Febrile Neutropenia

1
Febrile Neutropenia

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

2
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
3
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 practicesand
• Patient satisfaction, through linked expectations
  and increased patient teaching at our agencies.

Back to Start of Workshop
4
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 Start of Workshop
Back to beginning of FN section
5
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 Start of Workshop
Back to beginning of FN section
6
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 Start of Workshop
Back to beginning of FN section
7
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 Start of Workshop
Back to beginning of FN section
8
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 Start of Workshop
Back to beginning of FN section
9
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 Start of Workshop
Back to beginning of FN section
10
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 Start of Workshop
Back to beginning of FN section
11
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 Start of Workshop
Back to beginning of FN section
12
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 physicians 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 Start of Workshop
Back to beginning of FN section
13
Simulation Contd

• 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 todays 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 Start of Workshop
Back to beginning of FN section
14
Simulation Contd

• 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. Lets assume
  that Nancy was not given the antibiotic until 3
  hours after she arrived, because the ER staff
  were too busy and couldnt get to it immediately.
  This needs to be indicated as Not Met

Back to Start of Workshop
Back to beginning of FN section
15
Simulation Contd

• 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 Start of Workshop
Back to beginning of FN section
16
Simulation Contd

• 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 Start of Workshop
Back to beginning of FN section
17
Simulation Contd

• 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
• Lets 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 Start of Workshop
Back to beginning of FN section
18
Simulation Contd

• 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 Start of Workshop
Back to beginning of FN section
19
Febrile Neutropenia Quiz

1. What are the inclusion/exclusion criteria for
   this pathway?
2. What patient education materials are used for
   this pathway?
3. What is the Fever Alert Card?
4. What do you do with the teaching checklist?
5. What type of a pathway is this A) Day B) Phase ?

Back to Start of Workshop
Answers
20
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