GUIDELINE FOR THE MANAGEMENT OF SUSPECTED NEUTROPENIC SEPSIS INDUCED BY CYTOTOXIC THERAPY

Transcription

1 GUIDELINE FOR THE MANAGEMENT OF SUSPECTED NEUTROPENIC SEPSIS INDUCED BY CYTOTOXIC THERAPY This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. Introduction This guideline refers to the management of chemotherapy induced suspected febrile neutropenia. It encompasses the pathway of care to follow when a patient over the age of 16 who has received chemotherapy in adult services presents to Worcestershire Acute Hospitals NHS Trust. This policy refers to all patients over the age of 16 who have received chemotherapy in adult services within the last 6 weeks presenting to Worcestershire Acute Hospitals NHS Trust. This guideline is for use by the following staff groups: This guideline is for utilisation by trained medical and nursing staff. Educational updates will be provided for medical and nursing staff. Lead Clinician(s) Mrs S Sharp Mrs S Toland Dr J France Dr S Shafeek Chemotherapy/Radiotherapy Project Nurse Lead Chemotherapy Nurse Emergency Medicine Consultant (A&E) Haematology Consultant/CD FOR Haematology/ Dr N Murukesh Dr C Price Dr C Irwin Dr C Catchpole Mrs A Jones Mrs A Harrison Consultant Medical Oncologist-AOS lead Consultant Medical Oncology Consultant Clinical Oncology Microbiology Consultant Acute Oncology Nurse Practitioner Matron for Chemotherapy and Radiotherapy; Countywide Lead Nurse for Palliative Care and End of Life WAHT-HAE-003 Page 1 of 22 Version 2

2 Guideline approved by Chemotherapy Action Group on: 18 th September 2015 Guideline approved by Chairman s action on behalf of Medicine Safety Committee on: 29 th September 2015 This guideline should not be use after end of: 29 th September 2017 Key Amendments made to this document: Date Amendment By Guideline approved by Clinical Effectiveness Committee Revised by Clinical Leads and approved Mrs S Sharp January 2009 December 2010 January 2011 August 2011 March 2012 April 2013 April 2015 by Medicines Safety Committee Doses revised by Lead Pharmacist Revised by Chemotherapy Project Nurse Revised and minor amendments to charts pages 4 &5 Revised and minor amendments on page 6 Revised with amendments on pages 4,5 & 8 Revised to reflect NICE Guideline (CG151) where clinically appropriate and agreed by accountable director Reviewed Clinical Leads. amendments for a further 2 years. Mrs S Sharp Mrs S Sharp Mrs S Sharp Mrs S Sharp Mrs S Sharp Mrs S Sharp Dr S Shafeek Mrs S Sharp Sept 2015 Reviewed by Clinical leads. Changes made and Mrs S Sharp resubmitted to appropriate committees Sept 2015 Agreed by Chemotherapy Advisory Group Mrs S Toland Sept 2015 Agreed on behalf of MSC Mr S Graystone WAHT-HAE-003 Page 2 of 22 Version 2

3 Contents: Section:- 1. Introduction 2. Definitions 3. Management of Suspected Neutropenic Sepsis Induced by Cytotoxic 4. Initial Assessment Pathway 5. Ongoing Management 6. Contact Numbers for Advice 7. References 8. Monitoring Tool 9. Appendix 1- Just in case pack 10. Appendix 2- Operational Arrangements for admission of Neutropenic patients to Worcestershire Acute Hospitals NHS Trust 11. Appendix 3- ED Neutropenic sepsis pathway 12. Appendix 4- Letter for GP/Medical notes 13. Appendix 5- Patient letter 14. Contribution List 15. Supporting Document 1 - Equality Impact Assessment Tool 16. Supporting Document 2 - Financial Impact Assessment WAHT-HAE-003 Page 3 of 22 Version 2

