University of Colorado Hospital Clinical Nursing Guideline
Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
Related Policies and Procedures: Standard Precautions Hand Hygiene-Outside the Surgical Setting Hospital Infection Control Isolation/Transmission Based Precautions Blood/Body Fluid Spills Aseptic Technique in Invasive and Operative Procedures Clean/Sterile Supply Storage in Clinical Areas Infectious/Regulated Waste Management Employee Work Restrictions for Infectious Diseases Live Plant and Flower Restrictions Diet Restrictions and Recommendations for the Hematology and Oncology Immunocompromised Patient Central Venous Lines Animal Assisted Activities/Therapy Program
Approved by: . Director Hematologic Malignancies and BMT Programs: Clay Smith, MD Nurse Practitioner: Glen Peterson, RN, ACNP-BC, DNP Clinical Nurse Specialist Educator: Barbara Wenger, RN, MS, AOCNS, CRNI
Pharmacist: Jeff Kaiser, Pharm. D Bone Marrow Transplant/Cancer Center Practice Manager: Erin Stohner, RN, BSN, OCN
Effective: 5/14
Description: This guideline defines Neutropenia, as well as febrile neutropenia, and the necessary assessment parameters, guidelines, interventions, and environmental modification that must be implemented by University of Colorado Hospital health care providers in UCH clinical settings when caring for neutropenic/immunocompromised Hematopoietic Stem Cell Transplant Patients.
Accountability: All University of Colorado Hospital employees, physicians, volunteers, students, temporary and contract employees are responsible for complying with the precautions/measures described in this policy/procedure. Visitors and other non-hospital- employee personnel will be informed of and asked to comply with the provisions of this policy by the University of Colorado Hospital staff. Non-compliance will be dealt with on an individual basis.
Definitions: Neutrophils are the bodys first line of defense against microbial invasion. They constitute Pamela Heinke 5/1/14 2:04 PM Pamela Heinke 4/29/14 1:42 PM Pamela Heinke 5/1/14 2:04 PM Wenger, Barbara 4/30/14 1:02 PM Pamela Heinke 5/1/14 2:06 PM Formatted: Font:Times New Roman, 12 pt Pamela Heinke 5/1/14 2:21 PM Formatted: Indent: Left: 0", First line: 0" Pamela Heinke 5/1/14 2:06 PM Formatted: Font:Times New Roman, 12 pt Pamela Heinke 5/1/14 2:06 PM Formatted: Font:Times New Roman, 12 pt Pamela Heinke 5/1/14 2:06 PM Formatted: Font:Times New Roman, 12 pt Pamela Heinke 5/1/14 2:06 PM Formatted: Font:Times New Roman, 12 pt Pamela Heinke 5/1/14 2:06 PM Formatted: Font:Times New Roman, 12 pt Pamela Heinke 5/1/14 2:06 PM Pamela Heinke 5/1/14 2:15 PM Pamela Heinke 5/1/14 2:21 PM Formatted: Indent: Left: 1", First line: 0.5" Pamela Heinke 5/1/14 2:05 PM Pamela Heinke 5/1/14 2:05 PM Pamela Heinke 5/1/14 2:21 PM Pamela Heinke 5/1/14 2:23 PM Unknown Formatted: Bullets and Numbering Deleted: Policy and Procedure Deleted: a Deleted: Oncology and Comment: Double check that these are the actual names of the policies- they have been checking that recently. Deleted: Professional Practice, Policy and Procedure Committee Deleted: Deleted: 10/07 Deleted: Reviewed: 9/11 Deleted: policy Deleted: patients Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
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Pamela Heinke 4/29/14 1:53 PM Pamela Heinke 5/1/14 2:24 PM approximately 40%-60% of the total white blood cell count that usually ranges from 4,000-10,000/mm 3 . ANC = WBC count * ((PMNs/100) + (Bands/100)) ANC: absolute neutrophil count WBC: white blood cell PMN: polymorphonuclear cell Neutropenia is defined as an absolute neutrophil count (ANC) less than 500/mm 3 . 1. The relative risk for infection increases as the ANC decreases. The ANC is categorized into grades, which reflect the risk for infection. a. Grade 1: ANC 1500-2000/mm 3 = No Significant Risk b. Grade 2: ANC 1000-1500/mm 3 =Slight Increase in Risk c. Grade 3: ANC 500-1000/mm 3 =Moderate Risk=Neutropenia d. Grade 4: ANC less than 500/mm 3 =High Risk=Neutropenia
Signs and Symptoms of Infection 1. Localized symptoms of infection: pain at the site of infection that may or may not include erythema or exudate. 2. Generalized symptoms of infection: chills, myalgias, arthralgias, cognitive or mental status changes, anorexia, nausea/vomiting, fatigue, tachycardia, hypotension, tachypnea, hypoxemia, oliguria, and fever. 3. Site-Specific symptomatology/exam findings: cough, dyspnea, abnormal breath sounds oral pain, back pain, rigors, rectal discomfort with bowel elimination, pain at vascular access device site, burning/urgency with urination. Sources of Infection 1. The skin and mucous membranes are vulnerable sources of microbial invasion due to IV/Central line access and mucositis. Additional risk factors include GVHD (Graft versus Host Disease), and toxicities from conditioning regimens that cause prolonged neutropenia (10-30 days). 2. Primary sites of infection in the neutropenic patient are the digestive tract (mouth, pharynx, esophagus, large and small bowel, rectum), as well as the sinuses, lungs, and skin. 3. Hand hygiene is considered the most important procedure to prevent the spread of infections. Refer UCH Policy and Procedure: Hand Hygiene-Outside The Surgical Setting.
