Management of the deteriorating patient in the community
Our patients may become unwell due to their disease or treatment while in the community. Without urgent assessment and intervention this can be life threatening.
Patients may be immunocompromised and may not display the typical signs and symptoms of infection, therefore thorough assessment is critical.
You should manage all patients presenting with fever following recent anti-cancer treatment as if they have neutropenic fever and receive empiric antibiotics without waiting for laboratory confirmation of neutrophil count.
Neutropenic fever is defined as a temperature of greater than 38.0*c and neutrophil count (ANC) of less than 1.0 x 10(9) cells/L.
Any delay in the commencement of antibiotics may cause increased morbidity and mortality.
Our patients require a range of central venous access devices (CVAD’s) for systemic anti-cancer therapy, supportive therapy, and medication administration. Devices that we can insert at our Parkville campuses include:
All patients are provided with written information and education following the insertion of CVAD. Upon discharge, the following information should be provided:
The type of CVAD inserted and required care and TGA card from cancer imaging
Patients are shown by the Registered Nurse how to complete a daily visual CVAD observation and esnure it is unchnaged from day prior
Reportable signs and symptoms (redness, swelling, pain, discomfort, catheter
Damage/migration, presence of discharge/bleeding, non-intact dressing)
Relevant contact details and what to do in an emergency
Provide patients with appropriate written information from eviQ depending on type of CVAD inserted:
Following insertion, and prior to initial use, catheter tip position must be confirmed. This is done using Radiological confirmation and a patency assessment.
The insertion note provides confirmation of the tip position. For CVADs, the catheter tip location with the highest safety profile is at the Cavoatrial (CA) junction. The lower third of the superior vena cava is also acceptable. If this information has not been documented in the insertion notes, contact Peter Mac @ Home on (03) 8559 6800 nursing staff for confirmation.
A catheter is typically inserted percutaneously into the basilic or cephalic vein and threaded up the arm until the catheter tip is positioned in the superior vena cava (SVC). These devices are used for treatment required for medium term (weeks-months).
Permacath: These devices are used for long term (months to years) treatment. This type of catheter also has a large lumen width, enabling sufficient venous access for therapeutic apheresis procedures, including collection of haematopoietic progenitor cells, as well as haemodialysis. The tunnel creates distance between the exit site and the puncture entry site, reducing the risk of catheter-related blood stream infections.
Hickman: These devices are used for long term treatment (months to years). The tunnel creates distance between the exit site and the puncture entry site, reducing the risk of catheter-related blood stream infections.
The Peter Mac CVAD dressing, securement device and cap change clinical procedure provides information on how to complete a Hickman & Permacath dressing in the community. See our Principles of CVAD Management Clinical Guideline outlines Tunnelled device management on pages 10-14.
This device is used for the administration of fluids, blood products and medications and blood sampling. Implanted ports may be single or double lumen. These devices can be used long term treatment (months to years). A surgically inserted CVAD consisting of a self-sealing silicone injection housed in a body of inert material, connected to a silicone catheter. The catheter is inserted into the venous system, typically placed with the tip positioned in the superior vena cava (SVC) but it can be in the upper arm via the basilic or brachial vein or less commonly, can be implanted in the abdomen.
The Peter Mac Tunnelled Implanted Vascular access device (TIVAD) Management (Implanted PORT) clinical procedure provides information on implanted port accessing and deaccessing. Our Principles of CVAD Management Clinical Guideline outlines Implanted Port principles for management on pages 4 - 11.
Systemic Anti-Cancer Treatment (SACT) via an elastomeric Baxter device
Patients would be discharged to your service with an elastomeric Baxter delivering Systemic Anti-Cancer therapy (SACT) over 24, 46 or 96 hours. Your service will only disconnect the chemotherapy and will not attach it to the patient’s CVAD device.
All patients should be educated on the Baxter elastomeric device and treatment related side effects, as well as cytotoxic precautions, and spills management. The educating nurse will provide the patient with the eviQ patient handout on elastomeric infusion on connection at Peter Mac.
Patients receiving any Intravenous systemic anti-cancer medications can be at risk of extravasation. If any concerns the medication has been incorrectly infusing or concerns the medication has leaked from the device, please follow our steps on the Management of Anti-Cancer Drug Extravasation guideline on pages 7-9.
The only drug we outsource is 5FU (Fluorouracil), which falls under the irritant drug classification. Please refer to pages 28-30 of our Management of Anti-Cancer Drug Extravasation clinical guideline for the management of irritant extravasation.
Troubleshooting with Systemic anti-cancer treatment administered via a Baxter device
Clamp the line and see the EviQ hazardous drug spill management clinical guideline for directions on appropriate PPE (Personal Protective Equipment) and spill management.
If a patient has an implanted port, they must visit either Peter Mac or their local emergency department to have the gripper needle replaced and flushed with (X2 10mls NACL 0.9%).
For outsourced patients with PORT/TIVAD, an urgent medical review is required if SACT drug has been incorrectly infusing. If the infusion is administered via a PICC or a tunnelled CVAD, the site will need to be assessed by the visiting nurse for signs of extravasation and infection. Take a photo of the CVAD site with patient consent and perform a comprehensive skin assessment to ensure chemotherapy has not leaked all over the skin. If evidence of redness marks the area, contact Peter Mac @ Home and wait for a medical plan. Ensure the patient takes a shower immediately and thoroughly washes the affected area.
If the patient meets are acutely unwell and meets sepsis criteria, call 000. Follow the clinical deteriorating pathway in the community.
Determine the approximate volume remaining if the device becomes disconnected. The patient may require an additional dose and may need to visit the Day Therapy unit at Parkville campus. Peter Mac @ Home may require a photo of the Baxter for the medical team and pharmacy records.
Please call Peter Mac @ Home on (03) 8559 6800 between 8am-5pm, 7 days a week, to advise, discuss further action required, and document thoroughly.
The minimum education requirement for nurses administering cytotoxic drugs includes the completion of the Peter Mac Chemotherapy Module One or an equivalent program, in addition to completion of our Cytotoxic Chemotherapy Competency Assessment Tool.
Your organisation may have an in-house education program or alternatively utilise resources available from EdCaN or eviQ .
Speak with your manager regarding your organisations' requirements.
A cytotoxic spill refers to both a liquid or powder spill of a cytotoxic drug and / or the bodily fluids of the patient within seven days of administration of a cytotoxic drug. Equipment used in this situation can be disposed of in a sealed cytotoxic waste bag (purple) and placed in a cytotoxic bin (purple).
