Oncology/Haematology Telephone Triage Tool Kit for Children … area... · 2016. 9. 22. · •...

1

September 2016

Oncology/Haematology

Telephone Triage Tool Kit

for Children and Young People

This presentation will cover….

• What is the Telephone Triage Tool Kit?

• Background

• Development history

• Evaluation

• Implementation

• How to use the Tool Kit

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What is The Telephone

Triage Tool Kit?

A risk assessment tool using a RAG

(RED, AMBER, GREEN) scoring system.

For telephone triage of children and

young people with cancer and serious

blood disorders.

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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.

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Background

•United Kingdom Oncology Nursing Society

(UKONS)

•Adult version 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 use of tool kit reported during the pilot

or since release

•Updated Version released in August 2016

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Development of a Telephone Triage Tool Kit

for Children and Young People

• Meeting with key stakeholders to discuss collaborative working to develop

and pilot adapted version of the adult tool for CYP setting

• RCN provided funding and advice to support the pilot of the Tool Kit

• Pilot – replicated the pilot and evaluation process used in the development

of the adult version of the Tool Kit

• Training – all staff using the Tool Kit received training and assessment

of competency

• Two-step evaluation process; Log sheet review (274) and user

questionnaire (24)

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

All sites completed their log sheets during 2013

• Final version of the Toolkit developed with the support and design

assistance of CLIC Sargent following positive pilot and evaluation

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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.

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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 POSCUs and PTCs as well as between centres.

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), the

Children’s Cancer and Leukaemia Group (CCLG), the

Royal College of Nursing (RCN) and CLIC Sargent

• Principal Treatment Centres and Shared Care Units

are recommended to plan local implementation.

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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 using

the Tool Kit. 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.

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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. 10

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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.

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Assessment Tool

Main elements

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Log Sheet

Main elements

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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.

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The assessment process

step by step

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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.

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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.

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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!

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Contact record – the ‘Log Sheet’

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?

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

.......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.

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Step By Step

• 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.

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Step 2

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

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Step 3

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? 25

Step 4

Step By Step

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.

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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?

Admitted or

Discharged

Admitted - find them and check management.

Discharged - call to see if they are improving.

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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.

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Scenario 1

Mum rings to say patients bottle of 6MP has leaked/smashed on the floor

and the dog has eaten some of the medicine.

• Patients Name: Humpty Dumpty

• Age: 6yrs

• Diagnosis: ALL

• Male/Female: Male

• Consultant: Dr Betty

• Date/time: 12/8/13 14.00

• Who is calling: Mum

• Contact Number: 0191 111111

• Is the patient receiving chemotherapy or radiotherapy: Chemotherapy

• State regimen: Maintenance

• When did the CYP last have any treatment: On oral chemotherapy

• What is the CYP temperature: 36.5oC

• Last blood count: Not known

• Does the CYP have a CVL: Yes

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Scenario 1 – Assessment

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Toxicity/Problem Details

Fever Afebrile 36.5oC

Infection No signs of infections

Activity No concerns

Pain No reports of pain

Bleeding and Bruising No bleeding or bruising

Dyspnoea / Shortness of breath Normal breathing

Rash No rash

Nausea, Eating and Drinking Fine

Vomiting No

Mucositis No

Diarrhoea No

Constipation No

Neurosensory / Motor Normal

Extravasation No

Infectious disease contact No contact

Other Yes

Scenario 1 – Action taken

Please complete a Log Sheet with your

assessment and proposed actions.

We will check the against Training Log

Sheets shortly.

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Mum telephoned the Day Unit to say Lou has vomited four times, since waking this

morning, she is not herself, not playing but is watching TV.

• Patients Name: Looby Loo

• Age: 3yrs

• Diagnosis: Brain tumour with VP Shunt

• Male/Female: Female

• Consultant: Dr Betty

• Date/time: 12/8/13 14.00

• Who is calling: Mum



• State regimen: B12

• When did the CYP last have any treatment: 15 days ago

• What is the CYP temperature: 36.5oC

• Last blood count: Hb 9.5, Plts 150, WCC 1.5, Neut 1.0

• Does the CYP have a CVL: No

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Scenario 2


34


Fever Afebrile 36.5oC

Infection No signs of infections

Activity Symptomatic, not playing

Pain No reports of pain

Bleeding and Bruising No bleeding or bruising

Dyspnoea / Shortness of breath Normal breathing

Rash No rash

Nausea, Eating and Drinking Loss of appetite but eating and drinking

Vomiting Four times

Mucositis No

Diarrhoea No

Constipation No

Neurosensory / Motor Normal

Extravasation N/A

Infectious disease contact No contact

Other None

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Sheets shortly.

A four-year-old on treatment for ALL, parent concerned about a blotchy

rash, otherwise well.

• Patient Name: Jessie Jaybird

• Diagnosis: ALL

• Sex: Female

• Consultant: Professor Plum

• Date/ time: 20/08/13 14:00

• Who is calling: mum, Mrs Jaybird



• State regimen: UKALL 11

• What did the patient last receive treatment: 13/08/13

• What is the patients temperature: 36.9oC

• Last blood count: Haemoglobin 9.9, Platelets 135

• Does the patient have a central line: Portacath

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Scenario 3


37


Fever Apyrexial 36.9oC

Infection No obvious sign of infection

Activity Usual active self

Pain No pain

Bleeding and Bruising No

Dyspnoea / Shortness of breath No

Rash Rash on trunk – nowhere else

Nausea, Eating and Drinking No

Vomiting No

Mucositis No

Diarrhoea No

Constipation No – bowels opened this morning

Neurosensory / Motor No

Extravasation No

Infectious disease contact No

Other None

38





Sheets shortly.