Table of Contents: I. Assessment Parameters II. Nursing Intervention for Treatment of Febrile Neutropenia III. Neutropenic Precautions Sign, Appendix A IV. ED Approach to Patient with Possible Neutropenic Fever, Appendix B
Policy/Procedure: Policy The frequency and severity of infection are inversely proportional to the Absolute Neutrophil Count; the risks of severe infection and bloodstream infection are greatest when the neutrophil count is less than 100/mm 3 . For Patients undergoing HSCT, neutropenia can last from 10-30 days, which is consistent with the therapeutic goal of destroying malignant cells within the bone Deleted: a Deleted: Oncology and Pamela Heinke 4/21/14 1:56 PM Formatted: Font: Pamela Heinke 4/21/14 1:57 PM Formatted: Bullets and Numbering Pamela Heinke 4/21/14 1:56 PM Formatted: Font:Times New Roman Pamela Heinke 4/21/14 1:56 PM Formatted: Font:Times New Roman Pamela Heinke 4/21/14 1:56 PM Formatted: Font:Not Bold, Font color: Auto Pamela Heinke 4/21/14 1:56 PM Formatted: Font:Times New Roman Pamela Heinke 4/21/14 1:56 PM Formatted: Font:Times New Roman Pamela Heinke 4/21/14 1:56 PM Formatted: Font:Times New Roman Pamela Heinke 4/21/14 1:56 PM Formatted: Font:Times New Roman Pamela Heinke 4/21/14 1:55 PM Formatted: Indent: Left: 0.25", Hanging: 0.25", Bulleted + Level: 2 + Aligned at: 0" + Indent at: 0", No widow/orphan control, Don't adjust space between Latin and Asian text, Don't adjust space between Asian text and numbers, Tabs: 0.15", Left Pamela Heinke 4/21/14 1:56 PM Formatted: Font:12 pt, Not Bold Pamela Heinke 4/21/14 1:58 PM Pamela Heinke 5/1/14 2:30 PM Pamela Heinke 5/1/14 2:38 PM Pamela Heinke 5/1/14 2:31 PM Pamela Heinke 4/29/14 2:41 PM Deleted: and Deleted: For patients undergoing HSCT (Hematopoietic Stem Cell Transplant), additional Deleted: Most patients with solid tumors have neutropenia lasting 7-10 days and are at much lower risk for infection. Deleted: p Deleted: days which Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
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Pamela Heinke 4/29/14 1:53 PM Pamela Heinke 5/1/14 2:24 PM marrow; therefore, the intent of treatment is grade 4 neutropenia. After the neutrophil count recovers, humoral and cellular immune dysfunction may persist, maintaining susceptibility to infection for months. Approximately 48% to 60% of neutropenic patients who are febrile have an established or occult infection. Approximately 10-20% of patients with a neutrophil count less than 100/mm 3 will develop a bloodstream infection. Ineffective management of febrile neutropenia can result in delayed treatment potentially resulting in sepsis, septic shock, and poorer patient outcomes. Proactive management of neutropenia is critical to decreasing the depth and duration of neutropenia following HSCT, limiting exposure to opportunistic and nosocomial pathogens, and ensuring prompt intervention should febrile neutropenia or infection develop.
Procedure I. Assessment Parameters A. Fever (single oral temperature greater than or equal to 38.3 degrees Celsius or temperature greater than 38 degrees Celsius sustained for greater than one hour) is usually the first and only sign of a potentially life-threatening infection. Localized symptoms of infection such as redness, swelling, pain, and exudate may not be present due to the inability of the patients body to create an inflammatory response resulting from the absence or decreased number of neutrophils. 1. Although uncommon, a patient with neutropenia and signs or symptoms of infection (i.e. abdominal pain, severe mucositis, perirectal pain) without fever, should be considered to have an active infection.
