Summary

Central West and Wales UKONS members have developed, designed and piloted the UKONS Oncology/Haematology ‘24 Hour Triage, Rapid Assessment and Access Tool Kit’.

It is a risk assessment tool that, if used correctly, standardises and supports excellent practice, improving quality and safety and providing evidence of service provision. The tool provides a robust framework for triage assessment, action and audit, and as a result leads to improved quality and safety in patient care by: 

• Ensuring  patients receive a robust, reliable assessment every time they contact a   helpline for advice
• Ensuring  assessments are of a consistently high quality by the use an evidence-based assessment tool
• Advising on action and advice that is appropriate to the patients ‘level of risk’ 
• Ensuring patients who require urgent assessment in an acute area are identified and that action is taken, but also 
• Identifing and reassuring those who are at lower risk and may safely be managed by the primary care team or a planned clinical review and avoid unnecessary attendance 
• Providing a framework for triage training and competency assessment for practitioners.

Feedback assured us that with regular use the whole assessment process improves in terms of quality, structure and time taken.

The development process has been methodical, professional and democratic and is an excellent example of team work. The aims and objectives of the project were clearly agreed and with the completion of the pilot and evaluation have been achieved.

The tool kit has been piloted successfully in 35 hospital trusts in the UK and is now being used widely across the UK. There have been no reports of adverse events or clinical incidents linked to the tool during the pilot period or since.

Objectives

The groups primary aim was to develop NATIONAL triage guidelines in the form of a tool kit. 

The Tool Kit should be used by all members of staff who may be required to man 24 hour HELPLINES for adult patients who have:

• received chemotherapy /systemic anti-cancer therapy
• received any other type of anti-cancer treatment including Radiotherapy
• disease/treatment related immunosuppression (i.e. acute leukaemia, corticosteroids ) 

The tool kit should provide:

• Guidance and support to the practitioner at all stages of the triage process
• A simple but reliable evidence based assessment process
• Safe and understandable advice
• Communication and record keeping
• Competency based training
• An audit tool.

The tool kit should:

• improve patient safety and care by ensuring that they receive a robust, reliable     assessment every    time they contact a helpline for advice.
• ensure that the assessments are of a consistent quality and use an evidence based  assessment tool.
• ensure that the management and advice is appropriate to the patients’ level of risk. To ensure that those patients who require urgent assessment in an acute area are identified and that action is taken, but also to identify and reassure those patients who are at lower risk and may safely be managed by the primary care team or a planned clinical review and avoid unnecessary attendance. 
• form the basis of triage training and competency assessment for practitioners.
• provide a record /evidence of helpline contact for review when managing treatment plans 
• provide data for audit of quality and activity

We aimed to develop a generic tool that could be understood and used by the multi-disciplinary team caring for the patient and become a standard method of assessing, describing and recording the helpline process, a common process that would allow communication and training to cross trust, network and national boundaries.

Solution

The project began with a call for evidence and examples of current practice from the Central West and Wales area and gathering of relevant national and international information, this information was reviewed in two very well attended workshops.

The project aims and objectives were defined at the workshops and development group membership agreed. The group met regularly to develop, review and refine the tool kit. At each stage the members were asked to take the document/kit back to their muti-disciplinary clinical teams for discussion. The comments were then considered at the following meeting and the tool kit amended accordingly. The UKONS Chemotherapy Leads and Board Members, the Cancer team at the National Patient Safety Agency and Members of the National Cancer Action Team were invited to review the document/kit at regular intervals and their comments were also considered.  

Following steering group approval of the content and format of the tool kit, the Chair and Vice Chair of the group met with the Cancer Lead of the National Patient Safety Agency. This agency had been tasked with a review of reports relating to support for patients who have oncology treatment related complications (NPSA oral therapies alert 2008).The toolkit was identified as a positive step towards supporting patients by providing consistent reliable advice and support for both patients and staff.

The National Patient Safety Agency provided funding to support design and production of the “Tool Kit” for a multi-centre pilot. 
The pilot process:

Step one- Enrollment - teams were asked gain agreement from their employers to participate in the pilot and ensure that their governance group gave approval and obtain signed consent to participate and agreement of the pilot process. 