4 Guideline for the Management of Suspected Neutropenic Sepsis Induced by Cytotoxic 1. Introduction This policy refers to the management of chemotherapy induced suspected febrile neutropenia. It encompasses the pathway of care to follow when a patient over the age of 16 who has received chemotherapy in adult services presents to Worcestershire Acute Hospitals NHS Trust. 2. Definitions Neutropenic sepsis is defined as a patient who is having anticancer treatment and:- Fever: - A single oral temperature of 38.0 C Neutropenia:- A neutrophil count of <0.5x10 9 /l or less or a neutrophil count <1.0x10 9 /l and predicted to fall. And/or Other signs or symptoms consistent with clinically significant sepsis (NICE 2012) However in practice any chemotherapy patient presenting with a sustained fever of 37.5 and a neutrophil count of <1.0x 10 9 /l or who had chemotherapy within the last 6 weeks which on a regular basis is causing severe neutropenia irrespective of the current neutrophil count, should be treated as potentially presenting with a diagnosis of febrile neutropenia (Marshall E & Innes H 2008). It is important to note that fever may not be present or reach the defining levels for febrile neutropenia in a patient with severe sepsis or in septic shock (Dellinger RP et al 2008) It is vital to establish a robust clinical history as the possibility of neutropenic sepsis should be considered in any patient who presents clinically unwell and has received chemotherapy in the past 6 weeks or has a haematology malignancy. 3. Management of Suspected Neutropenic Sepsis Induced by Cytotoxic Chemotherapy induced neutropenia is a major dose limiting toxicity of systemic cancer chemotherapy and is associated with substantial morbidity, mortality and costs (Jeddi et al 2010); Mortality rates in adults range between 2 and 21% (NICE 2012).The incidence of infection rises as the neutrophil count decreases and is compounded by the rate of decline and the duration of neutropenia (Schimpff S 2001) The management of a patient who presents neutropenic and unwell is critical. As with all cases of sepsis, rapid recognition and administration of effective antimicrobial therapy is essential to prevent avoidable deaths (Rivers et al 2001; Mackenzie & Lever 2007) Febrile neutropenia is a time dependant medical emergency. Patients can deteriorate over a matter of hours with life threatening complications; it is recommended that intravenous antibiotics be commenced within the first hour of recognition of septic shock and severe sepsis (Kumar A et al 2006, Dellinger et al 2008).The publication of Chemotherapy: Ensuring Quality and safety (NCAG 2009) reflects this recommendation and a national standard of door to needle time of 1 hour for intravenous antibiotics for patients with suspected neutropenic sepsis has been established. WAHT-HAE-003 Page 4 of 22 Version 2

5 Referrals into the hospital should initially be after discussion with the advanced nurse practitioner (GPs or patients) or the relevant haematology / oncology consultant. In hours, all referred patients will be assessed in the appropriate environment dependent upon hospital site this maybe the ambulatory assessment unit on Laurel 3, Medical Assessment unit or A&E. Out of hours the patient will be assessed in A&E or MAU. Patients who are receiving chemotherapy at WAHNHST will have been provided with a chemotherapy alert card and an Emergency Just in case pack for Haematology and Oncology patients which includes an emergency prescription for patients presenting with suspected neutropenic sepsis to facilitate the prescribing of IV antibiotics within an hour. In the case of patients who are critically ill then these patients are best assessed initially in the resuscitation room of the emergency department (irrespective of time of day). All acutely unwell neutropenic patients should be managed in an area where a doctor is present and there is an ability to escalate care once that patient has had an initial assessment and treatment has been commenced. Escalation of care to the critical care team for a patient with a high PAR score or presenting critically unwell should be undertaken as soon as possible. The importance of the patient receiving IV antibiotics and other acute interventions within an hour irrespective of where the patient presents and is being managed should not be delayed by looking for a side room as this can be reviewed at a later stage, see appendix 2. There is an expectation that the Acute Oncology Team will be involved early on the care of patients who are potentially neutropenic. During the week 09:00-16:00 the Acute Oncology Team will endeavour to respond to calls to see potentially neutropenic patients within 15-30mins of them being informed of their arrival in the MAU or A&E. For oncology patients a healthcare professional with competence in managing complications of anticancer treatment should assess the patient's risk of septic complications within 24 hours of presentation to secondary or tertiary care. This should be based on presentation features and using a validated risk scoring system for example the Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients. Patients assessed as low risk of developing septic complications, consideration should be given to outpatient antibiotic therapy taking into account the patient's social and clinical circumstances and discussing with them the need to return to hospital promptly if a problem develops (NICE 2012) Haematology patients are exempt from MASCC scoring. Acute Myeloid Leukaemia Patients Patients with Acute Myeloid Leukaemia (AML) who are being managed with curative intent will be admitted from when they become neutropenic following chemotherapy (neutrophils <0.5x10 6 /l) until they are fit enough to be discharged and their neutrophils are recovering. Patients who do not wish to be admitted must be counselled on the risk of going home and have regular (>3xweek) review arranged. WAHT-HAE-003 Page 5 of 22 Version 2

