321TOXICITYGRADE GRADE GRADE GRADE

0 4

ONCOLOGY/HAEMATOLOGY HELPLINE TRIAGE TOOL

Fever and receiving cytotoxic chemotherapy or immunocompromised

IF TEMP 37.5ºC OR ABOVE or BELOW 36ºC or GENERALLY UNWELL – URGENT Assessment AND MEDICAL REVIEW – Follow neutropenia pathwayALERT – Pt’s on steroids/analgesics or dehydrated may not present with pyrexia but may still have infection (If in doubt do a count)

Chest painOnset? What makes it worse?Radiation? Any cardiac historySTOP CAPECITABINE or INFUSIONAL 5FU

NoneAdvise URGENT A&E for medical assessment

Performance StatusHas there been a recent change in performance status?

Asymptomatic Symptomatic but completelyambulant

Symptomatic, <50% in bed during the day

Symptomatic, >50% in bed, but not bed bound

Bed bound

NauseaHow many days? What is the patient’s oral intake?Is the patient taking antiemetics as prescribed?Assess patients urinary output

None Able to eat/drink reasonable intakeReview anti emetics as prescribed

Can eat/drink but intake significantly decreasedReview anti emetics according to local policy

No significant intakeArrange urgent assessment

and review

VomitingHow many days/episodes?What is the patient’s oral intake?Does the patient have constipation or diarrhoea?(See specific toxicity)Assess patients urinary output

None 1 episode in 24 hoursReview anti emetics as prescribed

2-5 episodes in 24 hoursReview anti emetics according to local policy

6-10 episodes in 24 hoursArrange urgent assessment

and review

>10 episodes in 24 hoursArrange urgent assessment

and review

Oral/stomatitisHow many days?Is there evidence of mouth ulcers?Is there evidence of infection?Are they able to eat/drink?Assess patients urinary output

None Painless ulcers, erythema,mild soreness able to eat/drinkUse mouthwash as recommended

Painful erythema, oedema or ulcers but can eat/drinkContinue to use mouthwash, drink plenty of fluids. Use painkillers either as a tablet or mouthwash

Painful erythema difficulty with eating and drinkingArrange urgent assessment and review

Mucosal necrosis and/or requires parenteral or enteral supportArrange urgent assessment and review

If your patient scores RED or AMBER for any toxicity you should contact the 24 Hour Helpline immediately for a full triage assessment.

ONCOLOGY/HAEMATOLOGY RISK ASSESSMENT TOOL FOR PRIMARY HEALTH CARE PROFESSIONALS INSTRUCTIONS FOR USE

AnorexiaWhat was their weight before? What is appetite like? Any contributory factors e.g. dehydration, diarrhoea, vomiting, mucositis, and nausea?��OLQN�WR�VSHFLÀF�WR[LFLW\

BleedingIs it a new problem? Is it continuous? What amount? Where from? Is the patient on anticoagulants?

BruisingIs it a new problem? Is it local/generalised? Is there any trauma involved?

Chest PainOnset? What makes it worse? Radiation? Any cardiac history?

ConstipationHow long since bowels opened?What is normal?Does the patient have any abdominal pain/vomiting?Has the patient taken any medication?Consider obstruction and/or perforation

DiarrhoeaConsider infection!How many days has this occurred for?How many times in a 24 hour period?Does the patient have any abdominal pain/discomfort?For how long? Has the patient taken any medication?6HH�VSHFLÀF�WR[LFLW\�IRU�SDLQ�LI�DSSOLFDEOHN.B If taking CAPECITABINE (Xeloda) chemotherapy please ask patient to discontinue treatment until they have had helpline review.

Dyspnoea/Shortness of breathIs it a new symptom? Is dyspnoea worsening?,V�WKHUH�DQ\�FKHVW�SDLQ"���OLQN�WR�VSHFLÀF�WR[LFLW\What can the patient do? (alteration in Performance status)Consider SVCO/Anaemia/Pulmonary ebolism

Extravasation - drug leakage around infusion site or along infusion pathwayHas the patient got pain, soreness or ulceration around or along the infusion pathway/injection site/central venous catheter ?

FatigueHow many days has this occurred for?Any other associated symptoms?

Fever Patients who are at risk of immunosuppression who have an abnormal temperature should be referred to the helpline for assessment

Fever and/or generally unwell and recieved systemic anti-cancer therapy (chemotherapy oral or I.V.) within the last6 weeks or disease related immunosuppression

If temperature is 37.5 C or above or below 36 C or generally unwell - Contact telephone helpline for URGENT Assessment - Risk of neutropenic sepsis

ALERT - Patients on steroids/analgesics or dehydrated may not present with pyrexia but may still have infection (if in doubt phone for advice)

TOXICITY

None Loss of appetite without alteration in eating habits

Mild, self limited controlled by conservative measures

Petechia/bruising, localised

Mild - no bowel movement in last 24 hoursAdvise - Dietary advice, LQFUHDVH�ÁXLG�LQWDNH��UHYLHZ�supportive medication

Increase to 2-3 bowel movements a day or overpre-treatment movements

Intravenous therapy Certain chemotherapy drugs can cause long term severe tissue damage if extravasation (leakage) occurs.

