Febrile Neutropenia

Febrile Neutropenia Education Workshop (click to go to the desired section) • Introduction to Workshop/Instructions • Evidence-Based Care Program • Febrile Neutropenia Workshop

Next Back Introduction • This interactive workshop is designed to go along with a copy of the pathway. Keep it handy as you go through the workshop to engage in the required activities. • This is a web-based workshop, and thus has links throughout each page to enable you to move throughout the workshop. Whenever you see words underlined like this, you can click on that area to go to another section or to find more information on a topic. • At the bottom of each page are navigational buttons to help you move through the workshop. • You can go through as much or as little of the workshop as you like at a time. • If you have any questions about how to use this workshop or the individual pathways, feel free to ask your Site Champion or contact the Evidence-Based Care Program. Back to Start of Workshop

Next Back Evidence-Based Care Program These pathways have been developed as a part of the Evidence-Based Care Program, which is Schedule 6 in the agreement of the Grey Bruce Health Network. The intent is to develop clinical pathways and other evidence-based care tools based on clinical practice guidelines, that flow across all hospitals and community services in Grey and Bruce (including Grey Bruce Health Services, Hanover and District Hospital, South Bruce Grey Health Centre, Grey Bruce Public Health and the Community Care Access Centre). It is hoped that these pathways will improve: • Coordination of care through more communication across professions; • Continuity of care, through increased linkages among hospitals and the CCAC; • Clinical outcomes, through increased usage of best practices;and • Patient satisfaction, through linked expectations and increased patient teaching at our agencies. Back to Start of Workshop

Next Back Febrile Neutropenia Pathway Package • This pathway is for patients who have febrile neutropenia, (defined as a fever and low white blood cell count ) inclusion criteria found on the first page of the pathway. • The pathway consists of 7 parts: • Clinical Practice Guideline • Pre-Printed Orders • Patient Pathway • Patient Education Sheets • Fever Alert Card • Teaching Checklist • Clinical Pathway Back to beginning of FN section Back to Start of Workshop

Next Back Febrile Neutropenia Clinical Practice Guideline • This guideline is the 2002 Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer, published by the Infectious Diseases Society of America. • This guideline summarizes the evidence used in the development of this pathway. • It can be found electronically on the GBHN website – www.gbhn.ca . Back to beginning of FN section Back to Start of Workshop

Next Back Febrile Neutropenia Pre-Printed Orders • These orders are to be initiated in emergency once a patient is determined to have febrile neutropenia. • A sample can be found by clicking here. • These orders can be found in the ER and on the unit by going to the www.gbhn.ca website or the Order Set Website. Back to beginning of FN section Back to Start of Workshop

Next Back Patient Materials • This package has a patient pathway, which explains to the patient what is happening to them while in hospital. (see sample) • It should be given to the patient early in the hospital stay and used to explain the care to the patient. • Also, there is a teaching checklist, which should be put on the chart and used to track what education has been done with the patient and what is left to cover before the patient is discharged. You should be familiar with these topics, if not you should look through the reference materials listed for each topic. (see sample) • The reference materials for the teaching checklist are two sheets – “Febrile Neutropenia Patient Information Sheet” (see sample) and “Giving Myself a Drug by Subcutaneous Injection” (see sample). • A final piece that should be given to the patient is the Fever Alert Card. This card should be filled out by the patient and carried with them at all times, to aid in their care should they suffer from febrile neutropenia again (see sample) Back to beginning of FN section Back to Start of Workshop

Next Back Febrile Neutropenia Clinical Pathway • This pathway is intended for patients who have been defined as having Febrile Neutropenia. Click here to see a sample of the pathway. The definition for Febrile Neutropenia is on the front page. • The pathway is focused on a 5 day length of stay, and is a day-style pathway, meaning that each page outlines tasks for one 24 hour period, beginning at the start of the day shift and ending at the end of the night shift. • At the right hand side of the sheet is a place to enter the date. There are also three columns, these are the time frames for the shifts working during that day. Indicate the time you are working with the patient in the appropriate column. Back to beginning of FN section Back to Start of Workshop