6 4. Initial patient assessment pathway The following pathway demonstrates the proactive approach to the assessment and management required within the first 60 minutes of presentation ensuring compliance with the national standard for a patient with potential neutropenic sepsis. WAHT-HAE-003 Page 6 of 22 Version 2

7 PRESENTATION CONSIDER NEUTROPENIC SEPSIS IF: Chemotherapy in last 6 weeks or known haematological malignancy. Temperature >38 o C or <36 o C Clinically Unwell Rigors Cough Altered mental state ASSESSMENT OBSERVATIONS Temperature Pulse Blood Pressure Respiratory Rate Oxygen Saturations INVESTIGATION Identify possible sources of Infection e.g. lines URGENT FBC, U/E'S, CRP. Blood Cultures Urine Sample Swabs Consider CXR Stool sample MANAGEMENT DO NOT WAIT FOR NEUTROPENIA TO BE CONFIRMED Antibiotics within 60 minutes MEROPENEM 1G IV 8 HOURLY For patients with suspected penicillin allergy please refer to flowchart for prescribing in suspected neutropenic sepsis (Appendix 2) Contact on call Consultant Haematologist/Oncologist for advice Escalation of care to the critical care outreach team for patient with a PAR score of >3 WAHT-HAE-003 Page 7 of 22 Version 2

8 5. On-going Management Monitoring Day of Admission Patient at Risk Score Chart Where possible the patient should be admitted to a side room and barrier nursing instigated however this should not be a reason for the delay of first dose antibiotics Observations every 30 minutes until stable then 2 hourly for 4 hours then 4 hourly if stable. Even if observations stable condition should be checked as a minimum every hour as condition can deteriorate suddenly Acknowledge that classic signs and symptoms may be absent, if patient is afebrile may still be septic Ensure the acute oncology ANP has been informed of attendance/admission who has responsibility for ensuring the clinician with responsibility for the patients chemotherapy or on call consultant is aware of admission the same day Medications DAY 2 and beyond Patient at Risk Score Chart Observations four hourly if stable FBC, U&E s & CRP to be repeated daily until neutrophils>1 CRP to be repeated alternate days to establish trend, other blood tests to be repeated as clinically indicated Review by medical team and discuss with treating clinician or on call consultant regarding on-going management Discontinue any chemotherapy related medications on admission ensuring safe storage/disposal following discussion with pharmacy Establish a robust medication history including allergies and ensure all appropriate medications are prescribed and available. GCSF may be considered in profound neutropenia following discussion with treating clinician or on call consultant Do not recommence any chemotherapy related medications until discussed with treating clinician Antimicrobials Check U&E results prior to 2 nd dose of antibiotics, if renal insufficiency demonstrated urgently check with medical staff/pharmacy prior to proceeding and seek microbiologists advice if required. If clear focus of infection, liaise with microbiology prior to alteration of antibiotic regimen. Review any microbiology culture and sensitivities as become available and seek microbiologist s advice regarding changes to antibiotic treatment. Fluid Balance Monitor urine output hourly aiming for urine output of 0.5ml/kg/hour Intravenous fluids administered to maintain circulating volume If fever unresponsive at 48 hours or central line in situ consider 2 nd line antibiotics following discussion with microbiologists Liaise with microbiology regarding potential for viral/fungal infections Antibiotics should be reviewed after 48 hours, consider discontinuation as soon as infection appears to have resolved and blood cultures negative to reduce risk of clostridium difficile following discussion with treating clinician. Maintain 4 hourly fluid balance if condition stable. WAHT-HAE-003 Page 8 of 22 Version 2

