rmo haematology handbook
TRANSCRIPT
RMO HAEMATOLOGY HANDBOOK Last updated: 12.01.2021
Contents
RMO HAEMATOLOGY HANDBOOK ...................................................................................................................................... 1
WELCOME FROM THE MEU ................................................................................................................................................ 4
MEU Contact Details ................................................................................................................................................ 4
INTRODUCTION ................................................................................................................................................................... 4
UNIT OVERVIEW ................................................................................................................................................................... 4
Term Supervisor ......................................................................................................................................................... 4
Consultants ................................................................................................................................................................ 4
RMO LEARNING OBJECTIVES ............................................................................................................................................ 5
RMO ROLE & RESPONSIBILITIES ......................................................................................................................................... 5
Ward Duties ............................................................................................................................................................... 5
Consultant Ward Rounds ........................................................................................................................................ 6
Clinic (Mccc) Duties ................................................................................................................................................. 6
Meetings ..................................................................................................................................................................... 6
Supervision ........................................................................................................................................................................... 7
ASSESSMENT AND FEEDBACK ........................................................................................................................................... 7
Assessment ................................................................................................................................................................. 7
Feedback ................................................................................................................................................................... 7
UNIT ORIENTATION .............................................................................................................................................................. 7
Orientation to the Ward .......................................................................................................................................... 7
Start of Term Checklist ............................................................................................................................................. 8
UNIT POLICIES AND PROCEDURES ................................................................................................................................... 8
Blood Products .......................................................................................................................................................... 8
General ...................................................................................................................................................................... 8
Special requests ........................................................................................................................................................ 9
Notes on routinely used blood products ............................................................................................................ 10
UNIT POLICIES & PROCEDURES ....................................................................................................................................... 15
Hours ......................................................................................................................................................................... 15
Sick Leave ................................................................................................................................................................ 15
Mater Policies and Procedures ............................................................................................................................ 15
Injured / Ill At Work .................................................................................................................................................. 15
Leave ........................................................................................................................................................................ 15
Kronos ....................................................................................................................................................................... 15
UNIT ROSTER & TIMETABLES .............................................................................................................................................. 16
APPENDIX 1 – TIPS & TRICKS ............................................................................................................................................ 18
Ward Duties ............................................................................................................................................................. 18
Admissions ................................................................................................................................................................ 18
Consults .................................................................................................................................................................... 18
Research .................................................................................................................................................................. 18
APPENDIX 2 – STANDARD WARD ROUND ...................................................................... Error! Bookmark not defined.
APPENDIX 3 - CHEMOTHERAPY ...................................................................................................................................... 19
General .................................................................................................................................................................... 19
Anti-Emetic Protocols ............................................................................................................................................. 19
Tumour Lysis Syndrome .......................................................................................................................................... 19
Chemotherapy Expiry: ........................................................................................................................................... 19
APPENDIX 4 - SAFE HANDLING OF CYTOTOXICS ......................................................................................................... 20
Work Areas And Practices: ................................................................................................................................... 20
Administration: ........................................................................................................................................................ 20
Patient Care ............................................................................................................................................................ 21
Waste ........................................................................................................................................................................ 21
Spills ........................................................................................................................................................................... 21
Discharge/Outpatient Medication Supplies ..................................................................................................... 21
Intrathecal Chemotherapy .................................................................................................................................. 22
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WELCOME FROM THE MEU
The Medical Education Unit would like to welcome you to this rotation. Please read this handbook in
conjunction with the RMO Orientation Handbook which is accessible on the MEU website via Zenworks or
http://mededu.matereducation.qld.edu.au/handbooks/
MEU Contact Details If you’re experiencing difficulty with any aspect of the term, clinical or otherwise, please contact the term
supervisor and/or PVMEO as early as possible.
Director of Clinical Training (DCT) Ph. 8229
Prevocational Medical Education Officer (PVMEO) Ph. 8431
Vocational Training Medical Education Officer (VTMEO) Ph.1560
Medical Education Admin Officer Ph. 8272
Medical Education Manager Ph. 8114
INTRODUCTION
Welcome to your haematology term at the Mater Hospital Brisbane. You will be exposed to a number of
malignant and non-malignant haematological conditions. We hope that you will enjoy and benefit from your
time with us. Feel free to refer to the Ward 10B NUM, Department Secretary, Advanced Trainee or the Consultants if you
have any further queries.
UNIT OVERVIEW
Our service offers inpatient clinical care including chemotherapy for acute haematological malignancies
primarily in ward 10B at the Adult’s Hospital, as well as outpatient clinics and chemotherapy for more chronic
conditions at the Mater Cancer Care Centre.
