24-Hour Triage: Standardizing Excellent Practice Through ...€¦ · tool for the triage of oncology and haematology patients who contact 24 hour advice lines: Identifying the need

Oncology Nursing Society 42nd Annual CongressMay 4–7, 2017 • Denver, CO 1General

Philippa Jones, RNMacmillan Associate Acute Oncology Nurse AdvisorMacmillan Cancer [email protected]

Key Session Takeaways1. Audience members will gain an understanding of how

change can be implemented on a national basis, by those working at the heart of care. This presentation will demonstrate how nurses identified common concerns relating to practice and united to implement change and innovation.

2. Delegates will take away a positive message about ben-efits that can be achieved when practice guidelines are standardized and how standardized risk assessment has improved care. They will be encouraged to review their own processes and consider the benefits of standardized practice.

3. Attendees will hear about the successful development and implementation of the UKONS 24 Hour Triage Tool in the UK, and how care and service delivery has been improved. We will consider the application and transfer-ability of the tool internationally.

24-Hour Triage: Standardizing Excellent Practice Through Risk Assessment

ONS 42nd Annual Congress

General 1

Philippa JonesMacmillan Acute Oncology Nurse Advisor UKONS Acute Oncology Members Interest

Group Lead

Speakers Bureaus: MERKAdvisory/Review Fee: AmgenAdvisory/Review Fee: Congora.com

Focus on the development of a risk assessment tool for the triage of oncology and haematology patients who contact 24 hour advice lines:

Identifying the need The development process Pilot and evaluation Implementation Progression


General 2

How change can be implemented on a national basis, by those working at the heart of care.

How nurses identified common concerns relating to practice and united to implement change and innovation.

There is a positive message about benefits that can be achieved when practice guidelines are standardised and how standardised risk assessment has improved care.

Hope that you will be encouraged to review your own processes and consider the benefits of standardised practice in this key area.

Registered nurse for 43

years

Registered nurse for 43

years

20 years emergency

care experience

20 years emergency

care experience

19 years oncology

experience

19 years oncology

experience

Lead Chemotherapy

Nurse/Clinical Nurse

Specialist

Lead Chemotherapy

Nurse/Clinical Nurse

Specialist

Lead Cancer Nurse

Lead Cancer Nurse Macmillan

Acute Oncology

Nurse Advisor

4 countries in the UK - population

Scotland = 5.422 MillionEngland = 55.04 MillionN/ Ireland = 1.86 MillionWales = 3.168 MillionTotal = 65.49 Million

We have Acute Oncology services in all 4 countries and the UKONS triage Tool is used throughout the UK


General 3

Triage in a medical setting can be described as a clinical assessment

process that identifies and prioritises patients according to the current or potential severity of the

presenting problem.

(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564046/)

A RED, AMBER, GREEN (RAG) risk assessment tool.

For telephone triage of patients who: Have received or are receiving systemic

anticancer therapy Have received any other type of anticancer

treatment, including radiotherapy and bone marrow graft

May be suffering from disease-/treatment-related immunosuppression (i.e. acute leukaemia, corticosteroids)

3/28/2017Philippa Jones9


General 4

It is:- A clear symptom based risk assessment

process, that uses a RAG scoring system Evidence based and has been piloted and

evaluated positively It recognises the differing levels of experience,

skill and ability of the triage practitioner It identifies patients at risk and advises action

according to that level of risk.

It does not:- Detail urgent initial management, this should

commence at the assessment/admission portal.

Identify all possible treatment related problems, some will only be picked up during regular monitoring and review

It may not pick up all signs and symptoms of concurrent health problems – though if completed properly it should alert the practitioner and prompt them to take action

• Brief background and development history

• Instructions for use• Training and competency

requirements and assessment performance

• The Triage Pathway Algorithm and Clinical Governance recommendations

• Examples of all component parts of the Toolkit.

Essential reading!!

12

The information and instruction manual


General 5

Assessment Tool

13

The assessment tool is based on the NCRI-CTCAE1 common toxicity criteria. It is a guideline, highlighting the questions to ask and leading the practitioner through the decision-making process.