Step two-“Pilot introduction and training days” all participating sites were asked to send a pilot lead and deputy to one of these days. Training included how to use the tool kit,how it was developed and the pilot evaluation process and governance. Pilot leads were asked to provide training for all staff who would man the helpline

Step three- Pilot- The pilot ran for two months or the completion of 100 log sheets after which time anonomised copies of the logsheets were sent to the project/pilot lead.
Participating staff  were asked to complete a questionnaire about their experience with the tool.

Step four- Evaluation-  All log sheets were reviewed (1,899) 500 randomly chosen entered onto an access data base for evaluation.  134 User questionnaires returned and reviewed.

Step five- Tool Kit amended following evaluation and Final Version launched.

The development group considered the physical evidence of completed log sheets and the comments relating to the format and the process that we received from practitioners and refined the tool kit accordingly. The group were heartened to realise that in fact very little needed to be amended from the original pilot and a final version of the tool kit has now been produced.

There were no reports of adverse events or incidents linked to the tool kit during the pilot or since.

The steering/development group all enrolled their clinical areas and  let people know that we were looking for interest from clinical areas who had not been involved with the development of the tool kit. We were inundated with expressions of interest and quickly realised that this was going to be an extensive pilot, 29 hospital trusts from England, Wales and Northern Ireland asked to take part; they were invited to send Pilot Leads to one of two training days. 27 Sites agreed to participate in the pilot at this point, included within these 27 were all the steering group members. The whole of the Greater Midlands Cancer Network enrolled.

19 cancer centres and 17 cancer units completed the pilot and are included in the final evaluation.

Results

Evaluation

The evaluation of the multi-centre pilot that was run to test the tool demonstrates that, the tool kit if used correctly does achieve our initial objectives (please see supporting documentation).

Evidence to support this achievement was  obtained from a review of 134 user questionnaires and 500 of the completed log sheets selected from the 1,899 that were returned revealed the following-

* The Tool Kit has been successfully used to assess adult patients who contacted  24 hour HELPLINES in 26 hospital trusts within the United Kingdom. 

* There have been no reports of adverse events or clinical incidents linked to the tool during the pilot period or since.

* Through effective management of calls the pilot has proved that with training and education, patients contacting the helplines were appropriately assessed and treated accordingly. 

* The pilot has proven the need to train triage nurses consistently in the use of triage tools, to effectively manage and treat this group of patients. The practitioner evaluation has shown that guidelines and a standardised approach are valued. The tool has increased confidence and provides support for decision making and reassurance for both the practitioner and the patient. 

* There is strong evidence indicating that chemotherapy patients value 24 hour access to health care professionals (Oakley et al 2010)(1) and this tool facilitates the consistent safe delivery of advice by, using a risk assessment tool based on internationally recognized assessment criteria and a defined process to provide safe outcomes of care. 

* The pilot provided us with significant data about the timing of calls and level of risk that patients exhibit.

* The majority of patients who were asked to attend for assessment were subsequently admitted to hospital and the majority of this group had either scored red triggers or been escalated to red with multiple amber triggers. The tool is identifying patients who require further urgent assessment consistently and appropriately.

* A significant number of patients who contact triage helplines may not report a single overwhelming problem but will have a number of lower grade problems. The cumulative significance of these problems is demonstrated in the pilot results for those patients who presented with two or more amber triggers,the majority of these patients were asked to attend hospital for assessment, all of these patients required intervention and over half of them required admission. This demonstrates the need for a methodical, rigorous assessment of all patients who contact helplines to ensure that significant signs and symptoms are not overlooked.

* Anecdotal evidence from practitioners relate feelings of anxiety and concern about unsupported decision making, and there is also evidence that decisions can be overturned by senior but less knowledgeable staff resulting in dire consequences (NPSA adverse events reports).The tool  supports decisions to ask the patients to attend for urgent assessment and  also supports the decision to manage the patient in their own home with either a follow up call/ review appointment or reassurance and simple advice.