9 6. Contact Numbers for Advice: Oncology Acute Oncology Service (Mon-Fri / ) Acute Oncology Nurses (Mon-Fri WRH Bleep 398 or 491 Alex Bleep ) Oncology Consultant On-call (24 hours) Via Switchboard Haematology Haematology patient 24 hour contact number Haematology Consultant On-call (24 hours) Via Switchboard Haematology CNS (Mon-Fri ) Ext / Bleep References Dellinger RP, Levy MM, Carlet JM et al (2008) Surviving Sepsis Campaign: International Guidelines for the management of severe sepsis and septic shock: 2008 [published correction appears in Critical Care Medicine 2008, 36: ] Critical Care Medicine : Hughes WT, Armstrong D, Bodey GP et al. (2002) Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer. Clinical Infectious Diseases 2002; Jeddi R, Achour M, Amor RB et al (2010) Factors associated with severe sepsis: prospective study of 94 neutropenic febrile episodes Hematology (1) Kumar A, Roberts D, Wood K et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock Critical Care Medicine 34 (6) Mackenzie I & Lever A (2007) Management of sepsis British Medical Journal Marshall E & Innes H 2008 Chemotherapy induced febrile neutropenia: management and prevention Clinical Medicine Vol 8 (4) National Chemotherapy Advisory Group 2009 Chemotherapy: Ensuring Quality and Safety Department of Health NICE 2012 Neutropenic sepsis: prevention and management of Neutropenic sepsis in cancer patients NICE clinical guideline 151 Rivers E, Nguyen B Havstad S et al (2001) WAHT-HAE-003 Page 9 of 22 Version 2

10 Early goal directed therapy in the treatment of severe sepsis and septic shock New England Journal of Medicine Schimpff S (Chap1) Textbook of Febrile Neutropenia Kenneth Rolston and Edward B Rubenstein (Eds) Martin Dunitz 2001 WAHT-HAE-003 Page 10 of 22 Version 2

11 8. Monitoring Tool Page/ Section of Key Document Key control: Checks to be carried out to confirm compliance with the policy: How often the check will be carried out: Responsible for carrying out the check: Results of check reported to: (Responsible for also ensuring actions are developed to address any areas of noncompliance) Frequency of reporting: WHAT? HOW? WHEN? WHO? WHERE? WHEN? All patients with suspected On-going door to needle On-going Acute Haematology/Oncology 4 times febrile neutropenia receive first dose antibiotics within 1 hour time audit Oncology Service directorate per year. WAHT-HAE-003 Page 11 of 22 Version 2

12 9. APPENDIX 1- Just in Case Pack Emergency Just in Case Pack for Haematology and Oncology Patients ONLY for use if an infection called neutropenic sepsis is suspected Your illness and/or your treatment mean that you are at high risk of infection. If you notice any of the symptoms below, you must contact the hospital straight away: If you have a temperature of 38 o C or above on any one occasion, (37 o C is normal) and/or Shivers or shakes (i.e. feeling hot or cold); generally feeling dreadful for no obvious reason; an ulcerated or sore mouth making drinking or swallowing difficult; severe vomiting or watery diarrhoea (more than 4-5 times a day); pain when passing urine; redness, discomfort, swelling, irritation or discharge from your injection site or PICC/Hickman line, unexplained rash. Emergency Contact Numbers If you feel unwell and need emergency advice Monday to Friday 9am 4.30pm, please call Outside these hours and at weekends please contact. (Please note: it may take a few minutes for your call to be answered). Please note this is an emergency line only and routine calls will not be dealt with. te: If you experience severe chest pain, difficulty in breathing, acute asthma attack, or sudden onset of stroke symptoms (such as face weakness, arm or leg weakness or speech problems) Dial 999 immediately for an emergency ambulance Remember to bring this pack with you. Please give it to the nurse so that your treatment can start as soon as possible. If neutropenic sepsis is suspected you should expect your antibiotics to be given within one hour of arrival to hospital. Please tell the staff, if you have taken Paracetamol within the previous 6 hours or are on steroids, as this can lower the temperature. Please note: In the event of you being asked to attend the Accident and Emergency Department, please show this pack to a member of staff and remind them that you must receive treatment promptly. Please note: This pack cannot be used after / / Please affix a patient label here WAHT-HAE-003 Page 12 of 22 Version 2

