Introduction

Aim

Definition of Terms

Assessment

Management

Education and Training

Special Considerations

Companion Documents

Evidence Table

References

Introduction

The home-based pre/post hydration model of care was developed to expand provision of local and home - based   care for paediatric cancer patients with osteosarcoma to ensure best practice is provided as close to home as possible. The program enables an osteosarcoma patient to have the majority of their care at home pre and post receiving the chemotherapy agent methotrexate .The model of care expands paediatric oncology treatment to be available outside the primary cancer services.

Aim

The aim of this guideline is to provide a comprehensive overview of the model of care for osteosarcoma patients receiving pre and post hydration for Methotrexate in the home.

Definition of Terms 

• CVAD- Central venous access device, a multipurpose venous catheter that terminates at or close to the heart or in one of the great vessels.
  
• FBE (full blood examination)- a blood test used to examine the blood and monitor the number of red blood cells, white blood cells (total number and types) and platelets circulating in the blood.
  
• FBC (fluid balance chart) - used to record patient fluid intake and output.
  
• LFTs (liver function test) - a group of blood tests used to monitor and evaluate for normal or abnormal liver function.
  
• Folinic acid- a medication administered to terminate the cytotoxic activity of methotrexate; limits toxicity to normal cells aiming to minimise severity of side effects.
  
• Osteosarcoma- a primary malignant tumour of the bone.
  
• Methotrexate- a chemotherapeutic agent; antimetabolite, inhibits DNA synthesis by depriving cells of folic acid.
  
• pH- urinary pH- monitors acidity/alkalinity of urine; urinary pH in this treatment must be maintained > 7.
  
• Port – a type of CVAD; a self-sealing injection port surgically placed under the skin of the chest wall; the catheter is tunnelled beneath the skin to the vein entry point, usually the internal jugular vein; accessed through the skin via a non-coring needle.
  
• Pre/post IV hydration- IV hydration fluids administered prior to and after chemotherapy, often given at a rate greater than maintenance IV fluids, hyper hydration.
  
• U&Es (urea & electrolytes) - a group of blood tests used to monitor and evaluate kidney function; monitors urea and the biochemical minerals and salts in the body.
  

Assessment

All oncology patients diagnosed with osteosarcoma should be assessed for suitability for pre and post hydration for Methotrexate in the home, based on the criteria below, (fig.1). The home – based model of care is an ‘opt in’ program, if a patient or their family does not wish to participate, care will be provided as normal within the hospital setting. 

Initial Assessment 
The initial assessment outlines the selection process for a patient to be eligible for homecare (fig 1a), this includes:

• Child being diagnosed with Osteosarcoma
  
• Pre-existing co morbidities 
  
• Place of residence 
  
• Suitable home environment 
  
• Review of PAT2 score 
  
• Patient/parent and or carer consent 
  
• Patient/parent and or carer training
  
• Patient completed a cycle of methotrexate  in the hospital without complications
  
• Medical stability of patient 
  
• Patient/parent and or carer competency
  

Figure 1.a. Initial Patient Eligibility Criteria

Further assessment is required to continue home - based   treatment after the first cycle, (fig 1.b).
Figure 1.b. Continuing Patient Eligibility Criteria 

Management 

This cycle of chemotherapy currently requires a 5 day inpatient stay and the patient receives multiple cycles throughout the course of their treatment. 

Following the home - based   model of care, on Day 0, the patient is reviewed in clinic by a consultant, port is cannulated in Day Oncology and then the patient travels home, with Wallaby nursing staff visiting them that evening to commence the IV fluids. Day 1 the patient returns to RCH in the morning for 4 hour methotrexate infusion, once completed they return home again, to continue IV hydration until Day 4 (fig.2). Regular visits from Wallaby nursing staff are scheduled throughout this time.

The parent, carer and/or patient are required to manage aspects of care following education and assessment of capability and comprehension. This includes administering pre and post hydration fluids via a Bodyguard IV pump, other supportive care such as antiemetics and folinic acid (oral medication), managing urine output and urinalysis, documentation of fluid balance, medication administration and identifying complications, along with escalation of concerns in a time appropriate manner, (fig.3).

