24 Hour helpline Rapid assessment and access toolkit

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24 Hour helpline
Rapid assessment and access toolkit

• Philippa JonesChemotherapy Redesign Manager
  Chair UKONS Central West
  Chemotherapy GroupGreater Midlands Cancer
  Network
• England
• United Kingdom

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Development

• At the inaugural meeting of the UKONS
  chemotherapy nurses forum in 2007 it was decided
  that the Central West Chemotherapy Nurses Group
  would review and develop 24 Hour Triage Services.
• The group began work in December 2007.
• Oncology and Haematology Nurses from within the
  central West Region were invited to attend a
  series of meetings to review current practice
  ,determine the project aims and objectives and
  develop a project plan.

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• The triage process was discussed in depth, this
  coupled with a comprehensive review of current
  pathways and guidelines led us to the conclusion
  that there were a number of steps involved in
  triage and assessment and that we should look at
  the requirements for each individually.
• The first step was identified as Helpline Triage

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• The decision to concentrate on the development of
  guidelines for helpline services was reinforced
  in 2008 by the publication of two reports -1.
  National confidential enquiry into patient
  outcomes and death. for better, for worse?
• 2.Chemotherapy Services in England ensuring
  quality and safety
• These reports identified the need for support for
  patients receiving chemotherapy and early
  detection and treatment of chemotherapy
  toxicities/side effects.
• They were produced in response to serious
  concerns about quality and safety, for patients
  receiving chemotherapy.

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• A steering group of Central West and Wales
  members have over an two year period developed a
• The core group was made up of experienced
  oncology/haematology nurses working within
  chemotherapy services.

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Who else has been involved?

• Consultation with
• Local teams
• consultant haematologists and
  oncologists
• pharmacy leads
• chemotherapy nurses
• UKONS Chemotherapy Leads and Board Members
• National Patient Safety Agency
• Information and discussion
• National Cancer Action Team
• BOPA members
• Chemotherapy Redesign Group

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• The group reviewed the telephone triage process
  and identified three clear steps-
• Contact
• Assessment/definition of problem
• Appropriate intervention/action
• The tool kit has been developed to provide clear
  guidelines and support for the practitioner at
  each stage of this process.

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• Aims and objectives
• To develop an assessment tool/process that
  would-
• improve quality and safety
• standardise care delivery
• define the role of the helpline practitioner
• support training for the staff managing helplines
• support the trainee and act as a reference point
  for practice
• support audit
• provide an explanation and rational for each step
  of the process

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The Tool Kit contents-

• Alert card
• Tool Kit manual with process map
• Log sheet
• Assessment tool
• Concertina card
• Competency framework

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National alert card

• We would like to promote the introduction of a
  national format for chemotherapy/oncology alert
  cards.
• National card should be linked to promotional
  campaign to encourage primary and emergency care
  providers to contact the helpline for advice
  regarding patient care.

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Tool kit document

• A simple document detailing
• How the tool was developed
• How it should be used
• Who should use it
• Training required
• It also contains examples of the
  documentation and assessment tools

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Assessment Pathway

• A process map that details each step of the
  pathway
• Helpline providers should have clear agreed
  assessment and admission pathways
• There should be a clearly identified Helpline
  practitioner for each span of duty

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Communication and record keeping

• 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 and any actions .
• The log sheet has been developed in a format that
  guides the practitioner through the process
• A log sheet should be completed for all calls and
  unscheduled patient visits. This will facilitate
  audit of the helpline service

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Log sheet

• Data collected should be-
• C complete
• A accurate
• L legible
• C concise
• U useful
• T traceable
• A auditable

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Assessment tool

• Prompt the practitioner with appropriate
  questions to ask in order to gain information
  from the patient
• Provide a reliable guide to toxicity grading
  based on WHO toxicity assessment and The NCI
  Common Terminology Criteria for Adverse Events
• 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
  action should follow immediately.
• Two or more AMBER toxicities should be escalated
  to red action.
• Amber one toxicity in amber should be followed up
  within 24 hours. 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 problems or their
  condition deteriorates.

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Exceptions

• If in the triage practitioners clinical judgement
  the guideline is not appropriate to that
  individual situation the rationale for that
  decision should be clearly documented.

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Follow up

• All Log sheets should be reviewed within 24
  hours-
• Was this the correct advice
• Call the patient to assess if they are improving
  or not
• Follow the patient were they admitted or not?
• Admitted..find them and check treatment.
• Discharged.. call to see if they are improving.
• Original log sheets should be filed in the
  patients treatment records.
• Duplicates retained for helpline audit.

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Concertina card
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Competency Framework

• This assessment should be undertaken by all
  medical staff and chemotherapy qualified nurses
  working within cancer services who are expected
  to manage
• 24 hour triage helplines.
• Approved triage practitioners will be assessed
  annually in line with chemotherapy annual
  assessment programme.

