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South West Nova District Health Authority Policy & Procedure TITLE: Febrile Neutropenia in Cancer Patients Effective Date: January 2015 NUMBER: 800.750 Page (1 of 3) Applies To: Nursing POLICY 1. Chemotherapy induced febrile neutropenia is the most common complication related to cancer therapy, and is a potentially life threatening medical emergency (CTAS 2). Guidelines for the medical management of febrile neutropenia in cancer patients have been developped by Cancer Care Nova Scotia to ensure cancer patients receiving chemotherapy receive treatment based on best practice guidelines when they present to emergency departments with cancer and fever. 2. The Oncology RN will provide verbal and written education to all cancer patients, receiving chemotherapy in SWH, on what to do if they develop a fever of 38°C or above or uncontrolled shivering. Patients and/or their caregiver must be aware of the risk of fever and act promptly when a fever is detected. 3. All cancer patients receiving chemotherapy in Nova Scotia receive a “Fever in a Cancer Patient” instruction and treatment recommendation yellow card (see Exhibit A) and education providing direction on how to use the card in the event they develop a fever. The patient should keep the card readily accessible. 4. The Oncology RN will instruct the cancer patient should they have a fever to come to the Emergency Department, present the “Fever in a Cancer Patient” card upon arrival, and let the emergency room physician know when he/she received the last chemotherapy treatment. 5. The Emergency Department staff will triage and do a complete assessment of the cancer patient presenting with fever based on the instructions on the “Fever in a Cancer Patient” card 6. All medications and diagnostic tests on the “Fever in a Cancer Patient” instruction card require a written physicians order. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server file version prior to use . Page 2 of 3 Exhibit :A Fever in a Cancer Patient Solid Tumour, Hematology, Stem Cell Transplant Instructions for Patients: This card is ONLY to be used when you have a fever. If your temperature is 38C (100.4 F) or higher: Do not take any medications to lower your fever, like acetaminophen or ibuprofen. Go to your local Emergency Department right away and give this card to the Emergency staff. o This card alerts Emergency Department staff that you are a solid tumour, hematology or stem cell transplant patient with a fever, and needing treatment within 60 minutes. o Although your care is a priority, you may still have to wait while other patients, with more urgent concerns, are treated. During the next business day, call your cancer doctor/nurse and tell them you have been seen in the Emergency Department. _________________________________________________________________________ Instructions for Emergency Department Staff: 1 This patient has cancer and is febrile. Febrile Neutropenia1 is a medical emergency (CTAS Level II). Patient is to be assessed and receive their first dose of antibiotics within 60 minutes of presentation. The patient does not need to be isolated At Triage: CBC (to be drawn within 10 minutes and sent as STAT). Blood Cultures: 2 sets (1 set = aerobic + anaerobic). ▪ If the patient has a central line: 1 peripheral set and 1 central set. ▪ If patient does not have a central line: 2 peripheral sets from different sites. Obtain electrolytes, BUN, Cr, urinalysis and urine C&S, chest x-ray. Other investigations as clinically indicated. Febrile Neutropenia is defined as a single oral temperature ≥38.3C (101F) or >38C (100.4F) for more than 1 hour, and an absolute neutrophil count <0.5 x10 9/L (500 cells/microlitre), or expected to fall below 0.5 x109/L (500 cells/microlitre). Instructions for Emergency Department Staff: Management of Febrile Neutropenia If the patient’s temperature is <38C when they present to Emergency Department, but they have recorded temperatures at home >38C, they should still be considered febrile. 1. If patient is febrile and neutropenic, initiate broad spectrum antibiotics within 60 minutes, Pipericillin-Tazobactam 3.375g IV q6h. Or, if the patient has a penicillin allergy: Ciprofloxacin 400 mg IV q12h and Vancomycin 1g IV q12h. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server file version prior to use . Exhibit :A Page 3 of 3 2. If the patient appears unwell (e.g: rigors, hypotension, etc), or lab results are delayed, give the first dose of antibiotic(s) before the blood work results are back. 3. High-risk febrile neutropenia patients require admission. After the physician has completed the assessment and administered the first dose of antibiotics, admit the patient to the appropriate service. 4. Low-risk febrile neutropenia patients may be treated as outpatients (refer to the CCNS Oncologic Emergencies Guidelines to review low risk criteria and treatment guidelines). 5. The patient’s Medical Oncologist/Hematologist and treating cancer clinic should be advised of the patients visit to the Emergency Department and their current status. Produced by Cancer Care Nova Scotia, August, 2014 For more information, refer to the CCNS Oncologic Emergencies Guidelines www.cancercare.ns.ca REFERENCES Cancer Care Nova Scotia (2014). Guidelines for the Management of Oncologic Emergencies in Adult Patients-Full Version. ©Crown copyright, Province of Nova Scotia. Retrieved at: http://www.cancercare.ns.ca/sitecc/media/cancercare/full%20version%20document%20revision%20july%2022.pdf This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server file version prior to use .