Next Back Febrile Neutropenia Clinical Pathway • As with the other pathways, using the column for your shift, initial tasks as they are completed, or enter N/A and initial if they are not applicable to the patient. For example, if it is the night shift and you are not doing any patient teaching, indicate N/A and initial in the section for Psychosocial/Education under “Review Patient Pathway” and “Review Teaching Checklist”. • Take a look on the Admission Day the indicator we are tracking is “Was appropriate antibiotic therapy given within 2hrs of arrival to hospital” indicate whether it was “Met”, “Not met” or “N/A” Back to beginning of FN section Back to Start of Workshop

Next Back Febrile Neutropenia Clinical Pathway • The Discharge Criteria, the last page of the pathway, should be checked daily. If any of the criteria have been met, these should be initialed and dated. • Once the Discharge Criteria have been met, the patient should be ready to go home. If four days have passed and the criteria have not been met, the patient should be reassessed by the Oncologist. Back to beginning of FN section Back to Start of Workshop

Next Back End of Febrile Neutropenia section This is the end of the general information for the Febrile Neutropenia pathway. To get further information by trying the pathway on a sample patient, move to the Simulation portion of the Febrile Neutropenia workshop. Test your knowledge of Febrile Neutropenia by doing the Febrile Neutropenia quiz. Back to beginning of FN section Back to Start of Workshop

Next Back Simulation Try it! Take a look at the pathway for the simulation. Nancy, a chemotherapy patient arrives in hospital with a fever. Based on initial tests, she has a low white blood cell count, and the physician determines she should be admitted. She then fits the criteria to be put on the Febrile Neutropenia pathway - find the inclusion criteria on the first page of the pathway. The pre-printed orders for Febrile Neutropenia should be pulled for the physician to use. The pathway should be started in Emergency, as this is where the care begins. If the patient is directly admitted from the physician’s office, the pathway can be started on the unit. The clinical pathway and teaching checklist goes on the chart, and the patient pathway and patient education materials are given to Nancy. Take a look at the clinical pathway. On the first page is a master signature sheet. Sign it, and then for the remainder of the pathway you can just initial as tasks are complete (if you have a Master Signature Sheet for your facility, this will not be on your pathway page). Back to beginning of FN section Back to Start of Workshop

Next Back Simulation Cont’d There are also some basic instructions on the first page on how to use the pathway. Each page will need a patient ID sticker. Flip to the first page of the pathway, “Admission Day”: On the first page of each pathway will be a section for comorbid conditions. Please list any conditions the patient has other than the Febrile Neutropenia, that may affect the care you are giving. This will help health records in coding Nancy appropriately. This page is used for the first day Nancy is in hospital. You will see three columns on the right hand side (one for each shift – if there are only two 12 hour shifts, you will only need two of these) –write in today’s date at the top). Below the date, write in the hours you will be caring for Nancy. You will then use this column to initial as each task on that page is completed. You can use your corporate progress notes if you require further documentation. Back to beginning of FN section Back to Start of Workshop

Next Back Simulation Cont’d The first section is the performance indicators “Was appropriate antibiotic therapy given within 2hrs of arrival to hospital” indicate whether it was “Met”, “Not met” or “N/A” . The rest of the page, lists the tasks that should be completed during the first day. For example, under assessments, Vitals should be taken QID and PRN. Initial in the column to the right that corresponds to your shift as each task is completed. Some tasks are not appropriate for all patients or all time frames. In these cases, you can indicate an N/A and initial to show this. Take a look back at the indicators. Let’s assume that Nancy was not given the antibiotic until 3 hours after she arrived, because the ER staff were too busy and couldn’t get to it immediately. This needs to be indicated as “Not Met” Back to beginning of FN section Back to Start of Workshop