It is a risk assessment tool used to grade the patient’s symptoms and establish the level of risk to the patient, and enables practitioners to provide a consistent robust triage.

It is a cautious tool and will advise assessment at a point that will allow early intervention for those at risk.

National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE)Version 4.0 : May 28, 2009 (v4.03: June 14, 2010)

14

Action selection is based on the triage practitioner’s grading of the presenting symptoms following interview, data collection and triage:

RED – any toxicities graded here take priority and assessment should follow immediately

2 or more AMBER – two or more amber toxicities should be escalated to red action and assessment should follow immediately

1 AMBER – one toxicity in amber should be reviewed/ followed up within 24 hours and the caller should be instructed to call back if they continue to have concerns, or their condition deteriorates

All GREEN – callers should be instructed to call back if they continue to have concerns or their condition deteriorates.

Log Sheet

15

It 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.A standardised telephone consultation recording format supports the triage process as follows: • A guide and check list for the

practitioner, reminding them about the important information they should collect and reassuring them that they have completed the process

• A communication tool relaying an accurate picture of the problem, and action taken, to the other members of the healthcare team

• A record of the process for quality, safety and governance purposes IF YOU HAVEN’T TICKED IT,

YOU HAVEN’T ASKED IT!


General 6

16

The assessment process step by step

17

Perform a rapid initial assessment of the situation: “Is this an emergency?” Do you need to contact the emergency services.......999

Ask questions in a logical sequence. Follow the log sheet and the assessment tool

Provide information slowly and thoughtfully assess the patient’s comprehension, anxiety and distress throughout the process

Do you have any doubt about the patient/carer’s ability to provide information accurately or understand questions or instructions provided? If so then a face-to-face consultation must be arranged

Record caller’s name and current contact details in case the call is interrupted and you need to get back to the caller.

18

Step By Step


General 7

What is the patient/carer’s initial concern, why are they calling?

You should assess and grade this problem first, ensuring that you record this on the Log Sheet. If this score is RED then you may decide to stop at this point and proceed to organising urgent face-to-face assessment

If the patient is stable you may decide to complete the assessment process in order to gather further information for the face-to-face assessment.

19

Step By Step

If the patient/carer’s initial concern scores AMBER, record this on the Log Sheet and proceed with further assessment

Move methodically down the triage assessment tool, asking appropriate questions. e.g. Do you have any nausea? If NO tick the green box on the Log Sheet and move on

If YES use the questions provided to help you grade the problem and note either amber or red and initiate action (tick the Log Sheet)

If the patients symptoms score RED or another AMBER at any time they should be asked to attend for assessment

20

Step By Step

Look back at your Log Sheet

Have you arranged assessment for patients who have scored RED?

Have you arranged assessment for patients who have scored more than one AMBER?

Have you fully assessed all the patients who have scored one AMBER, is there a tick in all the other green boxes of the Log Sheet?

Have you fully assessed all the patients who have scored GREEN, is there a tick in all the other green boxes of the Log Sheet?

Have you recorded the action taken and advice given?

Have you documented any decision you have taken or advice you have given that falls outside this guideline, and recorded the rationale for your actions?

Have you fully completed the triage process?

21

Step 4Step By Step


General 8

If, in the triage practitioner’s clinical judgement, the guideline is not appropriate to that individual situation, the rationale for that decision should be clearly documented

If the triage practitioner’s assessment is borderline select the higher risk category; be cautious

The organisation must agree the triage pathway and populate it with local detail and responsibilities.

22

The Hospital Designated Responsible Practitioner must review all Log Sheets within 24 hours of the call as follows:

Original log sheet “Review of actions taken” should be completed and filed in the patients medical records

GREEN Was this the correct advice? If not is any action / training needed now?

1 AMBER Call the patient to assess if they are improving or not?

2 AMBER orRED Follow the patient: were they admitted or not?

Was the patient asked to attend for assessment ? If so please follow instruction below:

Admitted - find them and check management.Discharged - call to see if they are improving.

