24 Hour Triage Oncology / Haematology 21/11/2018 Oncology / Haematology 24 Hour Triage RAPID ASSESSMENT AND ACCESS TOOLKIT November 2016 CYP Haem / Onc Telephone Triage Training Master Slides

This presentation will cover…. 21/11/2018 This presentation will cover…. What is the Telephone Triage Tool Kit? Background Development history Evaluation Implementation How to use the Tool Kit CYP Haem / Onc Telephone Triage Training Master Slides

What is The Telephone Triage Tool Kit? A risk assessment tool using a RAG (RED, AMBER, GREEN) scoring system. 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)

Aim of the Tool Kit To provide guidance and support to the practitioner at all three stages of the triage process: Contact and data collection Assessment/definition of problem Appropriate intervention/action. The Tool Kit has been developed to provide: A simple, reliable assessment process Safe, understandable advice Communication and record keeping Competency based training An audit tool.

No recognition of need, value or importance The past 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

Background United Kingdom Oncology Nursing Society (UKONS) The original version was developed in 2007/2009 Positively evaluated and released in 2010 Now used widely in all areas of the UK and internationally No serious incidents or adverse events due to the correct use of tool kit reported during the pilot or since release The tool has now been updated and Version 2 was approved in November 2016

Development of the Telephone Triage Toolkit 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 Meets national recommendations ,NCEPOD,NCAG and Acute Oncology Measures Extensive pilot in 26 cancer centres and units Positive evaluation and now widely adopted throughout the UK and internationally

Results of the pilot and evaluation The evaluation of the pilot demonstrated that the Tool Kit achieved its primary aims and objectives. It was shown to be reliable, robust and valuable. The evaluation recommended it should be used as a planned standardised approach to triage and assessment, providing: An evidence-based assessment tool A log sheet that acts as a checklist to prompt practitioners and a record of triage and assessment, supporting communication. The evaluation showed that the toolkit sets a standard for best practice and is an excellent training and educational resource: It can be used to provide evidence of quality and safety for both the organisation and the individual practitioner It is useful in identifying risks and poor practice, helping to determine education and training needs It can support consistency of advice, and consistency of service across Cancer Centres, Cancer Units and Primary Care. It was positively evaluated by those using it during the pilot.

National implementation The Tool Kit has been endorsed by the United Kingdom Oncology Nursing Society (UKONS) Macmillan Cancer Support The Society and College of Radiographers

Reports 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

Factors to consider when planning local implementation 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.

Training All staff using the Tool Kit must receive training and assessment of competency. Training should include: 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 have been provided to assist with training. Staff who are not trained to use the Tool Kit should not provide telephone advice.

How to use the Tool Kit

The Tool Kit Manual contains Brief background and development history Instructions for use Training and competency requirements and assessment proforma The Triage Pathway Algorithm and Clinical Governance recommendations Examples of all component parts of the Tool Kit.

Assessment Tool Main elements The assessment tool is based on the NCRI-CTCAE common toxicity criteria.  It should be used as 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 will enable 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.  

Main elements Log Sheet 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 will support 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

Scoring system Action selection is based on the triage practitioner’s grading of the presenting symptoms/toxicity following interview, data collection and triage: RED – any toxicity graded here takes priority and action should follow immediately. Patient should be advised to attend for urgent assessment as soon as possible 2 or more AMBER = RED – if a patient has two or more toxicities graded amber they should be escalated to red action and advised to attend for urgent assessment AMBER – one toxicity in the amber area should be followed up within 24 hours and 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 concerns or their condition deteriorates.

The assessment process step by step

Determine “the patient’s level of risk“ The assessment tool will Determine “the patient’s level of risk“ Prompt the practitioner with appropriate questions to ask, to gain information from the patient Provide a reliable guide to toxicity/problem grading Prioritise the level of urgency indicated by the presenting symptoms and will aid in identifying potential emergency situations.

Assessment tool RED – any toxicities graded here take priority and assessment should follow immediately 2 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.

Contact record – the ‘Log Sheet’ 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 Log Sheet should be completed for all calls and unscheduled patient visits. This will facilitate audit of the helpline service. The Triage boxes MUST all be marked accordingly. IF YOU HAVEN’T TICKED IT, YOU HAVEN’T ASKED IT!

Look back at your log sheet: - The Assessment Process Step By Step Step 1. Perform a rapid initial assessment of the situation: “Is this an emergency?” Do you need to contact the emergency services. 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 Name and current contact details in case the call is interrupted and you need to get back to the caller. Step 2. What is the patient/carers 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. Step 3. 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. Step 4. 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 one 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?