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Audit

• All copies of Log sheets should be retained
  safely for audit and clinical governance
  purposes.
• Information may be entered onto a data base.
• Possibility of electronic format in the future.

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• Pilot
• And
• Evaluation
• Where are we now?

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• NPSA funded pilot
• 27 initial pilot sites in the UK
• All pilot leads attended train the trainer days
  prior to commencing
• All helpline practitioners should receive
  training and be assessed as competent prior to
  using the tool
• Training packs supplied to each area
• Tool kits supplied to all areas
• Pilot time line
• 100 log sheets or two months use

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Evaluation process

• Anonomised copies of log sheets returned to
  project lead.. 25 sites completed and
  returned
• 2 in the process of
  returning
• Information from all log sheets will be entered
  onto a data baseapproximately 2,500 to 2,700
• User questionnaire

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Preliminary report..Log sheets

•  Treatment
• On active treatment 68 71
• Not on treatment 28 29
•  
• All patients receiving treatment were on
  chemotherapy
•  Treatment last given when phone call made
•  1-7 days 32 47
• 8-14 days 19 28
• 15-28days 8 11
• gt28days 5 8
• Other 4 4

• Sample size 96
•  
• Timing of calls
• Night 19
  
• Day 81
• Day defined as 08.00 20.00hrs
• Distribution at night
• 8pm - 12 midnight 33............ 6 calls
• 12 midnight 6am 27........... 5 calls
• 6am -8am 40.......... 7 calls
  
• In a 2 month period

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• Grade of staff receiving calls
•  
• CNS 6
• Sister 31
• Staff nurse 58
• Other 1 (doctor)
• Omitted 4
•  
•  
• Grade of staff making follow - up call
•  
• CNS 3
• Sister 51
• Staff nurse 42
• Omitted 4
•  
• Follow up time interval
•  
• lt12hrs 27

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Data recording on the forms and any omissions.

•  Filling in the form
• 34 had all the data requested recorded
• ..
• 66 had data missing.
•  of these the data missing related to-
• 48 medical history/clinical trial/current
  medication.
• 10 had not recorded temp/central line
  information.
• 8 had not filled in the toxicity scores.

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User Questionnaire

• How long have you been caring for
  oncology/haematology patients?
•  
• A. less than 12 months
  5
• B. between 1 year and 3 years 17
  
• C. more than 3 years
  78
•  
• Prior to being involved in the pilot did your
  Trust have a 24 hour helpline
• Yes 86
• No 14
• Prior to being involved in the pilot did you use
  any other tool for assessing patients contacting
  the helpline
•  
• Always 26
• Sometimes 26
• Never 48
• General comments very positive standardised
  practice

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• The Tool Kit Contents and Training.
•  
• Was the design and layout of the tool kit
  satisfactory?
• Yes 86
• liked traffic light system and pocket
  assessment tool
• No 14
• wanted more space to write
• Did you find any parts of the new tool difficult
  to understand?
•  
• No 91
• Did you feel the training you received to use the
  tool kit was adequate?
•  
• Yes 97

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• Did you find the tool easy to use?
•  
• Yes 94
• No 6
•  
•  Did you find the Assessment Pathway flow chart
  helpful?
• Yes 100
• Did you find the use of the traffic light
  colouring system (red,amber,green) on the
  Assessment Tool poster helpful?
•  
• Yes 94
• A number of comments on how useful
  this is

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• Did you understand the way in which the questions
  on the Assessment Tool poster were written?
•   yes 100
•  Did the Assessment Log Sheet capture all the
  information required for the assessment process?
• Yes 86
• No 14 Lack of space to write
• Was the duplicate sheet helpful?
•   Yes 94
• 16 said difficult to read and poor
  photocopying quality

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•  What effect did the new tool have on the
  admission process?
•  
• More patients attending for further assessment
  43
• Fewer patients attending for further assessment
  30
• More patients admitted
  17
• Fewer patients admitted
  10
•  
• Did you find the tool reliable?
•  
• Yes 94
•  
• During the pilot did you feel more confident
  about managing the helpline?
•  
• Yes 80
• No 6 (felt
  confident any way)
• Sometimes 14

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• Helpline follow up.
•   
• Did you have staff time allocated to follow up
  helpline patients?
•  
• Yes 37
• No 37
• Sometimes 26
• A number of comments about lack of time to follow
  up..acute oncology team?
•  
•  We will have to review a larger sample to gain
  significant information relating to amber follow
  up calls.
• Initial feedback is that when given time to make
  calls both staff and patients find them very
  valuable.
• The majority of patients admitted for assessment
  were traceable and initial feedback is that this
  process is useful again we will look at a larger
  sample for more significant information.

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Forward!

• 3 more pilot sites starting
• Edinburgh Cancer Centre
• Sussex Cancer Network
• The Christie Triage Team
• Continue with evaluationend of March to collate
  first round data
• Presented at ICCN in Atlanta
• Consider adapting the tool for primary care
  information and patient guide.

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Thank you