While the RMO’s role is primarily related to inpatient care, there will be opportunities to attend clinics at the
Mater Cancer Care Centre when a room is available.
Consultant ward rounds occur Monday, Wednesday and Friday mornings or occasionally on the afternoons if
the consultant is unavailable. Rounds on Tuesday and Thursdays will be undertaken by the Ward registrar and
resident.
Term Supervisor Dr Naadir Gutta
Consultants Dr Naadir Gutta, Dr Mohammed Shanavas, Dr Emma Taylor, Dr Mimi Yue, Dr Courtney Tate.
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RMO LEARNING OBJECTIVES
Knowledge
• Develop a broad understanding of the classification, staging investigations and treatment of malignant
haematological conditions including leukaemias, lymphomas and myeloma.
• Assessment and management of complications of treatment of malignant conditions including
o Appropriate transfusion
o Electrolyte imbalances
o Pain management (mucocytis, etc.)
o Febrile neutropenia
• Indications for, and principles of, autologous stem cell transplantation
• Indications for allogeneic transplantation
• Management of psychosocial aspects of disease (particular relevant to acute life threatening
malignancies).
• Investigation of cytopenias (anaemia, neutropenia and thrombocytopenia) and related conditions.
• Principles of managing veno-thromboembolic disease
• Interpretation of common tests including the full blood count and coagulation studies.
• Principles and indications for apheresis.
Skills and Procedures
• Lumbar puncture for CSF diagnostic purposes and for administration of chemotherapy.
• Venepuncture
• Bone marrow aspirate and trephine (not mandatory).
RMO ROLE & RESPONSIBILITIES
Ward Duties • Review and update inpatient flow sheet first thing in the morning. Pathology results should be reviewed
daily and should be entered into the unit flow sheet.
• See all patients early in the morning
o Liaise with nursing team leader to identify any issues from overnight and prioritise patients who
are most unwell.
o Order blood products and communicate special needs to the blood bank. Orders to be in
prior to 10:00 am).
o Identify and correct electrolyte abnormalities daily.
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• Communicate with allied health staff and request assessments as required/ directed by senior staff.
• Identify patient discharges early and where possible, have discharge scripts ready the day prior to
discharge.
• Order pathology (day before) and on Friday for the weekend, as directed by your registrar.
• Arrange and follow up radiological and other clinical investigations, consults, etc.
• Discharge summaries and clinical notes should be performed in a timely manner and outpatient follow up
appointments should be requested and communicated to patients prior to discharge.
• Booked admissions must be made through the 10B ward clerk. Patients are to only be admitted via the
Admissions Lounge or via MCCC – no direct admissions are allowed without separate approval by both the
10B NUM and the on-call Consultant. All patients are to be asked to arrive NO LATER than 1pm on the day
of admission.
Consultant Ward Rounds
• Ward rounds occur Monday, Wednesday and Friday
Clinic (Mccc) Duties • Attend clinic whenever possible and when a room is available. (Remember your priority is care of
haematology inpatients).
• You may be required to backfill registrars on occasion in the clinic.
Clinics occur on the following days and times:
• Tuesday and Thursday mornings – starting 8.00am;
• Tuesday afternoons – starting 1.00pm;
• Wednesday afternoon – starting 1.00pm;
• Monday and Friday afternoons – MCCC registrar clinics.
Meetings You are expected to attend and contribute to all Department meetings. These are as outlined in the
timetable but namely:
• attendance and participation at MDT meetings,
• attendance and participation at Wednesday 10AM meetings (per separate rosters)
• attendance at Friday Morphology meetings (fortnightly)
Other meetings exist and you have protected teaching time on Tuesday and Thursdays as outlined in the
Department Timetable.
Ask the Registrar to supervise you if you are not confident or need help with a particular task.
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Supervision
You report directly to the Registrar of the Unit – if he or she is unavailable (e.g., absent on sick leave), please
report to the relieving registrar. Your term supervisor can also be contacted at any time however but you are
encouraged to discuss cases with the Registrar of the Unit in the first instance. If further assistance is required,
you are able to contact the On-Call Consultant or your Term Supervisor. The hospital is also serviced by a MET
(Medical Emergency Team) for critical changes in condition.
