Intravesical BCG clinical care pathway

Transcription

1 Intravesical BCG clinical care pathway

2 Acknowledgments The WA Cancer and Palliative care Network wish to recognise Fremantle Hospital for their collaboration in the development of this document. Disclaimer All information and content in this material is provided in good faith by the Department of Health, Western Australia and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the Department of Health, Western Australia and their respective officers, employees and agents, do not accept legal liability or responsibility for the material, or any consequences arising from its use. The Local implementation, training and evaluation of clinical staff remains the responsibility of the employee authority.

3 Intravesical BCG clinical care pathway explanatory notes Intravesical therapies are the mainstay of treatment for non-muscle invasive bladder cancer. BCG, including maintenance treatment is the current gold standard for high risk disease, though optimal regimes remain undefined. This care pathway was developed to assist in the delivery of intravesical BCG induction and maintenance treatment by providing clinicians and nursing staff with a clear framework for treatment delivery utilising best practice principles. 1, 2 The diagram below is a 12 month schedule for BCG induction and maintenance with suggested cystoscopic surveillance. It fulfills current guidelines for BCG and maintenance administration though other maintenance schedules exist. 3, 4 Induction BCG treatment Week Maintenance Month GA cystoscopy and biopsy Flexible cystoscopy Flexible cystoscopy GA cystoscopy and biopsy Patients should be screened to exclude urinary tract infection prior to commencing each cycle of BCG, as per shown in the algorithm on page 3. Once clearance to proceed has been obtained, regular surveillance cystoscopies should be undertaken during maintenance regimes, and this should be documented in the scheduling chart shown on page 4. 1

4 Intravesical Bladder Cancer Aims of Intravesical BCG clinical are pathway The patient will receive Intravesical therapy at weekly intervals with managed side-effects and a cystoscopy performed at defined intervals Risk factors Any urinary bladder operation (eg. TURBT), cystoscopy +/- biopsy performed within last 2 weeks Using the Clinical Pathway The Clinical Pathway is a guide that should be altered to meet the patient s needs as required Record and code variations from the pathway on the variance page. If required, variance documentation may be expanded further in the integrated notes Complete the signature register only on the FIRST occasion of caring for the patient Signature register Print Name Initial Desig Print Name Initial Desig 2 Fremantle Hospital & Health Service Permission to use

5 Algorithm Clearance to proceed algorithm Urine M/C/S (MSU) form given by nurses for collection at hospital pathology on the Monday prior to intravesical commencing. Treatment area nurse to review MSU results day prior to intravesical treatment day. MSU - Scanty, Light Growth or Mixed organism. Leukocytes less than 100 x 10^6/L. No Yes Is this result following a repeat MSU? No Treatment cannot proceed Repeat MSU Inform patient Record variance. Severe LUTS*. Contact Urology Registrar to consider dose reduction or repeat MSU. Treatment may proceed at reduced dose. Yes MSU - no growth & may include: Isolated pyuria Contaminants. No symptoms to mild/moderate LUTS*. Treatment can proceed. MSU - moderate to heavy growth. Treatment cannot proceed. Contact Medical Officer. Inform patient to see GP for antibiotic therapy and not to come in for the intravesical treatment. Arrange a repeat MSU 3 days post completion of antibiotics. Record variance. Inform booking clerk of treatment delay. Is this 3 rd positive MSU? Yes Stop pathway. Contact Urology Registrar or Urology Consultant for management plan. No * LUTS Lower Urinary Tract Symptoms MEDICAL Medical Officer to review MSU growth results & sensitivities, and contact Microbiologist or Infectious Diseases physician for further clarification of urine culture and susceptibility results if required. Contact GP to organise antibiotic therapy and repeat MSU. 3