27

The 24 Hour Triage tool is a guideline and should be approved for use according to the user organisations governance and approval process.

The tool is a guideline which makes recommendations for best practice, these are not binding and should be seen as suggestions and or advice, they do not replace clinical judgment or remove autonomy 2.

Neither UKONS nor authors bear any responsibility for the use of the tool.

Governance and responsibility


General 9

All staff using the Toolkit receive training and assessment of competency. Training includes:

• Formal education session• Discussion • Scenario and role play• Observation

A competency framework is supplied to be completed prior to using the Tool Kit Example scenarios are provided to assist with training.

Staff who are not trained to use the Tool Kit should not provide telephone advice.

25

We know that Systemic Anti Cancer Treatment (SACT) will produce unwanted side effects/toxicities some of which can be life threatening

We have to provide a 24 hour advice line service for patients receiving Systemic Anti Cancer Treatment (SACT) UK.

We know that we do not always identify those patients at risk from side effects/toxicities.


General 10

Patient contacted chemotherapy helpline – symptoms described in line with spinal cord compression. Advised to ring 999 for assessment in ED.

Patient contacted help line again 3 days later –condition worse – had attended ED as directed previously but was discharged after a 5 hour wait.

Patient was later admitted to ward and treated for MSCC.

Patient now immobile.

Patient on chemotherapy with a temperature phoned ward in the early hours and was advised that patient would need admission and IV antibiotics as per policy but told no beds available and to ring again in four hours (against policy).

Patient presented to an Oncology Day Unit when open (four hours after call). Patient was very unwell, in pain and found to be neutropenic – treatment commenced and patient transferred to ward.

Patient later died of neutropenic sepsis and renal failure.


General 11

Consistency – this varied greatly according to who received the call – what time of day the call was received – where the call was received.

Robust – without consistency it is impossible to provide a hardy, reliable service.

Evidence based – there appeared to be little information about the use of evidence based practice tools, advice given depended on the experience of the call handler.

Little or no governance planning or process Reactive not pro-active - reviewing incidents

individually No clear advice line process mapping or

expectations of the service Little or no evidence relating to the calls and

actions taken – impossible to prove quality or highlight areas of concern

No formal education or training process –expected to answer calls based on knowledge and experience

No assessment of competency – not included in the chemotherapy education and assessment programmes

Learn from others in practice – but who has taught and/or assessed them?


General 12

Scanty or non existent data collection processes Unable to assess level of activity – times,

numbers, appropriate contacts Unable to look at the groups of people calling

and why they are calling – assessment of risk factors/groups

Unable to assess and report on quality


No agreed triage process or pathway –multitude of numbers- changing admission points – different level of service out of hours.

No agreed training or competency assessment

No quality control or review

No data collection

No recognition of need, value or importance

Confidential Enquiry into Patient Outcome and Death Group (NCEPOD) -Systemic Anti-Cancer Therapy: For better, for worse? (2008)3.

In total 546 cases were reviewed.

The major concerns were the decision to treat poor performance status patients with advanced disease and the management of patients with SACT toxicity.

An inappropriate decision to treat with SACT

An inappropriate decision to continue SACT

An adverse event in prescribing, dispensing or in administration

Poor communication between patient and clinicians Poor communication between clinicians Delay in admission with toxicity Inappropriate investigation of toxicity Delay in treating toxicity Inappropriate management of toxicity


General 13

Developed over a 3 year period by a group of experienced senior nurses working within chemotherapy haematology and oncology.