B. Assessment Guidelines 1. Determine expected duration and severity of neutropenia a. Consider the patients current and past treatment regimens including one or more of the following: chemotherapy, radiation therapy, immunotherapy, immunosuppressive therapy, HSCT. b. Consider the patients comorbitities, medications, history of prior documented infections, recent antibiotic therapy, exposure to infections from household members, pets, travel (including Tuberculosis exposure), HIV status, and recent blood product administration. 2. Assess for common sites of infection in patients with fever and neutropenia: the alimentary tract, groin, skin, lungs, sinus, ears, perivagina, perirectum, and vascular access device sites 3. Monitor vital signs (T,P,R,BP) Q4h or more often depending on clinical situation (Provider decision) 4. Monitor Intake and Output Q4h 5. Obtain BID weights on all active HSCT patients and all HSCT that are readmitted post transplant. 6. Monitor laboratory data: a. CBC with differential, including WBC count. If ANC less than 1000, institute neutropenic precautions. Refer to Neutropenic Precautions sign (Appendix A). Deleted: a Deleted: Oncology and Pamela Heinke 4/21/14 2:04 PM Pamela Heinke 4/21/14 2:04 PM Pamela Heinke 4/21/14 2:05 PM Wenger, Barbara 4/30/14 1:09 PM Pamela Heinke 4/29/14 2:13 PM Pamela Heinke 4/29/14 2:24 PM Formatted: Bullets and Numbering Pamela Heinke 4/29/14 2:13 PM Deleted: Deleted: Deleted: due to Comment: The typically use the term provider for all of these. Deleted: 8 Deleted: (Q4h for active transplant patients) Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
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Pamela Heinke 4/29/14 1:53 PM b. Comprehensive Metabolic Panel, LDH, Uric Acid, Creatinine, BUN, LFTs, Total Serum Bilirubin, and lactate as ordered by provider. c. Blood and other Culture Reports-notify Provider if positive and institute appropriate transmission based precautions if necessary. Refer to UCH Policy and Procedure: Isolation/Transmission Based Precautions. d. Consult Provider for potential chest x-ray, urinalysis, urine culture/sensitivity, and pulse ox. Chest x-ray for all patients with respiratory symptoms.
II. Nursing Intervention For Treatment of Febrile Neutropenia A. Febrile Neutropenia in HSCT patients a. Patients admitted for HSCT are treated with prophylactic antibiotics prior to becoming neutropenic and throughout the expected neutropenic state during hospitalization. Once patients receive their stem cells, they may begin G-CSF (Dual cord SCT or Autologous SCT) therapy to assist in WBC recovery. Refer to EHR for details. b. When a patient becomes febrile (a single oral temperature greater than or equal to 38.3 degrees Celsius or temperature greater than 38 degrees Celsius sustained for greater than one hour), refer to EHR , which indicate obtaining a chest x-ray, urinalysis, urine culture and sensitivity, and at least two sets of blood cultures. At least one of the two sets of cultures is to be obtained from the patients vascular access device if present. 1. Collaborate with the Provider regarding obtaining one of the two sets of blood cultures peripherally. c. According to the 2013 NCCN guidelines, if there is entry or exit site inflammation around the vascular access device; 1) obtain a set of blood cultures from each lumen 2) swab exit site drainage (if present) for culture and 3)Vancomycin should be considered. If the vascular access device cultures are positive for infection, collaborate with the Provider regarding obtaining further blood cultures from each lumen, removal of vascular access device, and additional antibiotic therapy. Notify provider immediately if port pocket infection is suspected. Do not access the implanted port if infection is suspected due to increased risk of further infection. d. If patient symptomatology warrants, collaborate with the Provider regarding obtaining site specific cultures including rectal, stool, skin, mouth, throat, sputum, and nasopharynx. e. If patient continues to be febrile, blood cultures, chest x-ray, urinalysis, urine culture and sensitivity are to be done only once every 24 hours. f. Refer to pre-printed orders for fever day antibiotic instructions. Once the patient is febrile (a single oral temperature greater than or equal to 38.3 degrees Celsius or temperature greater than 38 degrees Celsius sustained for greater than one hour ), antibiotics are to be given according to Fever Day 1 instructions. Initiate antibiotic therapy within the hour of the fever but not before obtaining blood cultures. DO NOT HOLD ANTIBIOTICS FOR RESULTS FROM CHEST X-RAY AND/OR URINE TESTS (refer to RRFP in Appendix