Chemotherapy extravasation requires urgent specialist review and management.Increased fatigue but not altering normal activitiesAdvise - Rest accompanied with intermittent mild activity

n/a

Moderate or causing GLIÀFXOW\�SHUIRUPLQJ�VRPH�activities

> 37.5 C - 38 C

Severe loss of ability to perform some activities Bedridden or disabling

No new symptoms

Increase to 4-6 episodes a day or nocturnal movement/moderate cramping

Dyspnoea on exertion Dyspnoea at normal level of activity

Dyspnoea at rest or requiring ventilatory support

Increase to 7-9 episodes a day or incontinenceSevere cramping

Increase to > 10 episodes a day or grossly bloody diarrhoea or need for parenteral support

Moderate - no bowel movement in last 48 hours

Severe - no bowel movement in last 72 hours.Consider bowel obstruction and/or perforation.

Life threatening sepsisConsider bowel obstruction and/or perforation.

Arrange URGENT A&E attendance for medical assessmentA number of chemotherapy drugs are cardio toxic urgent assessment is essential.

Moderate petechia/purpuraGeneralised bruising

Generalised petechia/purpuraGeneralised bruising

Uncontrolable haemorrhage - Arrange URGENT A&E attendance for medical assessment

Oral intake altered without VLJQLÀFDQW�ZHLJKW�ORVV�RU�malnutrition

Oral intake altered in DVVRFLDWLRQ�ZLWK�VLJQLÀFDQW�weight loss/malnutrition

Life threatening complications e.g collapse

None

None

None

None

None

None

None

Normal > 38 C - 40 C > 40 C

It is important that the effects of treatment are QRW�XQGHUHVWLPDWHG�DQG�WKDW�WKH�VLJQLÀFDQFH�of lower level amber toxicites is recognised.

Risk assessment processThere are a number of questions to ask and information that will need to be collected to make sure that the correct advice is given.Step 1. The user moves methodically down the triage assessment tool, asking appropriate questions.e.g. do you have any nausea? If NO move on.

If YES use the questions provided to help

you grade the problem and note either amber or red and initiate action according to step 2.Step 2.Red and/or Amber:If your patient scores RED or Amber for any toxicity you should contact the 24 Hour Helpline immediately for a full triage assessment unless URGENT referral to A&E is advised.Patients may require urgent assessment in a suitable clinical area that provides access to investigation and treatment facilities.The helpline team will arrange assessment and/or further monitoring for the patient.Green:-If your patient scores green in all toxicities they should be reassured that the problem at present does not give cause for concern but they should be vigilant and if the situation gets worse or does not improve they should call the Helpline immediately.

The UKONS 24 Hour Triage Tool is a widely utilised recognised tool that is used to a perform risk assessment for patients who have : � Received systemic anti-cancer therapy including chemotherapy in the previous 6-8 weeks� Radiotherapy � Disease related immunosuppressuon

It is a simple reliable evidence based process that grades the toxicities according to the VLJQLÀFDQFH� RI� SUHVHQWLQJ� V\PSWRPV� DQG�advises action accordingly.

321TOXICITYGRADE GRADE GRADE GRADE

0 4

ONCOLOGY/HAEMATOLOGY HELPLINE TRIAGE TOOL

Fever and receiving cytotoxic chemotherapy or immunocompromised

IF TEMP 37.5ºC OR ABOVE or BELOW 36ºC or GENERALLY UNWELL – URGENT Assessment AND MEDICAL REVIEW – Follow neutropenia pathwayALERT – Pt’s on steroids/analgesics or dehydrated may not present with pyrexia but may still have infection (If in doubt do a count)

Chest painOnset? What makes it worse?Radiation? Any cardiac historySTOP CAPECITABINE or INFUSIONAL 5FU

NoneAdvise URGENT A&E for medical assessment

Performance StatusHas there been a recent change in performance status?