ASSESSMENT AND FEEDBACK
Assessment It is the responsibility of the RMOs to seek a mid-term and end-of-term assessment with their term supervisor. If
you’re experiencing difficulty with any aspect of the term, clinical or otherwise, please contact the term
supervisor and/or medical education, early. The MEU will send out a reminder email with instructions to all
RMOs one week prior to all due dates. The assessment form can be accessed at any time from the Medical
Education Unit website via Zenworks or http://mededu.matereducation.qld.edu.au/cpd-requirements/all-
forms/
Your end-of-term assessment will reflect the expectations as outlined above but particularly:
• attendance at clinics and meetings,
• documentation – medical records and letters (clarity and timeliness),
• timely implementation of plans and investigations,
• discharge planning – discharge summary (on-time = <48h), discharge medications,
• reliable performance of hand hygiene and VTE prophylaxis on admissions.
There is also an optional self–assessment section located at the beginning of the assessment form, which you
are encouraged to complete and discuss with your supervisor. However if you wish to complete this
separately you can complete the RMO form Self-Assessment Form which is located on the Medical Education
Unit Website under the Assessment Forms tab.
Feedback Your clinical supervisor/s will provide regular written feedback regarding your progress via your assessment
forms, and verbal feedback on a daily basis. If you have concerns or would like more regular feedback, speak
to your supervisor in the first instance and the MEU if required. At the end of your rotation, you are required to
complete the end-of-term unit evaluation survey and provide valuable feedback on your supervision.
For more information regarding assessment and feedback, please refer to the RMO Orientation Handbook.
UNIT ORIENTATION
Orientation to the Ward The Term Supervisor or Ward On-call Consultant will conduct a face-to-face unit orientation with you on the
first 2 days of the term. The following areas will be covered:
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• reporting lines,
• daily roster
• unit policies and procedures,
• term learning objectives,
• discussion and documentation of your individual learning objectives for the term (see the 'term learning
plan' below),
• assessment,
• handover with the previous junior doctor,
• how daily clinical handover is conducted ,and
• miscellaneous (tour of the department, introductions to staff, etc)
• Start of term orientation checklist
Start of Term Checklist All RMOs complete the Start of Term Checklist with their Term Supervisor within the first week of a new term.
The checklist is completed online and the link is available on the Medical Education Unit website
(http://mededu.matereducation.qld.edu.au/cpd-requirements/all-forms/ ).
UNIT POLICIES AND PROCEDURES
Blood Products
General Blood is a precious resource and careful consideration is required when ordering and prescribing blood
products. It is your duty to consent patients for blood products and to order and prescribe these
appropriately.
1. All Mater inpatients require written consent for blood products. Consent should be sought for a maximum
(12 month) period for all haematology patients.
2. Cross matches need to be current for all patients who are anticipated to require transfusion because of
their underlying disease (e.g., MDS, myelofibrosis, bleeding patients) or because they are receiving
myeloablative chemotherapy.
Note: The laboratory enforces stringent collection standards to ensure that potentially fatal mistakes do not
occur because of incorrectly labelled samples. If you are collecting the blood yourself, please ensure that
o You have positively identified the patient;
o You have handwritten patient details (Full name and UR/DOB) on both the form and the tube
(pink);
o Both the form and the tube are signed.
3. When products are required you will need to contact the blood bank to order the products. Blood
products should be prescribed on a Transfusion administration chart and all transfusion orders should be
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relayed verbally to the Nurse in charge of the shift, so they can plan for the transfusion. Note: Routine
transfusion should occur during business/ daylight hours so if reactions do occur, senior staff are present to
help with this.
Special requests 1. Leucocyte filters
All blood products in Queensland are leuco-depleted; thus leucocyte filters are not routinely used for
transfusion.
2. Irradiated blood
Blood products can be irradiated to eliminate the risk of potentially fatal transfusion- associated graft vs
host disease. With relevance to our unit, the following patients should receive irradiated blood products.
o All patients with Hodgkin’s and Non Hodgkin’s Lymphoma during the course of therapy,
o All Acute leukaemia patients during therapy,
o All patients undergoing an autologous stem cell transplant (from 7 days prior to transplant
and to 3 months post-transplant),
o Patients planned for a allogeneic stem cell transplant (i.e. younger acute leukaemia
patients),
o Patients on purine analogue therapy (e.g., Fludarabone, Pentostatin, Cladribine and
Bendamustine),
o Aplastic anaemia on therapy,
o All patients on Alemtuzumab therapy, and
o ALL other patients on INTENSIVE chemotherapy regimens (anticipated neutrophil nadir of 0.5).
Check with your consultant.
1. CMV-negative products
Transfusion-associated CMV infection has declined drastically following universal leucodepletion. However,
CMV seronegative products should be requested in only specific circumstance which now do not
universally include patients with haematological malignancies. The indications include:
• Intrauterine transfusion.
• Preterm neonates (up to 28 days after expected date of delivery).