Supported by UK Oncology Nursing Society Multidisciplinary consultation. Supported by the U.K. National Patient Safety

Agency Extensive pilot in 26 cancer centres and units Positive evaluation and now widely adopted

throughout the UK and internationally

37

Improve patient safety and care by ensuring that patients receive a robust, reliable assessment (triage) every time they contact a helpline for advice. Consistency

Those assessments (triage) are of a consistent quality and use an evidence based assessment (triage)tool. Evidence based

That management and advice is appropriate to the patients ‟level of risk”. This will ensure that those patients who require urgent assessment in an acute area are identified and that action is taken, but also to identify and reassure those patients who are at lower risk and may safely be managed by the primary care team or a planned clinical review and avoid unnecessary attendance. Appropriate

To develop guidelines that would form the basis of triage training and competency assessment for practitioners. Educational


Development group

Development group

Evidence gatheringEvidence gathering

WorkshopWorkshop

Development

workshops to produce the

tool

Development

workshops to produce the

tool

ConsultationConsultation

Pilot and evaluation


General 14

3/28/201740

26 UK cancer centres and units were involved.

A two step evaluation process;-1.Questionnaire 2.A review of completed log sheets

The pilot ran for a two month period or completion of 100 log sheets

3/28/2017Philippa Jones.41

Guidance and support to the practitioner at all steps of the helpline process

A simple but reliable assessment process Robust and understandable advice Communication and record keeping Competency based training An audit tool

Improved patient safety and experience



General 15


Improved confidence = 85% (confident anyway)

Helpful assessment pathway = 99% Traffic Light system = 93% Ease of use = 95%Easy to understand = 97% Reliability = 85% Good Layout = 87% ( requested more space to write)

Training and education = 98%Pilot leads commented that they really appreciated the training programme and competency framework

Questionnaires -134 received

The vast majority of comments and feedback included in the questionnaires were positive.

There were also a small number of negative responses though these were on the whole constructive.


Tool has standardised practiceToxicity assessment poster very

popularPocket card extremely popularVisible reassurance of assessmentAids inter departmental communicationTrainers like the competency

framework



General 16

2 ambers are not always red time consuming - feedback has been provided

that lets us know that the time taken to complete the process lessens with experience

There were a number of comments relating to the format of the tool kit, all of which were considered at the steering group evaluation meeting. All were addressed in the improved design of the final Tool Kit.


Negative


One person thought :-no good for PBSCT patientsdoes not cover oncological emergenciesdoes not cover neutropenic sepsis

We felt that this highlighted the need for individual training and assessment.

1,899 forms received from 25 sites

Correctly completed toxicity assessment =72.5% (1,378)

Incomplete toxicity assessment =14.5% (276)

Illegible – poor copying or handwriting = 13% (245)

A number of correctly completed forms were randomly selected for review = 26% (500)



General 17


Red = 30% (150)

2 or more Amber = 20% (101)

1 Amber = 30% (149)

Green = 20% (100)

Scores / Triggers

RED30%

2+ AMBER20%

1 AMBER30%

GREEN20%

3/28/2017Philippa Jones 50

48% (240) of the patients who contacted the helpline were asked to attend hospital for assessment.

Of this group:

70% (169) were admitted

30% (71) were assessed and discharged following intervention.

Patients who were admitted to hospital:

73% (124) presented with RED triggers 23% (39) presented with 2 + AMBER triggers 2% (3) presented with 1 AMBER or/and a

concurrent problem not listed on the assessment sheet “other”

2% (3) presented with ALL GREEN triggers, but with a concurrent problem not listed on the assessment sheet “other”



General 18

The majority of patients with red triggers were asked to attend hospital for assessment = 91% (138)

A small number of patients were managed either by the GP or telephone advice = 9% (12)

Those who attended for assessment:

Most required admission to hospital = 90% (124)

Only a small number were able to go home following assessment = 10% (14)


Red triggers

Only 44% of patients with a red trigger had pyrexia of 37.50c or above recorded, 20% of patients had no pyrexia and 36% had no recording of temperature.

Conclusion...56% of red trigger patients were not related to pyrexia, these patients still required assessment and most required hospital admission.

Though it is recognised that the presence of a pyrexia in a patient who may be immuno-compromised is a significant indicator of risk, it is clear from the information collected on the log sheets that it is not the only indicator of risk.

3/28/2017Philippa Jones

53


TWO or more AMBERS

Hospital69% (70)

GP17%(11)

Phone11% (11)

Refused3% (3)

Attenders• 57% (40) of those asked to

attend for assessment were admitted to hospital

• 34% (23) of those who attended for assessment were allowed home following intervention

• 9% (7) had no documented outcome


General 19


A significant number of patients who contact triage helplines may not report a single overwhelming problem but will have a number of lower grade problems (20% = 100).