6 Cystoscopy Scheduling Chart Cystoscopy Date Range Required Date Request Sent GA cystoscopy/ biopsy (Post Induction) Flexible cystoscopy (First) Flexible cystoscopy (Second) Flexible cystoscopy (Third*) GA cystoscopy/ biopsy (Post maintenance completion) Recorded on cystoscopy booking form Recorded on cystoscopy booking form Recorded on cystoscopy booking form Recorded on cystoscopy booking form Recorded on cystoscopy booking form *Determined by length of time of the maintenance course. Date Procedure Scheduled Patient informed Patient informed Patient informed Patient informed Patient informed Signature High Grade Non-muscle Invasive Bladder Cancer patients require a follow up General Anaesthetic (GA) cystoscopy and bladder biopsy at a minimum of two weeks post therapy. These should take place following completion of the induction course and then following completion of the maintenance course. High Grade Non-muscle Invasive Bladder Cancer patients on maintenance intravesical therapy require follow up flexible cystoscopy third monthly. Ongoing cystoscopy surveillance thereafter is to be determined by the patient s Urologist. 4

7 Induction treatment This pathway is a guide and should be altered to meet the patients needs as required Category 1 Education & Discharge Planning Pre Admission and patient understands UTI symptoms, MSU collections and GP follow up of abnormal results with antibiotics explained BCG patient handout Bladder cancer information booklet. Patient aware cystoscopy/biopsies will be carried out post induction; third monthly whilst receiving maintenance; and on completion of maintenance. 2 Consults Nursing admission complete Medical admission complete Consent signed 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management Week 1 of 6 Educated on follow up arrangements and bookings algorithm completed and charted (pages 14 and 15) Date instillation given 6 Diet & Hydration and fluids 7 Hygiene Education provided on Chlorhex wash Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages technique - sitting to void and double flush tablet after toileting technique (sit to void and Signatures Medical Allied Health Nurse AM PM AM PM 5

8 Induction treatment This pathway is a guide and should be altered to meet the patients needs as required Category Week 2 of 6 1 Education & Discharge Planning 2 Consults Educated on follow up arrangements and bookings Week 3 of 6 Educated on follow up arrangements and bookings 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management algorithm completed and charted (pages 14 and 15) Encourage oral fluids algorithm completed and charted (pages 14 and 15) Encourage oral fluids 6 Diet & Hydration 7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages Signatures Medical Allied Health Nurse AM PM AM PM 6

9 Induction treatment This pathway is a guide and should be altered to meet the patients needs as required Category Week 4 of 6 1 Education & Discharge Planning Educated on follow up arrangements and bookings Week 5 of 6 Educated on follow up arrangements and bookings 2 Consults Refer to Pre-Admission Clinic for GA cystoscopy and biopsy Booking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management algorithm completed and charted algorithm completed and charted 6 Diet & Hydration 7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages Signatures Medical Allied Health Nurse AM PM AM PM 7

10 Induction treatment This pathway is a guide and should be altered to meet the patients needs as required Category Week 6 of 6 1 Education & Discharge Planning Educated on follow up arrangements and bookings 2 Consults GA cystoscopy and biopsy booking date recorded on Cystoscopy Scheduling Chart of this pathway 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management algorithm completed and charted 6 Diet & Hydration 7 Hygiene Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages Signatures Medical Allied Health Nurse AM PM 8

11 Maintenance treatment This pathway is a guide and should be altered to meet the patients needs as required Category Maintenance treatment: 1 of 10 1 Education & Discharge Planning Educated on follow up arrangements and bookings Maintenance treatment: 2 of 10 Educated on follow up arrangements and bookings 2 Consults Refer to Pre-Admission clinic for GA cystoscopy and biopsy Booking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management algorithm completed and charted (pages 14 and 15) algorithm completed and charted (pages 14 and 15) 6 Diet & Hydration 7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages Signatures Medical Allied Health Nurse AM PM AM PM 9