• Patients with Severe combined immune deficiency (SCID) who are CMV negative.
• Granulocyte transfusions for recipients who are CMV seronegative, or whose status is unknown.
• Cytomegalovirus-negative products are generally not required in other clinical settings
Premedication for blood products
This is not routine practice. Pre-medication could be considered in special circumstances where a patient has
mild ongoing transfusion-associated fevers or rash. This should be directed by a registrar or consultant.
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Premedication would include both an antihistamine (loratadine or phenergan) and steroid (hydrocortisone
I.V.).
Notes on routinely used blood products
1. Packed red cells
o Generally transfuse one unit at a time.
o As a general guide, most patients will tolerate Hb level > 80g/l without any major symptoms.
Special circumstances where you may consider transfusion at a higher Hb would include:
▪ Patients with heart disease: e.g., IHD (angina at lower haemoglobin levels) and severe
cardiac failure patients.
▪ Severe oxygen-dependent lung disease
▪ Elderly patients
o Consider frusemide (20mg IV) following transfusion in fluid overloaded and cardiac failure
patients.
2. Platelets
o 1 bag of platelets should be transfused at a time.
o General thresholds for transfusion:
▪ if platelets <10 in a well, afebrile patient
▪ if Platelets<20 in a febrile or systemically unwell patient
▪ if platelets<50 and any bleeding (this does not include bruising and petichae).
o Patients who have been heavily transfused previously may develop platelet antibodies
(usually HLA mediated). An indication of this would be poor platelet increment. Other causes
of poor increment include sepsis, drugs, DIC, etc. If the patient is thought to be refractory, in
the first instance, single donor platelets should be used and the Australian Red Cross Blood
Service should be contacted for HLA matched platelets.
3. Clotting factor replacement (Fresh Frozen plasma, cryoprecipitate, etc.)
o Indicated in special circumstances. e.g. factor replacement when using asparaginase
chemotherapy, DIC, anticoagulant reversal
o Always discuss with a consultant or registrar prior to use.
4. Intravenous Immunoglobulin
o This pooled product is prescribed for a number of conditions including
▪ Immune Thrombocytopenic purpura
▪ Primary and secondary gammaglobulin deficiencies.
o Application forms for intragam need to be authorised by the Red Cross blood service and
can online by the Consultant or Advanced Trainee on BloodStar..
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5. Granulocyte infusions
o Not routine and have been superseded by G-CSF and other supportive measures. These are
generally not advocated within our service.
Transfusion reactions
Blood products in Australia are very safe, but you need to be familiar with transfusion reactions that can
occur from time to time. It is not within the scope of this document to discuss all transfusion reactions in detail,
but the principles of management of common reactions are important.
Please refer to the following resource for more information:
http://www.transfusion.com.au/adverse_transfusion_reactions/classification_and_incidence
All transfusion reactions should be reported:
http://quality/docs/policies/PR-MHS-000103.pdf
Febrile non- haemolytic transfusion reactions (FNHTR)
• These occur because of reactions between donor leukocytes or cytokines in the transfused product and
the recipient.
• The incidence of FNHTR have decreased with universal leucodepletion, but cytokines are still present and
these reactions are still relatively common.
• Typically, these reactions are mild and present with a fever during the blood transfusion. Patients are
typically stable and, besides the fever, are asymptomatic.
• Management
o The transfusion should be ceased and the patient should be assessed.
o Look at the transfused product and make sure that it is labelled with your patients details. If
not, remember that there is another patient at risk!
o If the patient is well and the temperature is settling, the transfusion can be restarted.
Paracetamol can be used as an adjunct.
NOTE: If a patient is systemically unwell, other causes should be considered, e.g., haemolytic transfusion
reaction, septic transfusion reaction or a fever unrelated to the transfusion.
Acute haemolytic transfusion reactions
• This occurs when there is a major antigen: antibody incompatibility between the patient and the product
transfused (e.g., ABO incompatibility).
• The patient is usually febrile and systemically unwell, i.e. hypotension, rigors and tachycardia
• Management
o Stop the transfusion immediately and assess the patient. General supportive management is
essential, i.e. fluids. It would not be unreasonable to call for MET team.
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o Contact senior staff ASAP.
o Remember: Another patient may be at risk. Check patient and product details and inform
the laboratory. All (same product) transfusions on the ward should be ceased till the event
has been investigated and resolved. The blood bank should be contacted ASAP and
another blood specimen and a urine specimen is to be sent for transfusion reaction testing;
Other transfusion reactions to be aware of include:
• TRALI (Transfusion associated acute lung injury)
• Allergic transfusion reactions
• Post transfusion purpura
• Septic transfusion reactions.
