1. Oncology/Haematology 24 Hour Telephone Triage Rapid Assessment and Access Toolkit
Engage people in why we need a triage tool in the first place
Engage people in why they need a copyrighted tool
Explain how it was done
Inform people where you are up to with the development of the aussie tool
OUTLINE OF TALK
Introduction – Who am I build my credibility re your authority to discuss this topic.
I am NUM CDU, was one of the senior nurses who developed this tool kit and who now consults on the on the advisory committee for UKONS
Joan Thomas

2. What we will discuss today2
What we will discuss today
What is triage?
The development of the UKONS toolkit
UKONS/AUS version
Why we need triage training
What we need in place to be successful

3. What is triage?
Triage : a clinical assessment process that identifies and prioritises patients according to the current or potential severity of the presenting problem

4. What is triage?
In modern healthcare systems triage is used at significant points in the patient pathway to determine level of urgency and intervention required:
Triage on arrival at ED or Medical Assessment Unit.
Pre hospital triage – 000 calls or in our case 24 hour advice lines.
On site triage by the first clinician attending the patient- para-medics
In order to use triage effectively the infrastructure must be in place to manage the patient appropriately.

5. Why we need triage in Oncology / Haematology
We know that Systemic Anti Cancer Treatment (SACT) will produce unwanted side effects/toxicities some of which can be life threatening
We have to provide information and appropriate support for patients receiving Systemic Anti Cancer Treatment (SACT)
We know that we do not always identify those patients at risk from side effects/toxicities

6. Why we developed the UKONS toolkit
2 Driving Policies
Audit carried out in response to concerns about quality and safety for patients receiving chemotherapy
National confidential enquiry into patient outcomes & death. For better or worse (NCEPOD,2008)
National Chemotherapy Advisory Group in England: ensuring quality & safety (NCAG,2009)
Identified lack support/infrastructure for patients receiving chemotherapy and early detection and treatment of chemotherapy related toxicities/side effects
NCEPOD studied the death of those patients who died within 30 days of treatment, looking at whether the death was due to :-
treatment related toxicity *** or progression of malignant disease or an unrelated cause.
It looked for remediable factors in the process of care :-
in the prescribing and administration of SACT
in the clinical care following development of toxicity ***
the initial decision to treat with SACT. Was the patient fit enough
What infrastructure did organisations provide to patients if they became sick at home

7. No recognition of need, value or importance7
Why we developed the UKONS toolkit
No agreed triage process or pathway – multitude of numbers- changing admission points – different level of service out of hours
No agreed training or competency assessment
No quality control or review
No data collection
No recognition of need, value or importance
Just let me take you back
I mentioned NCEPOD, what did it identify.
It identified that we had no rigour or governance around our process of what happens when a patient calls because they are sick or concerned
And who do they call

8. Why we developed the UKONS toolkit
United Kingdom Oncology Nursing Society (UKONS)
The original version was 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 correct use of tool kit reported during the pilot or since release
The tool has now been updated and version 2 was approved in November 2016 includes Immunotherapy
Tool developed by UKONS senior nurses group
Now international tool
Proven tool no adverse events
It has copyright to keep the process rigour and standardised – only changed with review and consensus
Update Nov 2016 – with Aus ME in consolation
Now includes immunotherapy management Greater detail to the symptoms – Diarrhoea – immunotherapy
Symptoms not previously listed : urinary, confusion, ocular

9. Development of the telephone triage toolkit9
Development of the telephone triage toolkit
Developed over a 3 year period by a group of experienced senior nurses working within Chemotherapy Haematology and Oncology
Supported by UK Oncology Nursing Society
Multidisciplinary consultation.
Supported by the U.K. National Patient Safety Agency
Meets national recommendations, NCEPOD, NCAG and Acute Oncology measures
Extensive pilot study in 26 cancer centres and units
Positive evaluation and now widely adopted throughout the UK and internationally
Developed over 3 year period, lots of MDT discussions
Supported by UKONS, Patient safety Agency
Important to engage in the right stakeholders
Tool now meets national standards and Acute oncology Measures
Pilot 26 cancer centres and units
Positive evaluation

10. Pilot study and evaluation10
Pilot study and evaluation
The Tool Kit achieved its primary aims and objectives.
It was shown to be reliable, robust as a planned standardised approach to triage and assessment
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.
It 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 Cancer Centers, Cancer Units and Primary Care.
Positively evaluated by those using it during the pilot.
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.
Its delivers a planned approach to the Triage Process
And at a high standard for Best Practice
And an Excellent Educational Tool for practitioners to provide
The toolkit was positively evaluated across the pilot sites