C). For each subsequent fever not within consecutive 24 hour periods, collaborate with Provider regarding antibiotics to start/discontinue. If Deleted: aOncology and Pamela Heinke 5/1/14 2:32 PM Pamela Heinke 4/21/14 2:06 PM Formatted: Font:Not Italic Wenger, Barbara 4/30/14 1:08 PM Pamela Heinke 4/21/14 2:06 PM Formatted: Bullets and Numbering Pamela Heinke 5/1/14 2:39 PM Wenger, Barbara 4/30/14 1:10 PM Wenger, Barbara 4/30/14 1:10 PM Pamela Heinke 4/29/14 2:01 PM Pamela Heinke 4/29/14 2:02 PM Formatted: Font:Bold Wenger, Barbara 4/30/14 1:11 PM Wenger, Barbara 4/30/14 1:38 PM Pamela Heinke 4/21/14 2:13 PM Wenger, Barbara 4/30/14 1:40 PM Wenger, Barbara 4/30/14 1:44 PM Pamela Heinke 4/29/14 2:27 PM Pamela Heinke 4/29/14 2:42 PM Wenger, Barbara 4/30/14 1:44 PM Deleted: Physician/Nurse Practitioner Comment: May need a different work- consult Provider for these potential tests/ labs. Deleted: <#>HSCT patients
Comment: HER is the standard term for any EPIC documentation. Deleted: pre-printed orders Deleted: Deleted: pre-printed orders Deleted: Physician/Nurse Practitioner/Physician Assistant Deleted: 07 ,is to be obtained started or added to the existing empiric therapy Deleted: Physician/Nurse Practitioner/Physician Assistant Deleted: Physician/Nurse Practitioner Deleted: and y, and chest x-ray Deleted: Physican Deleted: Physician/Nurse Practitioner/Physician Assistant ... [1] ... [2] ... [3] ... [4] ... [5] Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
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Pamela Heinke 4/29/14 1:53 PM Pamela Heinke 5/1/14 2:24 PM a patient continues to be febrile for consecutive 24 hour periods, continue to follow the pre-printed orders indicating which antibiotics to administer. g. S/P Hematopoietic Stem Cell Transplant Patients returning to the hospital for complications related to their transplant, including infection, are to be directly admitted to the Hematopoietic Stem Cell Transplant unit when possible. When a bed is not available, they are to wait at home until a bed is ready or if their condition warrants, they are to go to the Emergency Department and be placed in a private room if possible. 1. If patient is febrile, ED Provider is to collaborate with Provider regarding ED Approach to Patient with Possible Neutropenic Fever (Appendix B) 2. If patient is being admitted through the ED or Inpatient due to a fever refer to the BMT/HEME ED/INPATIENT RAPID RESPONSE FEVER PROTOCOL (RRFP) (Appendix C) B. Environmental Modification 1. All neutropenic patients are placed in private rooms. Patients admitted for HSCT are to be placed in positive pressure rooms with HEPA filtration. 2. Neutropenia precaution sign is to be placed beside the door to alert staff and visitors of infection prevention protocol/measures. Refer to Neutropenic Precautions sign (Appendix A).
C. Protective Measures for Neutropenic Patients 1. Handwashing is the single most important intervention to prevent infection. a. All persons entering the room will soap and wash hands at time of entry and time of exit with either alcohol based gel or with soap and water for 15 seconds. 2. Anyone with symptoms of illness is to avoid contact with neutropenic patients. When contact is unavoidable, staff/visitors are to wear masks when entering the patients room and adhere to proper hand hygiene. 3. Children under the age of 12 are not to enter the Hematopoietic Stem Cell Transplant unit regardless of the presence of neutropenic patients. 4. Once neutropenic, ANC less than 1000, these patients are to be instructed to wear this mask whenever they leave their room. 5. HSCT patients who are under contact isolation due to their being infected with a highly transmissible infectious organism, such as VRE and MRSA, are to remain in their room at all times, unless required to leave their room for testing. In this case, the patient is to wear appropriate PPE, including yellow gown, and gloves. If the patient is neutropenic and/or under airborne/droplet precautions a mask is to be worn 6. Avoid rectal maneuvers (rectal temperatures, enemas, rectal medications, rectal tubes, digital exams) and urinary catheterizations. 7. Avoid breakdown of skin and mucous membranes by limiting venipunctures or other invasive procedures. Cleanse and protect wounds that break the skin as directed by the Provider. 