13 Contents of the Pack 1. A letter about your current illness and treatment. 2. Neutropenic Sepsis Pathway for the doctors and nurses to use. 3. Prescription for your first dose of intravenous antibiotics. te: Your antibiotics should be given within one hour of arrival to hospital. te: If you are admitted to this hospital and this pack is used, please contact the Acute Oncology Team on (Monday- Friday 9-4:30) so that arrangements can be made for it to be replaced WAHT-HAE-003 Page 13 of 22 Version 2

14 EMERGENCY ANTIBIOTIC PRESCRIPTION SHEET FOR HAEMATOLOGY/ONCOLOGY PATIENTS PRESENTING WITH SUSPECTED NEUTROPENIC SEPSIS Patient Details (apply label) te: This prescription sheet should be used for the initial management of suspected neutropenic sepsis. Please refer overleaf for summary of antibiotic prescribing guidelines for patients presenting with suspected neutropenic sepsis Known Drug Hypersensitivities: Yes / If yes, give details: Date recorded: Name: Signature: GMC/PIN: Weight: te: This weight has been recorded on the day of prescribing antibiotics. Please reassess if patient reports weight loss/gain ANTIBIOTIC PRESCRIPTION SHEET te: Please check with patient if any drug hypersensitivities have occurred since date of prescribing before administering drugs Date Prescribed Drug Dose Route Prescriber Date of Admin Specific Instructions: Signature: Name: GMC/PIN: Time of Admin Admin By: Date Prescribed Drug Dose Route Prescribers Details Name: Date of Admin Time of Admin Admin By: Signature: Specific Instructions: GMC/PIN: Date Prescribed Drug Dose Route Prescribers Details Name: Date of Admin Time of Admin Admin By: Signature: Specific Instructions: GMC/PIN: Prepared By: Checked By: Approved By: Version 1 This will be completed by the patient s oncology/haematology medical team and a process is in place to replace packs when used WAHT-HAE-003 Page 14 of 22 Version 2

15 FLOW CHART FOR PRESCRIBING OF FIRST LINE ANTIBIOTICS IN SUSPECTED NEUTROPENIC SEPSIS te: Please ensure peripheral (and central venous device if applicable) cultures are taken before starting antibiotics. A stool sample must always be taken before starting Clostridium Difficile treatment Does the patient have a penicillin allergy? Give MEROPENEM 1G 8 hourly IV BOLUS Yes te: GI symptoms do not, by themselves, constitute an allergic reaction to penicillins. Symptoms of allergic reactions may include erythema, puritis, angioedema, hypotension or shock, urticaria, rash, wheezing or rhinitis. An anaphylactic reaction (Type 1 hypersensitivity) occurs minutes after administration of penicillin. An accelerated allergic reaction occurs 1-72 hours after administration of penicillin Other Considerations Probable Central Venous Access Infection: Consider VANCOMYCIN 1g IV infusion 12 hourly. Perianal sepsis/abdominal pain: Consider adding METRONIDAZOLE 400mg TDS orally or 500mg TDS IV Diarrhoea/Possible Clostridium difficile associated disease: Consider empirical treatment with METRONIDAZOLE 400mg TDS orally (or VANCOMYCIN 125mg orally every 6 hours in case of severe infection) Always discuss with either the consultant haematologist or oncologist on call Patients WHO HAVE NOT HAD an anaphylactic or accelerated allergic reaction including delayed non urticarial rash: MEROPENEM 1G 8 hourly IV BOLUS Patients WHO HAVE HAD an anaphylactic or accelerated allergic reaction: VANCOMYCIN 1G IV infusion 12 hourly AND CIPROFLOXACIN 400mg IV infusion twice daily AND GENTAMICIN 5mg/Kg (estimated lean body mass) ONCE DAILY IV infusion (Maximum dose 560mg daily). One dose only should be prescribed For further information refer to the Guideline for Management of Suspected Neutropenic Sepsis Induced by Cytotoxic therapy (WAHT-HAE-003), Trust Antimicrobial Guidelines (on intranet) and the Product Information Literature for full details and dosing in renal impairment and hypotension. WAHT-HAE-003 Page 15 of 22 Version 2