See: http://www.transfusion.com.au/adverse_transfusion_reactions/classification_and_incidence
Febrile Neutropenia
Febrile neutropenia (FN) is potentially fatal and occurs most often as a complication of cancer treatment.
Success in FN management requires prompt recognition of and reaction to potential infection. Signs and
symptoms of infection in neutropenic patients can be minimal and fever can sometimes be the only
indication of a severe underlying infection.
TERM DEFINITION
Febrile neutropenia Oral temperature greater than 38.50C or two consecutive readings of
greater than 38.00C
and
an absolute neutrophil count less than 1x109/L or expected to fall below
0.5x109/L2,4.
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Current Guidelines for Febrile Neutropenia management
Probable Febrile Neutropenia
Commence empirical antibiotics if patient has
recorded temperature greater than 38°C or is not
febrile but shows signs of shock – consider sepsis
without fever and has one of the following:
• Up to 3 months post stem cell or bone marrow
transplant
• Prescribed long term steroids for Graft vs. Host
Disease
• Presents with a ‘febrile neutropenia emergency
letter’
• Has had recent chemotherapy e.g. last 4
weeks
• Is known to be neutropenic: neutrophils less
than 1.0 x109/L
NOTIFY HAEMATOLOGY / ONCOLOGY TEAM
IMMEDIATELY.
B. Stabilise patient
• Initiate IV cannula if no permanent IV access
present
• Gain alternate access if an existing line
suspected as source of infection and remove
existing line
• Fluid resuscitation
• commence 15 minutely observations
(minimum)
• commence fluid balance chart
• consider nurse special if clinically indicated
C. Investigations
i) Urgent Investigations
Please complete the following within 30 minutes:
Septic Screen:
• Blood cultures from peripheral vein & CVC /
PICC (if present)
prior to antibiotics IF ABLE
• Complete blood count • ELFT
ii) Non Urgent Investigations
Complete within 1-2 hours
• Chest x-ray • Sputum and urine
specimen for MC&S
• Respiratory viral PCR
• Other cultures as clinically indicated e.g.
mouth, perineum or
any suspicious lesion(s)
D. Considerations for ICU Consult
• Not responding to resuscitation
• Altered conscious state
• Hypoxia not corrected by oxygen therapy
• Clinical deterioration in any other form
Initial antibiotic therapy
(To Avoid SEPTIC SHOCK ADMINISTER ANTIBIOTICS WITHIN 30 MINUTES of presentation)
If patient is known to be colonised with a multi-resistant organism such as VRE, CRE or ESBL producer,
contact Infectious Diseases for advice on antibiotic choice
Piperacillin/Tazobactam (Tazocin®) 4.5g IV every eight hours
IF Penicillin allergy non-life threatening (Type II-IV hypersensitivity) use instead of above: cefepime 2g
IV every eight hours
IF Penicillin allergy life threatening (anaphylaxis)/Immediate (Type 1) use instead of above:
ciprofloxacin#~ 400mg IV every eight hours~ PLUS vancomycin#^ 25mg/kg (Actual Body Weight) IV
up to a maximum of 3g initial dose
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IF evidence of severe sepsis with life threatening haemodynamic instability and no absolute
contraindication ADD:
gentamicin*#^ 7mg/kg ideal body weight* IV as a single dose
IF evidence of sepsis and known to be MRSA colonised or suspected line source ADD:
vancomycin#^ 25mg/kg (Actual Body Weight) IV up to a maximum of 3g initial dose
# If allergic to vancomycin, gentamicin or ciprofloxacin, contact infectious diseases team (or ID
consultant on call after hours) for advice. Look up Mater adult vancomycin dosing and monitoring
guidelines on the intranet for further information or if ongoing dosing required.
*See dose table in section 3.3.1. Look up Mater adult gentamicin dosing and monitoring guidelines
on the intranet for further information or if ongoing dosing required.
^ Add to therapy on advice of senior medical staff only
~Reduce dose in renal impairment according to creatinine clearance (CrCl):
30-60L mLs/min 400mg every 12 hours
Less than 30mLs/min 200mg every 24 hours
For further information see “Guidelines for Initial Management of Febrile Neutropenia in Adult Patients” on
Mater Document Centre.
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UNIT POLICIES & PROCEDURES
Hours Regular rostered hours are from 8 am to 4:06 pm with a 30 minute lunch break.
Some flexibility is offered if a Consultant round needs to occur earlier than 8 am on occasion. In this instance,
you should adjust your hours accordingly and finish early.