8. Refer to the Diet Restrictions and Recommendations for the Hematology and Oncology Immunocompromised Patient Deleted: a Deleted: Oncology and Pamela Heinke 4/29/14 2:05 PM Wenger, Barbara 4/30/14 1:47 PM Wenger, Barbara 4/30/14 1:45 PM Pamela Heinke 4/29/14 2:09 PM Pamela Heinke 4/23/14 2:31 PM Formatted: Font:Not Italic, Underline Pamela Heinke 4/23/14 2:31 PM Formatted: Bullets and Numbering Pamela Heinke 5/1/14 2:40 PM Wenger, Barbara 4/30/14 1:48 PM Wenger, Barbara 4/30/14 1:48 PM Wenger, Barbara 4/30/14 1:48 PM Wenger, Barbara 4/30/14 1:48 PM Wenger, Barbara 4/30/14 1:49 PM Wenger, Barbara 4/30/14 1:49 PM Deleted: nurse Deleted: p Deleted: Nurse Practitioner/Physician/Physician Assistant Deleted: Deleted: <#>Solid Tumor Febrile Neutopenia patients not undergoing HSCT <#>Notify Physician Provider to obtain order to draw two sets of blood cultures. One set is to be drawn from the vascular access device if present, and one set is to be drawn peripherally. Obtain an order for urine culture/sensitivity and chest x-ray. <#>According to the 2007 NCCN guidelines, if there is entry or exit site inflammation around the vascular access device, a set of cultures is to be obtained from each lumen and Vancomycin should be started or added to the existing empiric therapy. If the vascular access device cultures are positive for infection, collaborate with Physician regarding obtaining further blood cultures from each lumen, removal of the vascular access device, and additional antibiotic therapy <#>Obtain order to start antibiotics. Initiate antibiotic therapy within the hour of the fever, but not before obtaining blood cultures. If patient symptomatology warrants, collaborate with Physician regarding obtaining site specific cultures including rectal, stool, skin, mouth, throat, sputum, and nasopharynx. <#>Collaborate with Physician regarding initiating G-CSF therapy. <#>Febrile Neutropenic solid tumor oncology patients in the Emergency Department are to be triaged according to the ED Approach to Patient with Possible Neutropenic Fever (Appendix B) Deleted: Allogeneic Hematopoietic Stem Cell Transplant patients are to be fitted for a N- 95 mask upon admission. Deleted: (N-95 for allogeneic transplant patients at all times, standard mask for autologous transplant patients, unless a N-95 is required for airborne/droplet precautions). Deleted: Physician/Nurse Practitioner/Physician Assistant Deleted: Place patient on neutropenic diet and ensure that patient receives bottled water. Patients undergoing HSCT are not to receive food prepared outside of the hospital due to the potential for infection. Deleted: Refer to Neutropenic Precautions sign (Appendix A) Deleted: Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
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Pamela Heinke 4/29/14 1:53 PM 9. Change urinals and hats when visibly soiled. Change nasal canulas, O2 masks weekly and when visibly soiled. 10. Encourage consistent patient personal hygiene a. Daily shower or bath, including shampooing head/hair. Use CHG wipes as directed for central line care. b. Change linens daily and more frequently if visibly soiled. c. Routine oral care. Refer to UCH Hospital Guidelines regarding oral care. 11. Live plant and flowers are not allowed in the rooms of neutropenic patients whose immune compromise is such that infection can be acquired from soil/plant organisms. Refer to UCH Policy and Procedure: Live Plant and Fresh Flower Restrictions. 12. Animals are restricted from the HSCT unit due to the potential infection risk for the immunocompromised patient population. Refer to UCH Policy and Procedure: Animal Assisted Activities/Therapy Program.
References: 1. Dellinger R.P., Levy M.M., Rhodes A, et al. (2012) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine. 41(2):580-637. (LOE 7) 2. Irwin, M., Erb, C., Williams, C., Wilson, B., & Zitella, L. (2013). Putting Evidence Into Practice:Improving Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society. (LOE 1) 3. Marrs, J. (2006). Care of Patients With Neutropenia. Clinical Journal of Oncology Nursing, 10(2), 164-166. (LOE 8) 4. NCCN. (2013). Fever and Neutropenia-v.1.2013. NCCN Clinical Practice Guidelines in Oncology. (CD). Jenkintown, PA: NCCN. (LOE 7) 5. Nirenberg, A., Bush, A.P., Davis, A., Friese, C.R., Gillespie, T.W., Rice, R.D. (2006). Neutropenia: State of the Knowledge Part I/Part II. Clinical Journal of Oncology Nursing, 33(6), 1193-1201, 1202-1208. (LOE 1) 6. Shelton, B.K. (2003). Evidence-Based Care for the Neutropenic Patient with Leukemia. Seminars in Oncology Nursing, 19(2), 133-141. (LOE 7) 7. Zitella, L., Friese, C., Hauser, J., Holmes, B.G., Woolery, M.A., OLeary, C., Andrews, F. (2006). Putting Evidence Into Practice: Preventions of Infection. Clinical Journal of Oncology Nursing, 10(6), 739-750. (LOE 1)
Appendix A
NEUTROPENIC PRECAUTIONS
WASH HANDS BEFORE PATIENT CONTACT Visitors with cold symptoms or contagious illness should not visit patient at this time. Patient MUST wear a mask when leaving room.