16 10. APPENDIX 2 Operational Arrangements for admission of Neutropenic patients to Worcestershire Acute Hospitals NHS Trust The importance of the patient receiving IV antibiotics and other acute interventions within an hour irrespective of where the patient presents and is being managed should not be delayed by looking for a side room as this can be reviewed at a later stage. The important issue is the acute management and treatment of the patient with potential Neutropenic Sepsis, ensuring all acute interventions are carried out as quickly as possible. Once these have been undertaken a discussion can be undertaken as to whether the patient should be nursed in a side room. Patients who are neutropenic (neut <1.0) and are admitted to a Worcestershire Hospital as an emergency should ideally be nursed in a side-room (non-negative pressure) but may be nursed temporarily in a bay with other patients (and must be isolated at earliest opportunity) while waiting for a side-room if: There are no side-rooms available Available side-rooms are not felt to be suitable by the admitting team for example: o Patient has complex or specialist nursing/care needs that can only be delivered in a certain ward/area e.g. CCU, ITU o Patient is very unwell and available side-room is in a ward where the staff do not have the skills to nurse the patient, or the room is remote and does not allow for easy patient observation The bay does not contain patients with active transmittable infection If there are several neutropenic patients waiting for side-rooms the following should be the priority: 1. Profound neutropenia following chemotherapy (a neutrophil count of less than 0.5) 2. Neutropenia following chemotherapy (a neutrophil count of between 0.5 and 1.0) 3. Chronic non-chemotherapy related neutropenia If there are patients without a haematological diagnosis in Laurel 3 then they should ideally be moved to allow haematology patients with neutropenia to be admitted to Laurel 3. WAHT-HAE-003 Page 16 of 22 Version 2

17 11. APPENDIX 3. ED Sepsis Pathway WAHT-HAE-003 Page 17 of 22 Version 2

18 12. Appendix 4: Letter for GP / Medical tes Worcestershire Acute Hospitals NHS Trust Dear Dr. Date: Re: Chemotherapy Drugs: Your patient is due to commence cytotoxic chemotherapy under the care of. (Consultants name and place of work), on Chemotherapy can cause serious side effects and when these occur they require prompt treatment. The most serious side effect of chemotherapy is infection and the most usual time when this occurs is 7 to 10 days after the start of the most recent course of treatment. However, it must be considered in any patient who has received chemotherapy in the last 6 weeks. If your patient experiences any of the following symptoms they should contact the hospital straight away for advice and to arrange a current, urgent, full blood count: Fever / temperature Any sign of infection Shivers, shakes or flu like symptoms Excessive bruising or bleeding from anywhere Generally feeling dreadful for no specific reason Severe vomiting, diarrhoea or exhaustion If the blood count confirms neutropenia urgent admission for intravenous antibiotics may be appropriate. This can be life saving when infection complicates significant neutropenia. The following oncology / haematology teams are available to offer advice, organise blood counts, or arrange patient admission to hospital: Appropriate Contact Details in working hours: Outside these hours contact: Thank you Signed: Name:. Title:... WAHT-HAE-003 Page 18 of 22 Version 2