Asymptomatic Symptomatic but completelyambulant

Symptomatic, <50% in bed during the day

Symptomatic, >50% in bed, but not bed bound

Bed bound

NauseaHow many days? What is the patient’s oral intake?Is the patient taking antiemetics as prescribed?Assess patients urinary output

None Able to eat/drink reasonable intakeReview anti emetics as prescribed

Can eat/drink but intake significantly decreasedReview anti emetics according to local policy

No significant intakeArrange urgent assessment

and review

VomitingHow many days/episodes?What is the patient’s oral intake?Does the patient have constipation or diarrhoea?(See specific toxicity)Assess patients urinary output

None 1 episode in 24 hoursReview anti emetics as prescribed

2-5 episodes in 24 hoursReview anti emetics according to local policy

6-10 episodes in 24 hoursArrange urgent assessment

and review

>10 episodes in 24 hoursArrange urgent assessment

and review

Oral/stomatitisHow many days?Is there evidence of mouth ulcers?Is there evidence of infection?Are they able to eat/drink?Assess patients urinary output

None Painless ulcers, erythema,mild soreness able to eat/drinkUse mouthwash as recommended

Painful erythema, oedema or ulcers but can eat/drinkContinue to use mouthwash, drink plenty of fluids. Use painkillers either as a tablet or mouthwash

Painful erythema difficulty with eating and drinkingArrange urgent assessment and review

Mucosal necrosis and/or requires parenteral or enteral supportArrange urgent assessment and review

ONCOLOGY/HAEMATOLOGY RISK ASSESSMENT TOOL FOR PRIMARY HEALTH CARE PROFESSIONALS

Infection - abnormal temperature see fever toxicityPatients who are receiving chemotherapy or at risk of immunosuppression that have any signs/symptoms of infection should be referred to the helpline for assessment.NauseaHow many days? What is the patients oral intake?Is the patient taking antiemetics as prescribed?Assess patients urinary output

Neurological Symptoms (Sensory and/or Motor)When did the problem start? Is it continuous?Is it getting worse? Is it affecting mobility/function?Any constipation or urinary incontinence?Does the patient have back pain?Consider spinal cord compression

Oral/StomatitisHow many days?Is there evidence of mouth ulcers?Is there evidence of infection?Are they able to eat/drink?Assess patients urinary output

PainIs it a new problem? Where is it? How long have you had it?Have you taken any analgesia?Consider thrombosis? Any swelling/redness?Back pain - Consider spinal cord compression

Performance StatusHas there been a recent change in performance status?

RashIs it localised or generalised?How long has it been there?Any signs of infection? Is it itchy?FOR HEAMATOLOGY PATIENTS CONTACT HEAMATOLOGY TEAM.

VomitingHow many days/episodes?What is the patients oral intake?Does the patient have constipation or diarrhoea?�VHH�VSHFLÀF�WR[LFLW\�Assess patients urinary output

Red Hands and/or Feet (palmar - plantar syndrome)This may be a side effect of certain chemotherapy and UHTXLUHV�VSHFLÀF�DFWLRQ�WR�EH�WDNHQ

TOXICITY If your patient scores RED or AMBER for any toxicity you should contact the 24 Hour Helpline immediately for a full triage assessment.

None

None

None

None

None

None

Asymptomatic

None

None

Generally Wellwith signs of infection

Generally unwellwith signs/symptoms of infection

Able to eat/drink reasonable intakeAdvise - Review prescribed anti emetics

Any of the following signs or symptoms -Mild parasthesia, subjective weakness with no objective ÀQGLQJV��back pain

Painless ulcers, erythema, mild soreness able to eat/drinkAdvise - Use mouthwash as recommended

Mild painNot interfering with functionAdvise analgesia review

Numbness, tingling, painless erythema and swelling

1 episode in 24 hoursAdvise - Review antiemetics and ensure patient is taking as prescribed

2-5 episodes in 24 hours 6-10 episodes in 24 hours 10 episodes in 24 hours

Petichiae/PetechialMacular or papular eruption or erythema with pruritus or other associated symptoms. Vesicular rashes may indicate localised varicella

Symptomatic unwell

Symptomatic but completely ambulant

Painful erythema and swelling

Symptomatic, <50% in bed during the day

Symptomatic, 50%> in bed, but not bed bound Bed bound

Moist desquamation ulceration, blistering and severe pain

Has painPain or analgesia Interfering with function, but not ADL

Severe painPain or analgesia interfering with ADL

Severe pain disabling

Painful erythema, oedema or ulcers but can eat/drink

3DLQIXO�HU\WKHPD�GLIÀFXOW\�with eating and drinking

Mucosal necrosis and/or requires parenteral or enteral support

Mild or moderate sensory loss, moderate parasthesia, mild weakness with no loss of function with or without back pain

Severe sensory loss, parasthesia or weakness that interferes with function with or without back pain

Paralysis

Can eat/drink but intake VLJQLÀFDQWO\�GHFUHDVHG

1R�VLJQLÀFDQW�LQWDNH

Severe symptomatic infection

Life threatening sepsisArrange URGENT A&E

attendance for medical assessment

24 HOUROncology/Haematology

TRIAGE

Helpline number:

PRIMARY CARE VERSIONVERSION 1 APPROVED 20.08.2013