Next Back Simulation Cont’d Flip to the next page of the pathway, which is used for the second day Nancy is in hospital. It works the same as the first page. Be sure to indicate the time you are caring for Nancy at the top of each column. The top section is for patient outcomes. These are goals we are looking to meet for the timeframe, in this case the remainder of the first day. The rest of the sections are tasks that are to be completed for that day. Again, some tasks are not applicable to each patient, or to each shift. For example, if it is night shift, you may not be teaching Nancy, so under “Psychosocial Support/Education”, you can indicate “N/A” and initial “Review Patient Pathway” and “Start Teaching Checklist”. On each day of all pathways, you will notice a referral to a Teaching Checklist and a Patient Pathway. Back to beginning of FN section Back to Start of Workshop

Next Back Simulation Cont’d The Teaching Checklist should be on the chart and be filled in as topics are covered with Nancy. This way the next nurse on shift will know what has been covered and can continue down the list. The Patient Pathway should also be given to the patient. However, if Nancy is not ready for education, indicate N/A and initial these tasks until she is ready for education. The education materials, including the Febrile Neutropenia Information Sheet and Subcutaneous Injections sheet can be referenced to aid you in teaching. Also, the Patient Pathway should be referred to on a daily basis to help Nancy understand the plan of care. The Fever Alert Card should also be given to Nancy and explained to her that she should carry this with her at all times, as it will help health care providers care for her in the event she should get Febrile Neutropenia again. . Back to beginning of FN section Back to Start of Workshop

Next Back Simulation Cont’d At the end of each day, in the Discharge Planning section (last section of each page), you will notice it says “Assess Discharge Criteria Daily”. This means you will need to flip to the last page of the pathway, the Discharge Criteria, on a daily basis, at some point during the day, and check if any of these goals have been met. If they have, initial and date them. Once all of these criteria have been met, Nancy is ready to go home Let’s assume it is Day 2 of the pathway, and Nancy has now achieved all the Discharge Criteria. As soon as these criteria have been met, she can go home. If it is the end of the fourth day in hospital, Day 3 on the pathway, and Nancy is not ready to go home, the pathway should be discontinued, and the Oncologist contacted for further care. Back to beginning of FN section Back to Start of Workshop

Next Back Simulation Cont’d If Nancy is transferred to another hospital, refer to the first page of the pathway under “How to use the Clinical Pathway” there is a list of documents to forward to the receiving hospital, so they can continue using the pathway. Send a copy of: • Discharge Criteria • MAR • Teaching Checklist Back to beginning of FN section Back to Start of Workshop

Back Febrile Neutropenia Quiz • What are the inclusion/exclusion criteria for this pathway? • What patient education materials are used for this pathway? • What is the Fever Alert Card? • What do you do with the teaching checklist? • What type of a pathway is this A) Day B) Phase ? Back to Start of Workshop Answers

Back Answers: Febrile Neutropenia Quiz • What are the inclusion/exclusion criteria for this pathway? All patients with fever and neutropenia as defined on front page of pathway (note pts may not present with fever, but may have symptoms such as hypotension, tachycardia or chills) • What patient education materials are used for this pathway? There is a patient information sheet about febrile neutropenia, an information sheet on subcutaneous injections, the patient pathway, and the fever alert card. All of these should be used in patient teaching. • What is the Fever Alert Card? This is a card that the patient should carry with him/her at all times to alert health care providers of the possibility of febrile neutropenia should something happen to him or her. • What do you do with the teaching checklist? This goes on the chart and is used to keep track of what education has been done. This sheet should be completed before the patient is discharged. • What type of a pathway is this A) Day B) Phase ? This is a Day type pathway, meaning each page is one day. • If you have had difficulty with any of these questions, go back through the material on this pathway and/or the general pathway information in this workshop, or ask your Site Champion any other questions you have. Back to beginning of FN section Back to Start of Workshop

Febrile Neutropenia