Emergency Department and

Rural Nurse Specialists

Date:

Immunosuppressed Patients Clinical Pathway (Haematology and Oncology Patients)

IS THIS PATIENT AT RISK? KEY QUESTIONS:

This pathway and treatment regime has been developed through collaboration with the:

Haematology, Oncology, Nephrology, Infectious Diseases, Pharmacology and Emergency Services

2. DOES THE PATIENT NOW HAVE (OR RECENTLY HAD) ANY OF THE FOLLOWING?

q Symptoms or signs of shockq Fever in last few hoursq Rigors in last few hoursq Other features of significant infection

1. DOES THE PATIENT HAVE ANY OF THE FOLLOWING? q Neutrophils known to be < 0.5 x 109/Lq Carries the immunosuppressed card q Is immunosuppressed e.g. post-transplant, lymphoma,

myeloma, myelodysplasia or chronic lymphocytic leukaemia

EXIT PATHWAY

DOCTORS ACTION PLAN: Within 10 minutes of arrival Review patient Prescribe all antibiotics

First-line IV Piperacillin 4 g / Tazobactam 500 mg (Tazocin 4.5 g) -- plus IV Gentamicin 7 mg/Kg in 100 mL sodium chloride 0.9 % as a 30 min infusion (based on ideal body weight)

Aminoglycosides should not be used for patients receiving high dose methotrexate

Second-line Penicillin allergy / Rural Nurse Specialist patients/Gentamicin contraindicated

IV Imipenem-Cilastatin 500mg (Primaxin) as slow IV bolusThird-line

IV Ceftazidime 2 g as a 5-10 min infusion If patient on long-term corticosteroids prescribe stat dose: IV

Hydrocortisone 100-200 mg

Within 30 minutes of arrival Obtain IV access Take cultures from a minimum of two sites including:

-- all existing lumens -- plus a peripheral site i.e. peripheral x2 or peripheral plus each existing lumen

Ask patient to provide MSU and sputum samples if available

NURSES ACTION PLAN: Within 10 minutes of arrival Ensure doctor reviews patient Draw up all antibiotics while doctor obtains IV

access and blood samples

Within 30 minutes of arrival Collect MSU and sputum samples if available

prior to antibiotics if possible Administer antibiotics Request bed for ALL patients

to allow time for the ward to make a bed available

Within 60 minutes of arrival Admit to ward

IV antibiotics urgently required irrespective of current or recent oral antibiotic therapy

If in doubt: Administer IV antibiotics even if: apyrexial in ED and / or currently on oral antibiotics Ask further questions later do not wait for: a new neutrophil count or the creatinine level

Sign overleaffor actions completed

YES to ANY answer in Question 1 PLUS YES to ANY answer in Question 2 OR

Referred by specialist to follow pathway= MEDICAL EMERGENCY TRIAGE 1 OR 2 ONLY

NO to ALL answers in EITHER Question 1 or 2e.g. well immunosuppressed patients presenting with injuries, or,

immunosuppressed patients without symptoms in Question 2

Reasons for not following the pathway (mandatory) Time Sign Designation

I M M U N O S U P P R E S S E D

P A T I E N T S

(Attach Label here or Complete Details)

NAME: _________________________________________ NHI: ______________ GENDER: ____ DOB: ______________ AGE: ______ WARD: __________

Ref: Issue 1 Authorised: Clinical Quality Improvement Team Page 1 of 2 Dec 2013

Immunosuppressed Patients

Clinical Pathway

INVESTIGATIONS AND INITIAL MANAGEMENT BY ED STAFF/RNS (within 30 minutes) Action for all patients Yes No/NA Comments / Variance Time Sign

Vital signs:

Set monitor to record Q15 min

IV Access: Specify size and location of:

Peripheral line: 22G or 24G only

Type of central line insitu

Apply green sticker when inserted in ED

Peripheral line:

Location:

Size (circle): 22G 24G

CVAD Type:

Septic Screen blood samples:

Haematology (1 tube)

Biochemistry (1 tube)

Blood cultures TWO sets (Peripheral vein x 2 or Peripheral vein PLUS one for each lumen insitu if easily accessible)

Mark samples as: URGENT Request:

CBC + Diff, HEMO and Cultures

Check Allergies

Antibiotics within 30 minutes (specify)

IV Piperacillin 4 g / Tazobactam 500 mg (Tazocin 4.5 g)

PLUS IV Gentamicin 7 mg/Kg in 100 mL sodium chloride 0.9 %

or (penicillin allergy/Rural Nurse Specialist/Gentamicin contraindicated)

IV Imipenem-Cilastin 500mg (Primaxin)

or

IV Ceftazidime 2 g

Do NOT wait for creatinine level for loading dose. Gentamicin levels need to be taken. Refer to WCDHB Gentamicin form. Dose based on ideal body weight.

IV sodium chloride 0.9 % (via pump for CVADs)

Update PMS (inc. rapid assessment)

TRANSFER TO WARD (within 60 minutes) Medical ward unless CCU considerations (i.e. not responding to resuscitation or an abnormal GCS)

Note: Any patient who comes into the ED and is put on this pathway is required to leave the ED within 60 minutes Discuss with Charge Nurse or Duty Nurse Manager ON ARRIVAL to facilitate Action Yes No/NA Comments Time Sign

Specialist team informed of patient arrival:

Daytime: Oncology CNS

on 03 769 7561

After hours: On call oncologist CDHB

Admit within 60 minutes Handover using ISBAR format

(Attach Label here or Complete Details)

NAME: __________________________________________ NHI: ____________ GENDER: ____ DOB: ______________ AGE: ______ WARD: __________

Ref: Issue 1 Authorised: Clinical Quality Improvement Team Page 2 of 2 Dec 2013

Emergency Department and