24 Hour helpline Rapid assessment and access toolkit

1. 24 Hour helpline Rapid assessment and access toolkit Philippa JonesChemotherapy Redesign Manager Chair UKONS Central West Chemotherapy GroupGreater Midlands Cancer Network England United Kingdom Philippa Jones

2. 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. Philippa Jones

3. 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 Philippa Jones

4. 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. Philippa Jones

5. 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. Philippa Jones

6. 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 Philippa Jones

7. 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. Philippa Jones

8. 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 Philippa Jones

9. The Tool Kit contents;- • Alert card • Tool Kit manual with process map • Log sheet • Assessment tool • Concertina card • Competency framework Philippa Jones

10. 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. Philippa Jones

11. 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 Philippa Jones

12. 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 Philippa Jones

13. 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 Philippa Jones

14. Log sheet Data collected should be;- Ccomplete Aaccurate Llegible Cconcise U useful T traceable Aauditable Philippa Jones

15. 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 Philippa Jones

16. 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. Philippa Jones

17. 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. Philippa Jones

18. 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. Philippa Jones

19. Concertina card Philippa Jones

20. 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. Philippa Jones

21. 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. Philippa Jones

22. Pilot And Evaluation Where are we now? Philippa Jones

23. 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 Philippa Jones

24. 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 base…approximately 2,500 to 2,700 • User questionnaire Philippa Jones

25. Preliminary report……..Log sheets 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 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% >28days 5 8% Other 4 4% Philippa Jones

26. Grade of staff receiving calls CNS 6% Sister 31% Staff nurse 58% Other 1% (doctor) Omitted 4% Grade of staff making follow - up call CNS3% Sister 51% Staff nurse 42% Omitted 4% Follow up time interval <12hrs 27% 12 – 24hrs 41% 24 – 36hrs 21% 36 - 48hrs 5% 48 – 72hrs 5% Philippa Jones

27. 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. Philippa Jones

28. User Questionnaire How long have you been caring for oncology/haematology patients? A. less than 12 month’s 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 Philippa Jones

29. 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% Philippa Jones

30. 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 Philippa Jones

31. 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 Philippa Jones

32. 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% Philippa Jones

33. 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. Philippa Jones

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

35. Thank you Philippa Jones