NO FRESH FLOWERS OR PLANTS. DIETARY RESTRICTIONS INCLUDE: Deleted: aOncology and Wenger, Barbara 4/30/14 1:50 PM Wenger, Barbara 4/30/14 1:51 PM Pamela Heinke 5/1/14 2:42 PM Wenger, Barbara 4/30/14 1:53 PM Wenger, Barbara 4/30/14 1:54 PM Wenger, Barbara 3/31/14 10:37 AM Wenger, Barbara 4/30/14 1:55 PM Pamela Heinke 4/21/14 2:38 PM Formatted Pamela Heinke 4/21/14 2:38 PM Formatted: Bullets and Numbering Wenger, Barbara 4/30/14 1:55 PM Pamela Heinke 4/21/14 2:38 PM Formatted Pamela Heinke 5/3/14 1:51 PM Formatted Wenger, Barbara 4/30/14 1:56 PM Pamela Heinke 4/21/14 2:09 PM Wenger, Barbara 4/30/14 1:56 PM Wenger, Barbara 4/30/14 1:57 PM Wenger, Barbara 4/30/14 1:57 PM Wenger, Barbara 3/31/14 10:38 AM Wenger, Barbara 4/30/14 1:58 PM Wenger, Barbara 3/31/14 10:39 AM Wenger, Barbara 4/30/14 1:58 PM Pamela Heinke 4/29/14 2:53 PM Pamela Heinke 4/29/14 2:37 PM Pamela Heinke 4/29/14 2:33 PM Pamela Heinke 4/29/14 2:33 PM Pamela Heinke 4/29/14 2:33 PM Formatted Pamela Heinke 4/29/14 2:33 PM Pamela Heinke 4/29/14 2:33 PM Pamela Heinke 4/29/14 2:33 PM Comment: DO we do this? Deleted: Change peripheral IVs every 3 days and IV tubing every 2 days. Refer to UCH Policy and procedure: Lines, Central Venous for instructions regarding dressing changes. Deleted: Comment: Is this the name? Deleted: the Oncology/ Comment: Find updated source Deleted: <#>Centers for Disease Control and Prevention. (2003). Guidelines for Environmental Infection Control in Healthcare Facilities, 2003 [Data file]. Available from Centers for Disease Control and Prevention web site, www.cdc.gov. (LOE I) Deleted: I Deleted: IV Deleted: 0707 Deleted: I Deleted: I Deleted: IV Comment: OLD Deleted: <#>West, F., Mitchell, S. (2004). Evidence-Based Guidelines for the Management of Neutropenia Following Outpatient Hematopoietic Stem Cell Transplantation. Clinical Journal of Oncology Nursing, 8(6), 601-613. (LOE IV) Comment: BOOKS: BMT ONS book, Chemo guidelines. Deleted: I Deleted: c301911 Deleted: Deleted: Deleted: Deleted: Deleted: Deleted: ... [6] ... [7] ... [8] ... [9] ... [10] ... [11] ... [12] ... [13] ... [14] ... [15] ... [16] ... [17] ... [18] ... [19] ... [20] ... [21] ... [22] ... [23] ... [24] ... [25] ... [26] ... [27] Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
Fresh fruit and vegetables ONLY if washed under running water prior to peeling, cutting, or eating (berries and sprouts excluded) NO soft cheeses, unpasteurized foods/fluids, or pepper (from pepper shakers or pepper mills) NO undercooked or raw meat, fish, eggs, or tofu. Unroasted nuts or nuts in a shell Teas will be prepared directly by staff for patient by request.
PLEASE SEE THE NURSE IF YOU HAVE ANY QUESTIONS REGARDING THESE PRECAUTIONS
Appendix B
ED Approach to Patient with Possible Neutropenic Fever
ED GOAL: PLEASE PAGE THE BMT/HEME TEAM IMMEDIATELY UPON PATIENT TRIAGE Pager: 303-266-4162 ! To administer antibiotics within 1 hour of ED presentation for patients with ANC (absolute neutrophil count) less than 1000 mm 3
! To recognize which patients require in-patient management and which can be safely managed as outpatients
(see Risk Stratification, p. 10) ! To facilitate outpatient AND inpatient work-up and continuity with patients oncology team. INTAKE PROCEDURE: ! Identify high risk patient at Pivot Patient with oncology information card Patient s/p chemotherapy/radiation treatment within 14 days Patient s/p hematopoietic stem cell transplant Oncology patient with fever or other vague c/o ! Provide and instruct suspected neutropenic patient to wear a mask ! Obtain patients weight ! Document Neutropenic Patient in comments on tracking board ! Assign patient to an Intake room from pivot (single patient area) to be evaluated by an attending physician. Intake attending may include neutropenic precautions if the patient has known or suspected neutropenia. The patient may then be placed in an ED treatment room in Main ED if recommended by provider. ! Notify Resource Nurse, who will notify attending or senior resident of patients arrival. ! Place Neutropenic packet of algorithms on patients chart and verify allergies once patient is in the Main ED.