Checklist 

Figure 2 Osteosarcoma Home Care Protocol Clinical Team Checklist 

Parents, carers and where appropriate, patients are educated on how to troubleshoot problems, identify complications and where to seek help when necessary. They are advised to always contact Wallaby staff on 9345 4770, except in the case of an emergency where they should immediately call 000. Wallaby staff will liaise with the oncology team as outlined in (fig. 3).

If the complication is a Grade 3 the family are advised to present to the emergency department. All home care osteosarcoma patient will be triaged as a category 2 or higher when presenting to emergency. Each patient will have a fast track card that is shown at presentation and in addition, an alert on their EPIC medical records. 

If unresolved complications occur out of hours patients contact the Wallaby ward number which will automatically transfer  to the emergency department (ED). Patients will be advised to attend the ED for further management. 

If the complication is related to a simple pump problem, Emergency department staff are encouraged to notify Kookaburra staff as they have the relevant training to manage the ‘Body Guard pumps’. Otherwise the pump should be changed to a standard RCH pump to ensure no delay to adequate fluid management.   

Figure 3. Osteosarcoma Home Protocol – Phone Advice Tip Sheet

If in doubt or for all other signs and symptoms contact the Solid Tumour Fellow on 55153 for further advice. After hours, contact the covering oncology consultant/fellow through switch.  

Education and Training

Staff Education

Nursing staff training is divided into three levels according to responsibility and involvement in the patient’s care. 

Level 1: Core Super Users
Role: provide face-to-face training to parents and/or nursing staff.

Level 2: Key points of contact
Role: provide phone advice to parents or provide nursing support at home, but do not provide primary training. 

Level 3: General users 
Role requires awareness of protocol, but do not provide parent training or phone advice. May be involved in supporting inpatient care. 

All training requirements (fig.4) are supported by the Osteosarcoma Home Care Learning Package Pre and Post Hydration for Methotrexate and the Oncology Clinical Nurse Educator.

Figure 4. Osteosarcoma Home - based   care – Training Requirements  

Parent Education

The nominated carer (or carer’s) in the home environment are trained during an inpatient stay by allocated nursing "trainers" from the Children’s Cancer Centre (CCC), to manage the care required at home. Once trained, assessed and deemed competent the carers are supported within the home environment by Wallaby nurses. 

Special Considerations

Infection Prevention

• Ensure that the insertion site of the central venous access device is securely covered with a transparent semi-permeable dressing. Dressings are to be changed if they become soiled or loosed, routinely changed at up to a maximum of seven days. Ensure dressing over CVAD port is well secured and IV line is secured with a safety pin
•  To Ensure hand hygiene principles are always followed adhere to aseptic technique principles when performing procedures (e.g. accessing IV line or changing IV fluid bags). 

Patient safety

• The insertion site of the CVAD should be regularly assessed by the parent or caregiver.
• Bodyguard IV pumps must be programmed by nursing staff as ordered with an infusion rate and IV bag volume limit. Ensure pump screens are then locked to prevent accidental alterations to pump programming whilst in use in the home environment.
• Ensure parents or caregivers are educated to minimise the risk of ‘air in line’. Pump will alarm when ‘air in line’ is detected, however removal of air must only be completed by nursing staff. 

Potential adverse events

• Any problems or concerns with patient management or condition must be immediately escalated to the treating team.

Companion Documents

• RCH Procedure - Aseptic technique   (RCH access only)
• RCH Procedure - Hand hygiene   (RCH access only)
• RCH Procedure -  Central venous access device   (RCH access only)
• RCH Procedure - Osteosarcoma home based care - ambulatory pump management (RCH access only)
  

Evidence Table

The Evidence Table for this guideline can be found here. 

References

Osteosarcoma Home Care Learning Package Pre and Post Hydration for Methotrexate, Royal Children’s Hospital

Please remember to read the  disclaimer.

The development of this nursing guideline was coordinated by Kylie Moon, Clinical Nurse Consultant Nursing Innovations, Lisa Barrow, Clinical Nurse Educator Children's Cancer Centre, Tracy James PICS Project Lead Quality & Service Improvement, and approved by the Nursing Clinical Effectiveness Committee. First published August 2018.