Sick Leave If you are unable to attend work for any reason, when you have been rostered to do so, it is your responsibility
to notify the following people as soon as you are aware you cannot attend. This will allow alternative
arrangements to be made to cover your absence. Please contact:
o Unit Administration Officer - 3163 8545
o Ward Haematology Consultant
o Medical Education Manager - 3163 8114
Mater Policies and Procedures Mater policies and procedures are located on the Mater Document Centre. To search for a policy, visit the
Mater Document Centre via Zenworks or the Mater intranet.
Injured / Ill At Work Your responsibilities as an employee:
• Notify your supervisor and complete an incident report form
• In an emergency attend the Emergency Department
• Contact the Staff Health and Wellbeing Unit (SHAW) ext. 8190. Work Cover claims are managed by the
SHAW Unit.
Leave
• Leave requests at least 6 weeks in advance if possible.
• All BT and AT requests to the department Administration Officer for approval FIRST in addition to any other
leave requirements per Division of Medicine – your allocation of patients in the Clinics can then be blocked
off.
Kronos It is the responsibility of all RMOs to ensure your hours are entered into Kronos as per the roster by the end of
each fortnight.
ANY UNROSTERED OVERTIME will need to be authorised (as per RMO Enterprise Agreement Section) by
the relevant Consultant/Director on each occasion. If you need help managing tasks, speak to the team
early; do not wait until your shift ends to speak up. When adding any approved unrostered overtime to your
Kronos timecard, in order to be paid the overtime, you must include a comment with the relevant UR Number
or reason for the overtime.
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Any other variances to your roster (i.e. sick leave or PDL taken) will need to be added to Kronos before the
end of the fortnight. On the Monday after each fortnight the department secretary will check and approve
your Kronos timecard. For any questions please contact #8545
UNIT ROSTER & TIMETABLES
Note: Times for the consultant ward rounds may vary depending on the consultant on call for the week.
Day Time Location
MONDAY 8.30 am: Consultant ward round
1 pm: Medical Grand Rounds
Ward 10B
Conference Room 4, Level 3
TUESDAY 8.30 am: Resident/ Registrar rounds
12.30 pm to 1.30 pm: Medical Education
Session – Protected Teaching Time [all RMOs]
Ward 10B
Duncombe Building, level 4,
WEDNESDAY 8.40 am Consultant ward round
10 am: Education meeting (rotating roster):
a. Lymphoma meeting week 1
b. Combined Education meeting week 2
c. Group tutorial week 3
d. Research meeting week 4
11 am: Multidisciplinary Ward meeting
11.30 am: Transplant meeting
Ward 10B
Mater Cancer Care Centre
Conference room
Ward 10B, Conference room
Ward 10B, Conference room
THURSDAY 8.30 am: Resident/ Registrar rounds
12.30 pm to 1.30 pm: Medical Education
Session – Protected Teaching Time [all RMOs]
Ward 10B
Duncombe Building, Level 4
FRIDAY 8.30 am: Consultant ward rounds Ward 10B
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UNIT EDUCATION & TRAINING OPPORTUNITIES
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
8 am: Springfield Clinic
Drs’ Gutta/Shanavas
(alt),
MCCC Reg
8.30 am: Consultant
Ward Round 10b
Service consultant,
ward Reg, RMO, CNC
8.30 am: Clinic
MCCC
Drs’ Gutta &
Shanavas
Ward & MCCC
Reg,
RMO when
available
8.30 am:
Department Ward
Round 10b
Service
Consultants, Ward
& MCCC Reg,
RMO, CNC
8 - 9 am: PAH
Registrar Tutorial
8.30am: Consultant
Ward Round 10b
Service Consultant,
Ward Reg, RMO, CNC
8.30 am: Admin
Drs’ Shanavas & Gutta
(weeks off-call)
9 - 10.30 am:
Bone Marrow
Biopsies
Lab AT
10am: Department
Meetings
Lymphoma
Combined
Education
Clinical Haem
Education
Refer Rosters A, B,
C
8.30 am (9.15 am
– Ward Reg):
Clinic MCCC
Drs’ Shanavas &
Gutta
Ward & MCCC
Reg
11 am:
Department MDT
All Consultants,
Ward & MCCC
Reg, RMO, NUM,
Allied Health Staff
12 noon: Physicians’
Group Meeting
(monthly)
12 noon:
- Discharge Admin
Ward Team
11.30 am:
Morphology (Alt
Week) A/Path – L3
Duncombe Bldg
12.30pm:
Protected
Teaching
Rmo
12.30 pm: BT
Education Meeting
12.30 pm:
Protected
Teaching
Rmo
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APPENDIX 1 – TIPS & TRICKS
Ward Duties This will form the bulk of your work – you will be responsible for:
• daily review of inpatients under Clinical Haematology;
• attending Haematology Clinics on Tuesday and Thursday mornings;
• attending Haematology Clinics on Wednesday afternoon.