ED PROCEDURE: INITIATE RAPID PRESPONSE FEVER PROTOCOL (RRFP) BASED ON ED OR HEME/BMT PROVIDER. Deleted: a Deleted: Oncology and Pamela Heinke 4/21/14 2:43 PM Unknown Pamela Heinke 4/21/14 2:45 PM Pamela Heinke 4/21/14 2:45 PM Pamela Heinke 4/21/14 2:45 PM Pamela Heinke 4/21/14 2:44 PM Formatted Pamela Heinke 4/21/14 2:45 PM Pamela Heinke 4/21/14 2:46 PM Formatted: Bullets and Numbering Pamela Heinke 4/21/14 2:46 PM Unknown Unknown Pamela Heinke 4/29/14 2:18 PM Pamela Heinke 4/29/14 2:35 PM Formatted Pamela Heinke 4/29/14 2:35 PM Formatted Pamela Heinke 4/29/14 2:21 PM Pamela Heinke 4/29/14 2:19 PM Formatted Pamela Heinke 4/21/14 3:30 PM Wenger, Barbara 4/30/14 1:59 PM Schimpf, Brandi 4/22/14 11:48 AM Pamela Heinke 4/21/14 3:30 PM Schimpf, Brandi 4/22/14 11:50 AM Pamela Heinke 4/23/14 2:16 PM Pamela Heinke 4/21/14 3:23 PM Pamela Heinke 4/21/14 3:24 PM Schimpf, Brandi 4/22/14 11:51 AM Schimpf, Brandi 4/22/14 11:52 AM Deleted: <#>thick skinned <#>(oranges, melon, bananas), not overly ripe and thoroughly washed with soap and water. Deleted: <#> Deleted: dried fruits Deleted: , Deleted: or loose tea. Deleted: or Deleted: <#>Fresh ice will be provided by staff from clean ice trays. <#>Serve bottled water ONLY to be ordered and provided on trays. Deleted: Deleted: Deleted: Page Break Deleted: Deleted: TRIAGE PROCEDURE Comment: What is this Deleted: ID Deleted: triage Comment: This is not done at Pivot, but in Intake by MD or in Main ED by RN Deleted: <#>Determine allergies Deleted: triage ESI Level 2 and bring Deleted: exam room immediately (consider Green Care Team ID Red/Yellow full) Deleted: (consider East, West, South) Comment: This would be done once in the Main ED by CTA/RN not in Pivot ... [28] ... [29] ... [30] ... [31] ... [32] ... [33] ... [34] ... [35] ... [36] ... [37] ... [38] ... [39] ... [40] ... [41] ... [42] ... [43] Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
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Pamela Heinke 4/29/14 1:53 PM Pamela Heinke 5/1/14 2:24 PM ! When patient is placed in exam room, immediately draw CBC with manual differential and at least two sets of blood cultures. ! Draw second blood culture from a different site than that of the first set of blood cultures. ! Notify physician as soon as ANC results have returned (lab will call results to primary RN). ! If ANC less than 1000, send all other labs as ordered on pre-printed order sheet. Other labs may be clinically indicated even if ANC is greater than 1000. ! After receiving ANC results, the ED Attending or Senior Resident will contact the inpatient BMT Nurse Practitioner/BMT Physician Assistant if the patient is s/p hematopoietic stem cell transplant; otherwise the Oncology Fellow is to be notified. ! Physician will stratify patient to either IP or OP treatment (according to clinical criteria listed in packet) and will order appropriate antibiotics if ANC less than 1000. ! If outpatient treatment is appropriate: the physician will call the patients primary Oncologist/Nurse and will coordinate discharge with PO antibiotics. ! Antibiotics must be administered immediately upon receiving the order from the Senior Resident or ED Attending.