The cumulative significance of these problems is

demonstrated in the evaluation: 69% (70) of the patients in this group were asked to attend hospital for assessment, all of these patients required intervention and over half of them required admission.

This demonstrates the need for a methodical, rigorous assessment of all patients who contact helplines to ensure that significant signs and symptoms are not overlooked.


1 Amber

83% (122) of patients of one amber trigger were managed in their homes with telephone advice, referral to the primary care team or next day review

A small number of patients in this group 17% (26) were asked to attend for urgent assessment:- 74% (19) of this group were discharged 11% (3) were admitted with concurrent problems 15% (4) outcome was unknown.

telephone ±Primary care

70%

Next day review13%

Hospital 17%

All Green

90% (90) of patients identified as all green triggers were safely left at home or were directed to primary care teams for further support.

The small number of patients who were asked to attend for urgent assessment (7%) all had a concurrent problem that would not be considered a toxicity related problem but would require urgent assessment e.g. central line problems, 3 of these patients required admission.

Reassured/home69% (69)

G.P.17% (17)

Assessment7% (7)

Presented 3% (3)

Planned review4% (4)


General 20

85%(127) of 1 amber patients received a follow up call

79%(99) of these patients had either improved or reported no change

19% (25) were asked to visit the G.P.

2% (3) of this group had deteriorated the follow up call identified these patients and facilitated assessment


None of the patients who had green triggers only required urgent admission or assessment on follow up

None of this group had contacted the helpline with further concerns.


55% 57%

28% 25%12% 14%

5% 4%

0%

50%

100%

SAMPLE Hospital A

Time since treatment last recieved

1‐7 days

8‐14 days

15‐28 days

more then 28 days


General 21


High risk patient groups Activity Patient tracking Proof of quality Identify poor practice Service planning and development Pro-active monitoring



There were no reports of adverse events or concerns relating to

advice given or actions taken as a result of using the Tool Kit from

any sites during the pilot.


General 22

The pilot and evaluation of this tool has shown that the group has developed triage guidelines that can be adopted as a national standard and will4:

Improve patient safety and care by ensuring that everyone receives a robust, reliable assessment every time the helpline is contacted for advice Ensure assessments are of a consistent quality and use an evidence-based assessment tool Provide management and advice appropriate to the patient’s level of risk. Ensure that those patients who require urgent assessment in an acute area are identified and that appropriate action is taken. Also identify and reassure those patients who are at lower risk and may safely be managed by the primary care team or a planned clinical review and avoid unnecessary attendance Form the basis of triage training and competency assessment for practitioners Maintain accurate records of the assessment and decision-making process in order to monitor quality, safety and activity.

64

The UKONS 24 Hour Triage Rapid assessment and Access Toolkit

Version 1 was launched in 2010

The following scenarios are real life occurrences that have been reported

as adverse events.

March 17P.J.Jones UKONS66


General 23

March 17P.J.Jones UKONS67

Patient receiving chemotherapy with a history of neutropaenic sepsis following each previous cycle of treatment.

Telephoned the Emergency Department for advice as she had a raised temperature.

She was advised to take regular paracetamol and to report if temperature of 38.00c whilst on paracetamol.

Patient presented at chemotherapy clinic, unwell, pyrexia 38.00c and neutrophils 0.1x10x9/L. Immediate admission for treatment of neutropaenic sepsis.

68

The patient was discharged post chemotherapy with recovering blood counts

The Clinical Nurse Specialist contacted the patient and gave them aftercare advice and the emergency contact number.

When the patient became pyrexial 380c he followed CNS advice and contacted the Helpline number/Ward.

The person who took the call told him to take some paracetamol.

UKONS have been asked to comment on two cases

1. A large trust that took it upon themselves to change the Alert temperature to 38.0o C. A patient rang twice with a temperature above 37.5 the second time it was 37.9oC – they were left at home and shortly after admitted with neutropenic sepsis.

