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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?