11. Pilot study and evaluation11
Pilot study and evaluation
Improve patient safety and care by ensuring that everyone receives a robust, reliable assessment every time the helpline is contacted for advice
Ensure assessments are of a consistent quality and use an evidence-based assessment tool
Provide management and advice appropriate to the patient’s level of risk. Ensure that those patients who require urgent assessment in an acute area are identified and that appropriate action is taken. Also 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
Maintain accurate records of the assessment and decision-making process in order to monitor quality, safety and activity.
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.
Its delivers a planned approach to the Triage Process
And at a high standard for Best Practice
And an Excellent Educational Tool for practitioners to provide
The toolkit was positively evaluated across the pilot sites

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Aim of the tool kit
To provide guidance and support to the practitioner at all stages of the triage process:
Contact and data collection
Assessment/definition of problem
Appropriate intervention/action
To provide:
A simple reliable assessment process
Safe understandable advice
Communication and record keeping
Competency based training
An audit tool
Aims of the tool – the toolkit is a framework
Improve patient safety and care by ensuring that they receive a robust, reliable assessment every time they contact a helpline for advice.
Ensure those assessments are of a consistently high quality by the use an evidence based assessment tool.
Identify action and advice that is appropriate to the patients’ level of risk.
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.

13. It’s a risk assessment tool kit?13
A risk assessment tool using a RAG
(RED, AMBER, GREEN) scoring system.
For telephone triage of patients who:
Have received or are receiving Systemic Anti Cancer Therapy (SACT)
Have received any other type of anticancer treatment, including Radiotherapy and bone marrow graft
May be suffering from disease/treatment related immunosuppression (i.e. acute leukaemia, corticosteroids)
It is what it says it is !!
For telephone triage of patients who:
Have received or are receiving systemic anticancer therapy
Have received any other type of anticancer treatment, including radiotherapy and bone marrow graft
May be suffering from disease-/treatment-related immunosuppression (i.e. acute leukaemia, corticosteroids)

14. It’s a risk assessment tool kit14
Action is based on the triage practitioner’s grading of symptoms/toxicity:
RED – priority and action should follow immediately. Patient should be advised to attend for urgent assessment as soon as possible
2 or more AMBER = RED – two or more toxicities graded amber should be escalated to red action
AMBER – one toxicity should be followed up within 24 hours, call from practitioner or call back if they continue to have concerns, or their condition deteriorates
GREEN – callers instructed to call back if they continue to have concerns or their condition deteriorates.
It’s a RAG system
It scores
it grades
Action is based on the triage practitioner’s grading of symptoms/toxicity:
RED – priority and action should follow immediately. Patient should be advised to attend for urgent assessment as soon as possible
2 or more AMBER = RED – two or more toxicities graded amber should be escalated to red action
AMBER – one toxicity should be followed up within 24 hours, call from practitioner or call back if they continue to have concerns, or their condition deteriorates
GREEN – callers instructed to call back if they continue to have concerns or their condition deteriorates.

15. The manual 15 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
So what does the toolkit – the manual itself contain
Everything you need to set up a triage process for your patients

16. The triage tool
The assessment tool is based on the NCRI-CTCAE common toxicity criteria. It should be used as a guideline, highlighting the questions to ask and leading the practitioner through the decision-making process
It is a risk assessment tool used to grade the patient’s symptoms and establish the level of risk to the patient, and will enable practitioners to provide a consistent robust triage
It is a cautious tool and will advise assessment at a point that will allow early intervention for those at risk
It is a risk assessment
It grades the patients symptoms
Then it points to what to do next

17. The log sheet 17 Standardised telephone consultation
Step by step process
A guide and check list for the practitioner
A communication tool
Methodical data collection process
A record of the process for quality, safety and governance

18. Why An Australian Tool
Nurses recognised the need to triage our patients to manage them safely, appropriate care at the right time and the right place by the right person
Evidence based practice - opportunity to bench mark our practice
UKONS received Aus requests to use the tool
Because you asked for it
Practitioners recognised the toolkit and contacted UKONS who contacted me !!