Appendix C BMT/ HEME ED/ INPATIENT RAPID RESPONSE FEVER PROTOCOL (RRFP) Patient Qualifies for RAPID RESPONSE FEVER PROTOCOL Hospital Admission Please note: This pathway is NOT an order set. This is a guideline for MDs/RNs for the INITIAL (first hour) management of Heme/BMT patients who present to the ED or Inpatient Unit with FEVER or other signs of serious infection. This pathway will be accompanied by an order set. PLEASE PAGE THE BMT/ HEME TEAM IMMEDIATELY UPON PATIENT TRIAGE Pager: 303-266-4162
" Vital Signs Every 15min. X4, then every 30min. X2, then every 60min. " Labs (CBC/diff, CMP, Mg, Phos, LDH, Uric acid, Lactate) " Deleted: a Deleted: Oncology and Pamela Heinke 4/29/14 2:22 PM Pamela Heinke 4/23/14 2:34 PM Formatted: Font:14 pt Pamela Heinke 4/29/14 2:47 PM Formatted Table Pamela Heinke 4/29/14 2:50 PM Formatted: Centered Pamela Heinke 4/29/14 2:50 PM Formatted: Centered Deleted: another site Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
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Pamela Heinke 4/29/14 1:53 PM Pamela Heinke 5/1/14 2:24 PM Blood cultures (2 sets from Central Line and 1 simultaneous peripheral set) If difficult peripheral stick, complete Central Line cultures only OR 2 set peripherally if no Central Line " IV Fluid Bolus NS 1000cc wide open) If patient unstable (SBP<90, HR>120, dizziness, altered mental status), start IV Fluid Bolus immediately after Vital Signs and notify NP/MD immediately " ANTIBIOTICS (Please use the RRFP FEVER order set) cefepime 2gm IV Q8 +/- Vancomycin (use ONLY if hemodynamic instability, suspected line or skin infection, suspected MRSA, PNA, mucositis) If severe allergy to PCN/cephalosporins, use alternative antibiotics per RRFP order set Above interventions to be completed within 30 min. of patient #########arrival to ED/Inpatient Unit if Direct Admit########## " Diagnostic Testing/Source ID CXR, CT, UA C&S, etc. Do NOT delay antibiotics waiting for CXR or UA!! " 11 th Floor Inpatient Management OR ICU Transfer for EGDT if Unstable
Risk Stratification in Febrile Neutropenia Fever is defined as a single oral temperature greater than or equal to !38.3C (101F) or greater than or equal to 38.0C (100.4F) for greater than or equal to 1 hour. Neutropenia is defined as a neutrophil count less than 500 cells/mm 3 , or a count less than 1000 cells/mm 3 with a predicted decrease to less than 500 cells/mm 3 . (IDSA, 2002) Group Description Deleted: a Deleted: Oncology and Pamela Heinke 4/29/14 2:55 PM Formatted: Left, Right: -0.08" Pamela Heinke 4/29/14 2:48 PM Formatted Table Pamela Heinke 4/29/14 2:49 PM Formatted: Font:12 pt Pamela Heinke 4/29/14 2:49 PM Formatted: Font:12 pt Pamela Heinke 4/23/14 2:40 PM Pamela Heinke 4/23/14 2:40 PM Formatted: Left Deleted: Page Break Bone Marrow Transplant Unit: Neutropenic/Immunocompromised Management for Hematopoietic Stem Cell Transplant Patients
Must meet all criteria $ No associated comorbid illnesses* $ Alert and oriented times 3 / No mental status changes $ Non transplant, solid tumor or hematologic malignancy with no previous fungal infection $ Serum creatinine less than 2mg/dl $ Liver function tests less than 3 times normal $ Receiving oncology care in the UCH system. $ Has resources and is able to fill oral antibiotic prescription within 12 hours (able to comply with and consent to outpatient pathway) $ !Contact Hematology-Oncology Fellow to initiate outpatient order set and consent form.
High Risk (II) $ Bone marrow transplant / hematologic malignancies or uncontrolled cancer $ Age greater than 60 $ Altered mental status or confusion $ Unable to take PO medication (nausea / vomiting or mucositis); dehydration $ No telephone or transportation, no acute medical center within 1 hour from home $ Serum creatinine greater than 2.0 mg/dl or renal failure requiring intervention $ Liver function tests greater than 3 times normal $ SBP less than 90 mmHg, HR (resting) greater than 100 bpm, RR greater than 20/min, O2 sat less than 90%(room air/baseline O2) $ Uncontrolled comorbid conditions*, significant burden of illness or poor performance status $ Expected prolonged neutropenia (less than 100/cells/mm 3 for greater than or equal to 7 days) or bleeding requiring transfusion $ Obvious central line infection , pneumonia or other complex infection $ ! Initiate inpatient febrile neutropenia order set for inpatient admission and contact Hematology- Oncology Fellow.
Critical (III) Meets high risk criteria and appears very ill (i.e. hypotension, shock) ! Initiate inpatient febrile neutropenia order set for inpatient critical car admission and contact Hematology- Oncology Fellow. *Comorbid conditions can include diabetes, COPD, CHF (cardiac problems or EKG changes.) The use of these guidelines is subject to the clinical judgment of the practitioner and the patients clinical presentation. OTR02030 (11/04)
Complications of Bothrops Porthidium and Bothriechis Snakebites in Colombia A Clinical and Epidemiological Study of 39 Cases Attended in A University Hospital - Otero