2. A patient rang with chest pain the nurse taking the call decided not to follow the unequivocal red alert and referred the patient to the GP. The GP left the patient at home. Patient died shortly after following cardiac arrest. The patient was also on a 5FU pump.

Both of these cases have left families and staff devastated.


General 24

No reports of increased or excessive attendance for assessment.

Almost all patients who attend for assessment have some sort of physical examination, investigation and/or intervention to support diagnosis and management of the problem

Admission rates following assessment have fallen slightly in some areas, particularly those with a functioning AOS team and/or assessment area, but patients still required investigation and intervention

Please remember that it is easy with the gift of hindsight, following physical assessment and examination, to say that the patient who can go home, perhaps shouldn’t have attended.

We are not privilege to the vital visual clues that have helped make this decision when assessing the patient over the phone

Reports

Organisational approval and agreement should be sought as the governance responsibility sits with the user/organisation

Clear decisions should be made about the triage pathway, identifying admission/assessment areas and triage practitioners who will provide review and follow-up calls

A plan for education, training and competency assessment. This is a vital step in the process; users need to have a clear understanding of the value of the Tool Kit and the risk to the patient and themselves if it is not used properly

Regular audit and quality review of all data collected – consider electronic data collection

Governance process – as with any service, the advice line will need to be monitored and reported.

71

Implementation


General 25

Standardised evidence based triage

Training and competency assessment

Communication and data collection

Quality and safety assessment No reports of incidents or

adverse events linked to the correct use of the tool

Supports innovation and changes in practice- Scotland and Shropshire

The Tool Kit has been endorsed by the United Kingdom Oncology Nursing Society (UKONS)

Macmillan Cancer Support

The Society and College of Radiographers

74

Train the trainer implementation process.Used widely throughout the UK.Recommended in National Guidance and

by respected institutions/organisations.Australia- national processNew ZealandPortugese translationSwedish involvement


General 26

Progression

We have reviewed and updated the tool kit in light of the new therapies that are now being used.The changes:

Lengthened side effect profile Warning regarding diarrhoea management Pneumonitis alert Addition of further information regarding rashes Urinary disorders Cognitive disturbance Ocular problems Log sheet update- number of calls, alert for immunotherapy, anti-

pyretic

Launched in December 2016 and now available on the UKONS website

Scotland – 1 advice line number covering most of the population and a number of hospitals – non clinical call handlers

Shropshire – covering two areas and using primary/community based clinicians


General 27

Revised Initial management guidelines

Primary Care Risk Assessment Tool

Hospice helpline pilot underway.

CYP version launched in March/April 2016

August 20165

An understanding of how change can be implemented on a national basis, by those working at the heart of care.

This presentation will demonstrate how nurses identified common concerns relating to practice and united to implement change and innovation.

There is a positive message about benefits that can be achieved when practice guidelines are standardised and how standardised risk assessment has improved care.

They will be encouraged to review their own processes and consider the benefits of standardised practice in this key area.


General 28

Thank you

1. National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE)Version 4.0 : May 28, 2009 (v4.03: June 14, 2010)https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf(last accessed 23.01.2017)

2.Royal College of Physicians - Developing concise guidelines.(2012)https://www.rcplondon.ac.uk/about-rcp/work-rcp/develop-guidelines (last accessed 23.01.2017)

3. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) For better, for worse? 2008 http://www.ncepod.org.uk/2008report3/Downloads/SACT_summary.pdf (last accessed 23.01.2017)

4. UKONS Oncology/Haematology 24 Hour Triage ,Rapid Assessment and Access Toolkit -Evaluation (2010) http://www.ukons.org/reports (last accessed 23.01.2017)

5.Childrens Cancer and Leukaemia Nurses Group. Oncology/Haematology Telephone Triage Tool Kit for Children and Young People (2016) http://www.cclg.org.uk/triagetool

Documents

24-Hour Triage: Standardizing Excellent Practice Through ...€¦ · tool for the triage of oncology and haematology patients who contact 24 hour advice lines: Identifying the need