Pediatric Telephone Triage Tool Kit: A Comprehensive Guide for Cancer & Blood Disorders in Children

1. Oncology/Haematology Telephone Triage Tool Kit for Children and Young People September 2016

2. This presentation will cover…. • What is the Telephone Triage Tool Kit? • Background • Development history • Evaluation • Implementation • How to use the Tool Kit

3. 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.

4. 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.

5. 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

6. 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

7. 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 POSCUs and PTCs as well as between centres. It was positively evaluated by those using it during the pilot.

8. 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.

9. 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.

10. 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.

11. How to use the Tool Kit

12. 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.

13. Main elements Assessment Tool

14. Main elements Log Sheet

15. 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.

17. The assessment process step by step

18. 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.

19. 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.

20. 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!

21. 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 oneAMBER, 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?

22. 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.

23. 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 REDthen 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.

24. 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

25. 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?

26. 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.

27. 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 filedin the patients medical records

28. Scenarios

29. 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.

30. 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

31. Scenario 1 – Assessment

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

33. Scenario 2 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 • Contact Number: 0191 1111111 • Is the patient receiving chemotherapy or radiotherapy: Chemotherapy • State regimen: B12 • When did the CYP last have any treatment: 15 days ago • What is the CYP temperature: 36.5oC • Last blood count: Hb9.5, Plts150, WCC 1.5, Neut 1.0 • Does the CYP have a CVL: No

34. Scenario 2 – Assessment

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

36. Scenario 3 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 • Contact Number: 01910 2829836 • Is the patient receiving chemotherapy or radiotherapy: Chemotherapy • 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

37. Scenario 3 – Assessment

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

39. Scenario 4 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

40. Scenario 4 – Assessment

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

42. Scenario 5 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 • Contact Number: 0191 111111 • 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

43. Scenario 5 – Assessment

44. Scenario 5 – Action taken Please complete a Log Sheet with your assessment and proposed actions. We will check the against Training Log Sheets shortly.

45. Scenario 6 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

46. Scenario 6 – Assessment

47. Scenario 6 – Action taken Please complete a Log Sheet with your assessment and proposed actions. We will check the against Training Log Sheets shortly.

48. Scenario 7 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 • Contact Number: 0191 111111 • 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 lineremoval • What is the patient’s temperature: 36.4oC • Last blood count: unknown • Does the patient have a central line?: Yes – Double Lumen Hickman

49. Scenario 7 – Assessment

50. Scenario 7 – Action taken Please complete a Log Sheet with your assessment and proposed actions. We will check the against Training Log Sheets shortly.