12 Maintenance treatment This pathway is a guide and should be altered to meet the patients needs as required Category Maintenance treatment: 3 of 10 1 Education & Discharge Planning Educated on follow up arrangements and bookings 2 Consults Flexible cystscopy booking date recorded on Cystoscopy Scheduling Chart of this pathway 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management algorithm completed and charted (pages 14 and 15) Maintenance treatment: 4 of 10 Educated on follow up arrangements and bookings algorithm completed and charted (pages 14 and 15) 6 Diet & Hydration 7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages Patient educated on safe bleach tablet usage post toileting Patient educated on safe bleach tablet usage post toileting Signatures Medical Allied Health Nurse AM PM AM PM 10

13 Maintenance treatment This pathway is a guide and should be altered to meet the patients needs as required Category Maintenance treatment: 5 of 10 1 Education & Discharge Planning Educated on follow up arrangements and bookings 2 Consults Refer for flexible cystoscopy Booking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management algorithm completed and charted Maintenance treatment: 6 of 10 Educated on follow up arrangements and bookings Proposed flexible cystoscopy Booking date recorded on Cystoscopy Scheduling Chart of this pathway algorithm completed and charted 6 Diet & Hydration 7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages Signatures Medical Allied Health Nurse AM PM AM PM 11

14 Maintenance treatment This pathway is a guide and should be altered to meet the patients needs as required Category Maintenance treatment: 7 of 10 1 Education & Discharge Planning 2 Consults Educated on follow up arrangements and bookings Maintenance treatment: 8 of 10 Educated on follow up arrangements and bookings 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management algorithm completed and charted algorithm completed and charted 6 Diet & Hydration 7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages Signatures Medical Allied Health Nurse AM PM AM PM 12

15 Maintenance treatment This pathway is a guide and should be altered to meet the patients needs as required Category Maintenance treatment: 9 of 10 1 Education & Discharge Planning Educated on follow up arrangements and bookings 2 Consults Proposed GA cystoscopy and biopsy booking date recorded on Cystoscopy Scheduling Chart of this pathway 3 Investigations & Clearance to Proceed 4 Treatment & Assessment 5 Medications & Pain Management algorithm completed and charted Maintenance treatment: 10 of 10 Educated on follow up arrangements and bookings Refer to Pre-Admission clinic for GA cystoscopy and biopsy Booking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway algorithm completed and charted 6 Diet & Hydration 7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash 8 Elimination & Safety Special Needs & Team Messages Signatures Medical Allied Health Nurse AM PM AM PM 13

16 Integrated Report The variance report should record any unexpected variations to care. s should be reviewed regularly as part of local clinical Governance process. Date & Time Pathway Day Description & Action Taken Positive/ Negative Code Signature 14

17 Integrated Report Date & Time Pathway Day Description & Action Taken Positive/ Negative Code Signature Code A Patient Code B Clinical Code C Hospital Code D Community A1 Suspicion of bladder perforation A2 Allergic reaction A3 Poor tolerance of intravesical agent B1 Medical decision C1 Delay in test results D1 Delay in transport availability B2 Altered dose of intravesical agent B3 Altered frequency of intravesical agent C2 Delay in OR/ Procedure C3 Cancellation of procedure A4 Unable to catheterise B4 Other C4 Other D4 Other A5 MSU positive growth delaying treatment A6 Taken off pathway A7 Pre treatment MSU not provided A8 Other D2 Delay in home care/ community/ family support D3 Equipment/ supplies not available 15

18 16 Notes

19 References 1. Department of Health, Western Australia. Guidelines for the administration of intravesical cytoxic and immununotheapeutic drugs within the hosiplta setting. Perth: Healthnetworks Branch, Department of Health, Western Australia; British Association of Urological Nurses (BAUN) Section of Oncology (2005) Guidelines for the administration of Intravesical therapies. Bathgate, UK: Fitwise Management Ltd. 3. European Association of Urology (2010) Guidelines on Non Muscle Invasive Baldder Cancer. Accessed online 7/1/11 < bladder%20cancer% pdf> 4. Lamm, D, et al. Clinical Practice recommendations for the management of non-muscle invasive bladder cancer. European urology supplements 7 (2008) : Elsevier

20 This document can be made available in alternative formats on request for a person with a disability. HP11926F JAN 11 Department of Health 2011