Step By Step Step 1 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.

Step By Step Step 2 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.

Step By Step Step 3 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

Step 4 Look back at your Log Sheet Step By Step Step 4 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?

Special considerations 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.

Log Sheet review 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 or RED 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.

Additional information The tool has been piloted in its present format and should not be amended or adapted without the express permission of the UKONS board. There are new and novel drugs on the market that have a protracted side effect profile, please be careful when providing advice for this group of patients.

Governance and responsibility 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. Neither UKONS nor authors bear any responsibility for the use of the tool. RCP developing concise guidelineshttps://www.rcplondon.ac.uk/resources/developing-concise-guideline.

Competency Framework The manual contains a competency assessment document linked to the national key skills framework that should be completed for all those who undertake UKONS triage and assessment. It is recommended that this assessment be repeated annually to ensure that competency is maintained.

Audit Please ensure that all copies of Log sheets are retained safely for audit and clinical governance purposes. Information may be entered onto a data base.

Scenarios

Scenarios The following scenarios may be used to: Support role play activity during training Support general discussion about the value and relevance of the triage process Demonstrate practical application of the triage process in the clinical setting.

Scenario 1 Patient calls the helpline wanting reassurance. He describes an irritating cough especially at night and is breathless on minimal exertion which does not easily settle on rest. He has a dull chest pain which he associates with the cough. He has tolerated the treatment very well. He has until recently continued to work part time and play golf twice week. Patients Name: Paul Age: 56yrs Diagnosis: Lung Cancer Male/Female: Male Consultant: Dr Betty Date/time: 12/8/13 14.00 Who is calling: Patient Contact Number: 0191 111111 Is the patient receiving SACT or radiotherapy: SACT State regimen: Pembrolizumab When did the patient last have any treatment: Two weeks ago What is the patients temperature: 37.0oC Does the patients have a CVAD: No

Scenario 1 – Action taken Please complete a Log Sheet with your assessment and proposed actions. We will check the against Training Log Sheets shortly.

Scenario 2 Mrs Cooper calls the helpline. She has developed diarrhoea. Yesterday she had 3 bowel movements and today 4. Her children were off school last week with diarrhoea and vomiting .She denies vomiting herself. She says her symptoms are mild but have been worsening over the past week and she has occasional moderate abdominal pain . She has taken loperamide without effect. Patients Name: Emerald Cooper Age: 32yrs Diagnosis: Melanoma diagnosed 6 years ago Male/Female: Female Consultant: Dr Betty Date/time: 12/8/13 09.30 Who is calling: Patient Contact Number: 0191 1111111 Is the patient receiving SACT or radiotherapy: SACT State regimen: Ipilimumab When did the last have any treatment: course completed 10 weeks ago What is the patients temperature: 36.9oC Does the patient have a CVAD: No

Scenario 2 – Action taken Please complete a Log Sheet with your assessment and proposed actions. We will check the against Training Log Sheets shortly.  

Scenario 3 Mr Dumpty's wife contacts the advice line, Humpty has a raised temperature and is feeling under the weather. He has been of work for a couple of days and has had to stay in bed Patient Name: Humpty Dumpty Age: 76yrs Diagnosis: Prostate Sex: Male Consultant: Professor Plum Date/ time: 20/08/13 14:00 Who is calling: Mrs Dumpty Contact Number: 01910 2829836 Is the patient receiving SACT or radiotherapy: SACT State regimen: she's not sure, he has a drip every few weeks What did the patient last receive treatment: a week ago What is the patients temperature: 37.9oC Does the patient have a central line: No

Scenario 3 – Action taken Please complete a Log Sheet with your assessment and proposed actions. We will check the against Training Log Sheets shortly.

Scenario 4 Joe’s Mum telephones to say that he is feeling flu like and is quite sleepy, she is worried as he was discharged from BMT 3 days ago Patient Name: Joe Blogs Age: 20yrs Diagnosis: Post BMT for AML Sex: Male Consultant: Dr. Who Date/ time: 13/08/13 21.00hrs Who is calling: Mum Contact Number: 12345 109876 Is the patient receiving Chemotherapy or Radiotherapy: No State regimen: N/A What did the patient last receive treatment: 6 weeks post chemo. Day +41 What is the patients temperature: 38.1oC Does the patient have a central line: Yes,

Scenario 4 – Action taken Please complete a Log Sheet with your assessment and proposed actions. We will check the against Training Log Sheets shortly.

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 will: 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.

? Any questions?

21/11/2018 Thank you! CYP Haem / Onc Telephone Triage Training Master Slides