• “sign-off” therapy in consultation with Consultant for inpatients and outpatients being seen in your clinic;
• attend CHARM orientation (TBA separately);
• supervise acknowledgement of all MCCC (Public) results via VERDI by RMO.
You are NOT expected to “Pathway” or “Order” chemotherapy ie. Initiate chemotherapy pathways without
the supervision of a Haematology Consultant.
Admissions Booked admissions must be made through the 10B ward clerk. Patients are to only be admitted via the
Admissions Lounge or via MCCC – no direct admissions are allowed without separate approval by both the
10B NUM and the on-call consultant. All patients are to be asked to be arrive NO LATER than 1pm on the day
of admission and can be admitted in the Admissions Lounge or MCCC before arriving on the ward.
Consults The Advanced trainee will be responsible for all external consults ie. calls from outside the hospital.
The MCCC Registrar (Basic Physician Trainee) will see all internal consults for the Department. This is an
excellent learning opportunity and if time permits, you can see the patient with the basic trainee.
For urgent consults (same day review required) the MCCC Registrar may ask for your assistance initially.
Research There are a number of clinical trials that are conducted in the Haematology unit and if a trial patient is
admitted, you will need to liaise with the consultant who is the principle investigator on the trial and the
relevant clinical trial nurse involved. Remember that most clinical trials require notification of an admission
within 24hrs of the admission
While not mandatory, RMO’s are encouraged to undertake a clinical audit during the term. This will be
discussed during your orientation.
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APPENDIX 2 - CHEMOTHERAPY
General Chemotherapy is given using a defined protocol. Copies of protocols are kept in 10B, MCCC and Pharmacy
or alternatively can be assessed through CHARM.
Anti-Emetic Protocols There are guidelines for the types of anti-emetics to be given to patients receiving chemotherapy. Note that
Ondansetron and Aprepitant are only recommended for certain chemotherapy drugs/schedules.
Tumour Lysis Syndrome Massive cell death, usually as a result of chemotherapy, but spontaneously in some tumours with a very high
cell turnover rate (high grade lymphomas and some leukaemias) causes the release of intracellular elements
which can be toxic. Uric acid, the product of DNA metabolism, is relatively insoluble in acid urine and, in the
increased amounts resulting from high cell turnover, can precipitate in renal tubules and result in renal failure.
This is prevented by:
• allopurinol, which stops the conversion of purines to urate
• urinary alkalinisation as uric acid is more soluble in an alkaline environment and forced diuresis, to keep
urine output high and flush any urate crystals that do from out
Therefore any chemotherapy administered to a patient with haematological malignancy with a significant
tumour load should be preceded by Allopurinol to prevent uric acid nephropathy. This includes
chemotherapy for acute leukaemias, lymphomas and any other leukaemia when the white cell count is high.
If in doubt, ask. Depending on the extent of expected lysis and the time available, Allopurinol is usually given
at 300 mg daily until a few days after the chemotherapy is finished, or until the white cell count has fallen to
levels where tumour lysis is unlikely.
In patients at risk of tumour lysis, this is sometimes accompanied by urinary alkalinisation to make the urate
more soluble. This is done via oral sodium bicarbonate 500 mg - 1g qid and PRN to keep the urinary Ph >7 and
if necessary, IV Bicarbonate to achieve this.
As well as urate nephropathy, tumour lysis causes increase in serum potassium, phosphate and resultant
decrease in ionized calcium. To be alert to this, it is necessary to order serum Ca2+/ phosphate during the first
few days of chemotherapy. Also for those at high risk of tumour lysis, bd or even tds electrolytes are ordered
for the first couple of days of chemotherapy.
Chemotherapy Expiry: You will not be expected to order chemotherapy. Sometimes, however, you will be required to write the
chemotherapy on the fluid sheets, or to decide what priority different IV drugs should have. In order to make
the best decision, it is necessary to be aware that most chemotherapy agents have a limited viability. Some
have a very short half-life and must be used immediately (eg., nitrogen mustard), others have longer but
limited activities (eg Etoposide). If it is necessary to delay or alter chemotherapy check the expiry of the drug
and include this in your plans. Any alterations to chemotherapy should be discussed with the registrar or
consultant, as well as the pharmacy and nursing staff to convey the eventual plan.