Dad telephone to say his child who was discharged from BMT 3 days ago now had

viral symptoms – cough, snotty and temperature 37.1oC.

•Patient Name: Joe Blogs

•Diagnosis: Post BMT for AML

•Sex: Male

•Consultant: Dr. Who

•Date/ time: 13/08/13 14.00hrs

•Who is calling: Dad

•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: 37.1oC

•Last blood count: Neutrophils 2.12

•Does the patient have a central line: Yes, TLH

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Scenario 4


40


Fever Apyrexial 37.1oC

Infection No signs of infection - no chills, shivering or shaking

episodes

Activity Mild symptoms – (No real change as post BMT, so had low

levels of activity for sometime)

Pain No evidence of pain

Bleeding and Bruising No evidence of bleeding or bruising

Dyspnoea / Shortness of breath No change in breathing pattern, no shortness of breath or

chest pain

Rash Yes. Generalised red raised rash to trunk, hands and feet.

Papula with pruritis.

Nausea, Eating and Drinking No nausea, eating small amounts (as usual) and meeting

fluid target.

Vomiting None

Mucositis N/A

Diarrhoea No diarrhoea

Constipation No change from normal bowel habits

Neurosensory / Motor No change in mobility / function

Extravasation No chemo given for 6 weeks

Infectious disease contact No know contacts, on acyclovir

Other None

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Sheets shortly.

Attending home visit to do pre-chemo bloods and line flush. After; child feels

unwell and has developed a low grade fever. He says similar happened after line

flush last week but he didn’t tell anyone and felt better again (doesn’t like going to

hospital.) Line was difficult to bleed and stiff to flush.

• Patient Name: Spencer Wells

• Diagnosis: Ewing’s Sarcoma

• Sex: Male

• Consultant: Dr Phalange

• Date/ time: 13/08/16 11:00

• Who is calling: Home Visit Scenario


• Is the patient receiving Chemotherapy or Radiotherapy: Radiotherapy

• State regimen: Euro Ewing 2012

• What did the patient last receive treatment: VAC 10 days ago

• What is the patients temperature: 37.5oC

• Last blood count: unknown

• Does the patient have a central line?: Yes

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Scenario 5


43


Fever 37.5oC after line flush. Reports same last week.

Infection CVL Exit site – large dry scab. Not red. Felt unwell after

line flush

Activity Limited mobility due to surgery but no change recently

Pain None



Rash No

Nausea, Eating and Drinking No change to normal. Drinking well.

Vomiting No vomiting, feels a bit nauseous after line flush

Mucositis No

Diarrhoea No

Constipation No

Neurosensory / Motor No change from normal. Alert and responsive

Extravasation No

Infectious disease contact None

Other Triple lumen CVL stiff to flush and difficult to bleed

44





Sheets shortly.

Panicky call from Mum. Went into Peter’s room this morning. He is not rousable.

He is breathing but he is very pale and cold.

• Patient Name: Peter Smith

• Diagnosis: ALL

• Sex: M

• Consultant: Prof Plum

• Date/ time: 13/08/16 07:00

• Who is calling: Mrs Janelle Smith

• Contact Number: 0777 777 7777

• Is the patient receiving Chemotherapy or Radiotherapy: Chemotherapy

• State regimen: Regimen C

• What did the patient last receive treatment: 4 days ago

• What is the patient’s temperature: Feels cold to touch

• Last blood count: Not assessed

• Does the patient have a central line?: Yes

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Scenario 6


46


Fever Feels cold to touch

Infection

Activity

Pain

Bleeding and Bruising

Dyspnoea / Shortness of breath

Rash

Nausea, Eating and Drinking

Vomiting

Mucositis

Diarrhoea

Constipation

Neurosensory / Motor Unrousable

Extravasation

Infectious disease contact

Other

47





Sheets shortly.

Mum brought Daisy up to clinic after school with visible hole in blue lumen CVL.

Daisy says she got her line caught in her coat zip this morning play time.

• Patient Name: Daisy Bell

• Diagnosis: ALL

• Sex: Female

• Consultant: Dr Who

• Date/ time: 13/08/16 15:45

• Who is calling: Drop-in clinic visit. Accompanied by Mum Mrs Avril Bell


• Is the patient receiving Chemotherapy or Radiotherapy: None

• State regimen: UKALL 2013 Regimen A

• What did the patient last receive treatment: Completed treatment and awaiting routine line

removal

• What is the patient’s temperature: 36.4oC

• Last blood count: unknown

• Does the patient have a central line?: Yes – Double Lumen Hickman

48

Scenario 7


49


Fever No, 36.4oC

Infection Risk of infection. Damaged CVL – hole in blue lumen since this

morning and been at school all day.

Activity Normal. Active. Attending school.

Pain None



Rash No

Nausea, Eating and Drinking Normal. Good appetite

Vomiting No

Mucositis No

Diarrhoea No

Constipation No

Neurosensory/Motor Alert. Lively

Extravasation No

Infectious disease contact None

Other Damaged CVL.

50





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.

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Any questions?

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This training pack was developed by the Children and Young

People’s Telephone Triage Tool Kit Working Group, with design

and support from CLIC Sargent.

CLIC Sargent is pleased to support this work for the benefit

of children and young people with cancer and their families,

and has worked on the design and dissemination of the

Tool Kit documents.

To find out more about CLIC Sargent visit www.clicsargent.org.uk

Thank you!

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Oncology/Haematology Telephone Triage Tool Kit for Children … area... · 2016. 9. 22. · •...

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