19 13. Appendix 5: Patient Letter WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST PLEASE CARRY THIS LETTER WITH YOU AT ALL TIMES AND SHOW IT TO ANY HEALTHCARE PROFESSIONAL YOU ARE SEEN BY Dear (Patients name and date of birth) You are due to commence cytotoxic chemotherapy under the care of (Consultants name and place of work) On.. The chemotherapy drugs are as follows: Chemotherapy Drugs: Chemotherapy can cause serious side effects and when these occur they require prompt treatment. The most serious side effect of chemotherapy is infection and the most usual time when this occurs is 7 to 10 days after the start of the most recent course of treatment. However, it must be considered in any patient who has received chemotherapy in the last 6 weeks. If you experience any of the following symptoms you should contact the hospital straight away for advice and to arrange a current, urgent, full blood count: Fever / temperature Any sign of infection Shivers, shakes or flu like symptoms Excessive bruising or bleeding from anywhere Generally feeling dreadful for no specific reason Severe vomiting, diarrhoea or exhaustion If the blood count confirms neutropenia you may need to be urgently admitted for intravenous antibiotics. This can be lifesaving when infection complicates significant neutropenia. The following oncology/haematology teams are available to offer advice and can organise blood counts if required. Appropriate Contact Details in working hours: Outside these hours contact: Thank you Signed: Name:. Title:.... WAHT-HAE-003 Page 19 of 22 Version 2

20 14. CONTRIBUTION LIST Key individuals involved in developing the document Name Mrs S Sharp Mrs S Toland Dr J France Dr S Shafeek Dr N Murukesh Dr C Price Dr C Irwin Dr C Catchpole Mrs A Jones Mrs A Harrison Designation Chemotherapy/Radiotherapy Project Nurse - WRH Lead Chemotherapy Nurse Emergency Medicine Consultant Haematology Consultant WRH Consultant Medical Oncologist-AOS lead Medical Oncology Consultant Clinical Oncology Consultant Microbiology Consultant AOS Nurse Practitioner Project Matron for Chemotherapy and Radiotherapy Countywide Lead Nurse for Palliative Care and End of Life Circulated to the following individuals for comments Name Designation Dr N Pemberton Consultant Haematologist Dr F Clarke Consultant Haematologist Dr E Maughan Consultant Haematologist Dr T Skibbe Consultant Haematologist Dr J Mills Consultant Haematologist Dr M Crowther Consultant Haematologist Dr M Churn Consultant Clinical Oncologist Dr R Counsell Consultant Clinical Oncologist Dr A Hussain Locum Consultant Medical Oncologist Dr L Capaldi Consultant Clinical Oncologist Dr A Siva Consultant Clinical Oncologist Dr B Kurec Locum Clinical Oncologist Dr K Gupta Consultant Clinical Oncologist Ms V Rowlands Chemotherapy Unit Manager-Redditch Mrs R Desogus Chemotherapy Unit Manager Rowan Mr R Newman Laurel 3 manager Mr P James CNS Haematology Ms A Hawkes CNS Haematology Mr T Rees CNS Haematology Ms N Thompson Bone Marrow Transplant Coordinator Mrs A Sullivan Lead Cancer Manager/Macmillan Lead Cancer Nurse Mr A Makar Lead Cancer Clinician Mrs H O Connell Haematology/oncology directorate manager Mr M Squire Macmillan AO Nurse Practitioner Ms C Burton Acute Oncology Nurse Practitioner Mrs L Rowberry Matron for Haematology/Oncology-Inpatient Care and AOS Hassan Varachhia Pharmacist for Laurel 3 WAHT-HAE-003 Page 20 of 22 Version 2

21 15. Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? N/A N/A 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this key document, please refer it to Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Human Resources. WAHT-HAE-003 Page 21 of 22 Version 2

22 16. Supporting Document 2 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Title of document: 1. Does the implementation of this document require any additional Capital resources 2. Does the implementation of this document require additional revenue Yes/ 3. Does the implementation of this document require additional manpower 4. Does the implementation of this document release any manpower costs through a change in practice 5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff Other comments: If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval WAHT-HAE-003 Page 22 of 22 Version 2