Transcript In`s and Out`s of Neutropenia Inpatient and Ambulatory Carex

WELCOME
TO THE
NEUTROPENIA
SIG!
AGENDA
Introductions
Approve
2015 Congress Minutes
Presentation:
“In’s and Out’s
of Neutropenia: Inpatient and
Ambulatory Care
NEUTROPENIA SIG LEADERS
 Barbara
 Allison
J. Wilson, Coordinator
Streeter, Coordinator- Elect
 Alison
Gardner, Newsletter Editor
 Nancy
Corbitt, Virtual Community Adm.
 Janet
Cogswell, Ex-Officio
NEUTROPENIA:
INPATIENT AND
AMBULATORY CARE
Presented by
Allison Streeter, BSN, RN, OCN®
Mid Dakota Clinic, Bismarck, ND
Barbara J. Wilson, MS, RN, AOCN®,
ACNS-BC
WellStar Regional Medical Center, Marietta,
FINANCIAL DISCLOSURE
Barbara J. Wilson, RN, MS, AOCN, ACNSBC
 Nurse
Speakers Bureau for AMGEN,
Genentech, TEVA
 Will not be discussing off-label use
 Contact information: [email protected]
Allison Streeter, BSN, RN, OCN
 Nothing to disclose
OBJECTIVES
 Explain
the rationale for conducting
a risk assessment for neutropenia
prior to each chemotherapy cycle.
 Identify three patient risk factors for
developing infection during
chemotherapy induced neutropenia.
 Identify handwashing and bundled
care for central venous catheter care
as evidence based interventions
recommended to reduce infections.
Evidence
Based
Resources
•
•
•
ONS, 2014
CDC
NCCN
ONS
INCIDENCE OF INFECTION IN
CANCER PATIENTS
Approximately
50% of patients
with solid tumors
Approximately 80% of patients
with hematologic malignancies
60,000 patients will be
hospitalized this year for
infection
CDC, 2015
 1 of 14 will die
RISK ASSESSMENTS
Prevention and Treatment of
Cancer-Related Infections
 National
Comprehensive Cancer
Network (NCCN, 2016)
Prevention of Infection
 Oncology
Nursing Society “Putting
Evidence Into Practice (PEP): A
Pocket Guide to Cancer Symptom
Management” (ONS, 2014)
IT ALL STARTS WITH
PREVENTION!
Comprehensive
Risk Assessment
 Patient
 Disease
 Treatment
 Regimen
NCCN, 2016
PATIENT RISK FACTORS
 Age
> 65 years, Female gender, Low
BMI
 Comorbidities: cardiovascular, liver or
renal disease
 Lab abnormalities:
 Increased LD, Bili, Alk Phos
 Decreased Hgb, Albumin
 Poor performance or nutritional status
 Active infection or open wound or recent
surgery
DISEASE BASED FACTORS
 Advanced
stage of disease
 Bone marrow involvement
 Type of cancer: hematologic,
lymphoma, lung, breast, colorectal,
ovarian
 Specific genotypes
 History or presence of neutropenia
TREATMENT BASED
FACTORS
 Myelosuppressive
therapy
 Curative treatment goal
 Relative Dose Intensity (RDI) goal >85%
 Some medications (immunosuppressive)
 Regimen intensity:
high dose
 dose dense
 myeloablative

REGIMEN RISK
High: ANC <500 for > 10 days
Acute leukemia induction or
consolidation
Allogeneic HCT
Intermediate: ANC <500, 7-10 days
Autologous HCT
Chemotherapy w/ purine analog
Multiple myeloma, CLL, lymphoma
Low: ANC<500, < 7 days
Standard treatment for most solid
INPATIENT & OUTPATIENT
 Educate
staff, patients, family to
standardize practices
 Use teach back strategies
 Individualize information / resources
 Develop evidence based policies
 Adhere to established policies
 Address inconsistencies/
noncompliance
 Reward best practices
PREVENTING INFECTION
STRATEGIES
 Personal
Care
 Vaccinations
 Antimicrobials
 Growth factors
 Medical / care setting strategies
 Environment
 Life style risks
PERSONAL CARE TO MINIMIZE
INFECTION RISK
 Hand
Hygiene: Before eating, after using
bathroom or shaking hands
 Oral
Care: Soft toothbrush, non-alcohol
mouthwash, rinse often
 Bathing:
Daily, pat dry, moisturize
 Grooming:
Electric razors, careful nail/cuticle
clipping
 Women: Wipe front to back;
Avoid tampons or douche
 Safe
Sex
PERSONAL CARE CONT.
 Avoid
crowds
 Avoid people with colds,
infections or open sores
 Wear sunscreen
 Avoid gardening
 Avoid rectal thermometers,
suppositories, catheters
 Proper diet
 Exercise/Rest balance
HOUSEHOLD CARE
 Safe
Food Handling
 Remove shoes when entering home
 Avoid animal eliminations
 Water as mold potential
Ice
machines, denture cups, water
retaining toys, bird fountains, vases,
humidifiers, etc.
 Staff
sick!
members- stay home when
VACCINATIONS AFTER HCT
 4-6
months for Influenza
 6-12
months for DTaP, Hib, HepA,
HepB, Meningococcal, and Pneumoccocal
13
 >12
months for Pneumoccocal 23
 >24
months for MMR or Zoster

