%Sometimes 26%Never 48%General comments very positive standardised practice

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The Tool Kit Contents and Training. Was the design and layout of the tool kit satisfactory? Yes 86% liked traffic light system and pocket assessment tool No 14% wanted more space to write

Did you find any parts of the new tool difficult to understand?

 No 91%

Did you feel the training you received to use the tool kit was adequate?

 Yes 97%

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Did you find the tool easy to use? 

Yes 94%No 6%

   Did you find the Assessment Pathway flow chart helpful?

Yes 100%

Did you find the use of the traffic light colouring system (red,amber,green) on the Assessment Tool poster helpful?

  Yes 94%

A number of comments on how useful this is

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Did you understand the way in which the questions on the Assessment Tool poster were written?

  yes 100%

 Did the Assessment Log Sheet capture all the information required for the assessment process?

Yes 86%No 14% Lack of space to write

Was the duplicate sheet helpful?   Yes 94%

16% said difficult to read and poor photocopying quality

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 What effect did the new tool have on the admission process?  

More patients attending for further assessment 43%

Fewer patients attending for further assessment 30%More patients admitted 17%Fewer patients admitted 10%

 

Did you find the tool reliable?  

Yes 94%  During the pilot did you feel more confident about managing

the helpline?  

Yes 80%No 6% (felt confident any way)Sometimes 14%

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Helpline follow up.   Did you have staff time allocated to follow up helpline patients? 

Yes 37%No 37% Sometimes 26%A number of comments about lack of time to follow

up..acute oncology team?  We will have to review a larger sample to gain significant information

relating to amber follow up calls.Initial feedback is that when given time to make calls both staff and

patients find them very valuable.

The majority of patients admitted for assessment were traceable and initial feedback is that this process is useful again we will look at a larger sample for more significant information.

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Forward!3 more pilot sites starting Edinburgh Cancer Centre Sussex Cancer Network The Christie Triage TeamContinue with evaluation……end of March to

collate first round dataPresented at ICCN in AtlantaConsider adapting the tool for primary care

information and patient guide.

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