19. AUSTRALIAN Working Group
4 States & ACT
23 Hospitals
Expert Panel
6 Months review of toolkit & recent changes (2 years in total)
National Platform to host Toolkit - eviQ

20. Changes : UK - AUS 20 Terminology & Grammar
Temperature – Febrile Alert : 37.5*
What does this mean -New ways of thinking
Opportunity to prevent serious adverse events
early identification of symptoms and early management
its not always about the temperature …
its about the alert

21. Why do we need training for telephone assessment
All staff using the toolkit 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 toolkit
Example scenarios have been provided to assist with training
Staff who are not trained to use the toolkit should not provide telephone advice

22. Why do we need training for telephone assessment
How many calls do you anticipate
During Hours
Out of Hours
Who will take the calls:
in the uk evaluation 85% of staff had 3 years Chemotherapy experience and were senior grades
High volume of calls 8pm – midnight
What happens overnight
What happens at weekend and public holidays

23. Limitations of telephone triage
Barriers : only verbal and emotional cues
No visual information :what do we look for: colour, general appearance, body language, signs in behavior, smell !
Symptoms have a wide ranging differential :lack of visual cues, lack of ability to capture overall facial expressions, face to face assessment
Poor language
Cognitive impairment
Elderly
Evidence shows that elderly, those with 2nd language and cognitive impaired struggle to give

24. Common errors in telephone assessment
Inadequate talk time
Insufficient history taking and documentation
Absence of key questions
Lack of structure
Improper use of or failure to use protocols
Premature diagnosis, without detailed assessment
Risk of stereotyping of clients and problems
Second guessing or over reliance on callers
“ my new meds are making me dizzy” “ I have the flu”
Patient may seriously misrepresent the symptom

25. Carrying out the assessment
The data collection must be methodical and thorough 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!

26. Assessment RED- Priority & Action
Assessment tool acts as Prompt for Triage Practitioner
Reliable guide to toxicity grading based on NCI Common Terminology Criteria for Adverse Events
Practitioner judgement & experience plays a vital part in assessment.
RED- Priority & Action
AMBER- One Amber may require advice & follow-up. More than two Ambers may indicate assessment & follow-up.
GREEN- Patients should be encouraged to monitor symptoms & recontact if issues arise.

27. Good technique-structure
State your name and position
Obtain caller's name and telephone number
Record date and time of call.
Record person's name, gender and age
Speak directly with the person who has a problem.
Take a detailed and structured history.
Triage protocols or checklists :UKONS tool

28. Good technique-advice giving
Provide advice on treatment/disposition
Give specific advice regarding follow-up and when to contact
Summarise and record the main points covered
Request caller to repeat advice given.
Ask if the person has any outstanding questions or concerns.

29. Questioning techniques
Open questions:
Elicit more information,
Encourages clients to describe symptoms
Exceptions to open questioning:
Crisis-level calls and poor historians
Use facilitative questions instead: “Is your pain severe, moderate or mild”
Symptoms
UKONS tool, NCI Toxicity Grading
Symptom acronyms –SCHOLAR, OLDCART
Reflecting and paraphrasing
Clarifying and asking for detail
Attentiveness to verbal and emotional cues
S-Symptoms
C-Characteristics
H-History
O-Onset
L-Location
A-aggravating factors
R-relieving factors
L-location
D-duration
C-characteristics
A-aggravating
R-relieving
T-treatment

30. Step By Step
Step 1
Perform a rapid initial assessment of the situation: “Is this an emergency?” Ambulance or Attend
Ask questions in a logical sequence. Follow log sheet and triage tool
Provide information slowly, assessing the patient’s comprehension, anxiety and distress throughout the process
Do you have any doubt about the patient/carers 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.

31. 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 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.

32. 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

33. Step 4 Look back at your Log Sheet
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?

34. 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.

35. Review the log sheet GREEN
Was this the correct advice? If not is any action / training needed now?
1 AMBER
Call the patient to assess if they are improving or not?
2 AMBER or RED
Follow the patient: were they admitted or not?
Was the patient asked to attend for assessment ? If so please follow instruction below:
Admitted - find them and check management.
Discharged - call to see if they are improving.
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 filed in the patients medical records/EMR

36. Additional information
The tool has been piloted in its present format and should not be amended or adapted without the express permission of the UKONS board.
There are new and novel drugs on the market that have a protracted side effect profile, please be careful when providing advice for this group of patients.

37. Governance and responsibility
The 24 Hour Triage tool is a guideline and should be approved for use according to the user organisations governance and approval process
The tool is a guideline which makes recommendations for best practice, these are not binding and should be seen as suggestions and or advice, they do not replace clinical judgment or remove autonomy
Neither UKONS nor authors bear any responsibility for the use of the tool
RCP developing concise guidelineshttps://

38. Competency Framework
The manual contains a competency assessment document linked to the national key skills framework that should be completed for all those who undertake UKONS triage and assessment.
It is recommended that this assessment be repeated annually to ensure that competency is maintained.

39. Audit
Please ensure that all copies of Log sheets are retained safely for audit and clinical governance purposes.
Information may be entered onto a data base.

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Factors to consider when implementing the Toolkit in your health service
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. 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.

41. Thank You For Listening41
Thank You For Listening