only if no GVHD or ongoing
immunosuppression & pt is seronegative
NCCN, 2016
VACCINATIONS
 Influenza:
 TDaP/Td:
 HPV:
Yearly, only inactivated
One dose then booster every 10 yrs
3 doses through age 26
 Pneumococcal:
Complete 3 doses of Prevnar
13 then have one dose of Pneumovax 23
 Meningococcal:
1 dose if other risk factors
present
 Polio:
standard for children, not routine
adults
CDC, 2016
VACCINATIONS CONT.
 HiB:
post HSCT recipients only
 Hepatitis A: 2 doses only if necessary
 Hep B: HCT recipient & donor
candidates
 Zoster (live): 3 months after
chemotherapy
 Measles, Mumps & Rubella (MMR) &
Varicella (live): 3 months after chemo
 Yellow fever (live): endemic areas only
PROPHYLACTIC ANTIBIOTICS
Recommended
for patients expected
to have prolonged severe
neutropenia.
Flouroquinolones are recommended

Levofloxacin and ciprofloxacin have been
evaluated to most.
(NCCN, 2016)
PROPHYLACTIC
ANTIFUNGALS
Primary prevention
Recommended
for adults and
children when prolonged severe
neutropenia is expected
HCT
 chronic steroids

COLONY STIMULATING FACTORS
(CSFS)
CSFs
reduce risk of febrile
neutropenia
Comparison of prophylactic vs
reactive pegfilgrastim by (Flores
& Ershler, 2010)*
852 pts age >65 years
 Solid tumors FN reduced by 60%
(p=0.0001)
 NHL FN reduced by 59% (p=0.004)

CSF PRIMARY PROPHYLAXIS
 16%
reduction in neutropenia related
hospitalization



SEER data analysis in 2011 (Rajan, et al)*
Duration of neutropenia
Infection rate
Medical Care, 49, 649-657
CSF SECONDARY PROPHYLAXIS
Previous
febrile neutropenia
IV antibiotics
Dose reductions below
therapeutic threshold
Potential for life-threatening
infection in the next treatment cycle
NCCN, 2016
COLONY STIMULATING
FACTORS
 No


outcome difference in formulations
Filgrastim (Neupogen, Zarxio, Granix)
Pegfilgrastim (Neulasta, Leukine)
 Demonstrated
effectiveness to
stimulate WBCs to prevent infection
 Timing: <14 days before next tx or
>24hrs after
OUTPATIENT SPECIFIC
APPOINTMENTS
 Screen
for potentially infectious patients
 Educate patients to call ahead if they
have symptoms of infection
 If appointment is non-urgent, reschedule
 Involve registration staff to expedite
getting patient to private room / area
 Minimize contact with other patients
 Develop policies with ED to fast track
patients
CONTACT PRECAUTIONS
When patient presents with:
 stool incontinence
 loss of skin integrity: rash, wounds
 secretions not contained
Separate from other patient
 Hand hygiene, wear gloves
 Disinfect environment
CDC
DROPLET PRECAUTIONS
Implement for known & suspicious
cases
 Place patient in separate room with
door closed upon arrival
 Wear mask, face shield, goggle, gown
as warranted by exposure
 Assist patient with proper fit of
mask prior to leaving the room
CDC
PREVENTING CATHETER
RELATED INFECTIONS
 Aseptic
technique for peripheral IV starts
 Cleanse skin with >0.5% chlorhexidine
w/alcohol (insertion and dressing change)
 Use sterile dressing w/o ointment at site
 Bundle care for Central lines:






Hand hygiene
Chlorhexidine prep
Hub/cap care
Sterile barrier during insertion
Remove if not necessary
Avoid femoral/jugular access sites
(ONS, PEP 2014)
CHANGING POLICIES AND
PRACTICES
Locate
and work with others
Use the evidence
Educate!

Patients, family, staff, community,
students
CHANGING POLICIES AND
PRACTICES
 Update
policies and reference
evidence –based sources
 Monitor for adherence to practice
 Use “Journal Club” format
 Start small with trial or pilot
QUESTIONS?