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APPENDIX 3 - SAFE HANDLING OF CYTOTOXICS
Precautions are required for your own health and safety, for patients, visitors, and the environment. The main
areas of risk are:
• during administration, e.g., push doses and intrathecal injections
• patient handling
• waste disposal
• spills
Protection is mainly provided by Personal Protective Equipment (PPE), consisting of impermeable gowns with
closed front, long sleeves, closed cuffs and non-powdered latex gloves. Other circumstances may dictate
the use of masks and goggles.
• Gowns are NOT to be worn outside the designated areas
• Masks and eyeglasses with side shields are to be worn where there is a risk of splash, such as when handling
infusions, spills
DISPOSAL: all disposable PPE to be treated as cytotoxic waste
NB: any item of PPE that becomes contaminated should be changed immediately and disposed of as
cytotoxic waste.
Work Areas and Practices:
• Hands should be washed before and after donning PPE.
• Disposable plastic-lined paper liner to be used underneath drugs being handled. Dispose of this with
waste.
• Purple cytotoxic sharps containers are to be used where cytotoxic drugs are handled.
• All waste to be disposed of to be placed into plastic bags before being placed into purple wheelie bins.
• Spill kits are available in any area where hazardous substances are handled.
Administration:
• Gauze pads should be wrapped around connecting sites, i.e. syringe into IT needle.
• Use large-bore needles to prevent high pressure syringing of drug.
• Syringes and IV sets to have Lr-lock fittings
• All syringes and needles to be disposed of immediately into purple sharps containers without recapping,
crushing or clipping.
• Observe all connections for leakage during use.
• Specially-approved respirators should be used when administering aerosoled drugs (e.g., Pentamidine).
• Must be administered in specially ventilated treatment booths.
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Patient Care Universal precautions must be observed when caring for patients receiving cytotoxic substances. Disposable
protective gown and latex gloves should be worn when handling body wastes passed within 48 hours of
administration of cytotoxic substances. All linen of patients receiving cytotoxic therapy, and for 48 hours post
last dose, is to be placed into the purple linen bags. Any contaminated linen (cytotoxic drugs or body
wastes) is to be placed in soluble plastic bags within the purple linen bags.
Waste Specially labelled containers (purple wheelie bins) should be used to collect all cytotoxic waste, including
purple sharps containers when full. These should be located in every area where cytotoxic substances are
handled.
Spills Spills kits are kept in all areas where cytotoxic substances are handled. Incidental spills and breakages should
be cleaned up by a properly protected and trained person with the appropriate equipment. Hospital
Incident Reports are to be filled out. In case of contamination of PPE or clothing, direct skin or eye contact:
• Immediately remove contaminated PPE and discard
• Immediately cleanse affected skin with soap and water
• Affected eye to be irrigated with saline (IV bag with attached infusion line), for at least 15 minutes
• Medical attention to be obtained for staff having skin or eye contact
• Documentation in employee’s medical record
Discharge/Outpatient Medication Supplies Maximum discharge medication supplies are for 5 days. This is extended only for steroids, antibiotics and G-
CSF regimens.
Maximum outpatient medication supply is one month, and there is a dispensing fee.
Schedule 8 drugs for discharge or outpatients must have:
• only ONE item per prescription
• the exact dose, time interval of the drug
• the exact quantity of drug to be supplied.
e.g., MS Contin and Mist Morphine need two separate scripts. Mist morphine comes in 200ml bottle of 5mg/ml
strength.
The quantity of opioid needs to be written in both numbers and words (e.g., fifty six (56)).
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Intrathecal Chemotherapy On occasion, chemotherapy is administered intrathecally for either treatment of CNS disease or as
prophylaxis against CNS relapse.
Very few chemotherapeutic drugs may be administered intrathecally. At our unit, we would generally only
use either methotrexate or cytarabine. Other drugs can cause severe morbidity and mortality so it is vital that
care is taken in checking of the chemotherapy.
Process for intrathecal chemotherapy
• Anticoagulants and antiplatelet drugs should be withheld appropriately prior to the procedure.
• Both FBC and coagulation profile should be checked and abnormalities rectified prior to the procedure.
• Chemotherapy should be checked with a chemo competent nurse and signed off on the CHARM order
prior to administration.
• You should observe 2 procedures and be supervised until you are comfortable and deemed competent
by the registrar or consultant on the ward. A register is kept and you will need to be added to this prior to
performing this independently.
• The patient needs to lie flat for 2 hours following the procedure.
• Remember, whenever performing a lumbar puncture, CSF should be sent to the laboratory for cytology,
biochemistry +/- flow cytometry.