* The decision to leave a patient at home should not be taken lightly and should follow a complete risk assessment and supportive action or advice. The majority of patients  with one amber trigger were managed in their homes with telephone advice ,referral to the primary care team  or an oncology review arranged for the following day,so avoiding unnecessary emergency assessment and possible admission.  The small number of patients who were asked to attend for urgent assessment all had a concurrent problem that would  not  be considered a toxicity related problem but would require urgent assessment e.g central line problems.

* The majority of patients identified  as all green triggers were safely left at home or were directed to primary care teams for further support . The small number of patients who were asked to attend for urgent assessment all had a concurrent problem that would  not  be considered a toxicity related problem but would require urgent assessment e.g central line problems.

* The follow up process that was used during the pilot has provided us with evidence to support the effectiveness and safety of the tool when used correctly. Log sheets revealed that the majority of the one amber patients received a follow up call this allowed for a planned review prior to their next chemotherapy if required The majority of the pateints  had either improved or reported no change. In the case of no change a further follow up call on the next day is recommended. Reassuringly  only 2% of this group had deteriorated but with the safeguard of a follow up call they were identified and attended for assessment.

* None of the patients who had green triggers only required urgent admission or assessment on follow up.The majority had improved; none of this group had contacted the helpline with further concerns.

* The tool kit triage process is correctly identifying patients who do not require urgent admission and the follow up process is allowing a planned approach to problem management directing patients for appropriate review if required. 

* As previously stated  the majority of calls are within 14 days of receiving treatment; over half were within 7 days of treatment. This information would support the implementation of pro-active monitoring of patients within this high risk period. 

* The tool kit has been used successfully in one of the pilot sites to pro-actively assess patients at regular intervals and identify those at risk and in need of early intervention. This also supports an uninterrupted treatment schedule and avoids unplanned admission whenever possible.

* The comparison exercise within the evaluation reveals almost identical activity trends and may be of considerable use when considering resources required for managing a helpline. The level of activity out of hours (nights and weekends) may lend itself to a more centralised approach with trusts working together to provide out of hours support and advice.

* The level of activity within working hours is considerable and a review of who provides this support and how much time is allocated to the role is indicated. The tool kit recommends that the triage practitioner is clearly identified for every span of duty and this role should be recognised in the practitioners/department work plan.

* The comparison has allowed us to support the sample evaluation and confirm that the tool kit can be used safely to triage and manage patients correctly. It has also confirmed the audit and monitoring potential of the tool kit if used correctly.

1.Oakley et al (June 2010)  Benefits of a network approach to managing neutropenic sepsis.   
CANCER NURSING PRACTICE June 2010 | Volume 9 | Number 5

Innovation

This project has been innovative in a number of ways.

It has gathered a group of shop floor experts from a wide area who have then worked together to develop a tool that;

• improves safety and quality of care
• can be used with confidence
• crosses professional, organisational and geographical boundaries
• a communication and record keeping process

The group have developed a tool that will not only benefit their own patients, but could be used as a national standard.

This is the first tool of its kind that has been developed for this patient group .It supports equity of care by setting a standard for the assessment process and evidence of its application. Previously, (as we discovered during our development stage) there were many different varieties of triage assessments. Although most of the tools had a similar focus, they were not structured or formatted in a manner that was user friendly and auditable. There were no triage tools that had a specific focus on competency training. Our group incorporated training days to "train the trainer" which allowed teams across the UK to disseminate across their specific areas. 

A significant point in our project was the invitations from both the National Cancer Action Team and The National Patient Safety Agency to share our project ideas.       

The resources used have been minimal; the group have given their time freely and initial meetings were supported by an educational grant from a pharmaceutical company.

We received £12,000.00 from the National Patient Safety Agency to support the pilot, this was used to facilitate training, provide “Tool Kits”, evaluate data and produce the final version.

The training events have either been facilitated by cancer networks or UKONS

The tool kit costs £50.00 for a starter kit with recurring costs of the log sheets used to record the assessment at 30 pence per call/patient (£30 for a book of 100). These costs can be compared to the cost of an emergency bed day estimated at £200. 

The pilot process was innovative, we included many areas across the U.K. and collected a large amount of data, the enthusiasm for this project was evident from the level of response and our original belief that there was a need to produce a tool that could or would be used nationally has been validated.