SENIOR TRAINING FELLOWSHIP (STF)

1. NAME : Mrs. N. Menaka Raghuraman

2. DEPARTMENT : COLLEGE OF NURSING

CHILD HEALTH NURSING DEPARTMENT

3. YEAR OF STF : 2014

4. OBJECTIVES STATED IN THE APPLICATION FOR STF:

� To observe the physical set up of the pediatric oncology unit i.e.

inpatient and outpatient services, bone marrow transplant unit.

� To observe the services and best practices by pediatric oncology unit

nurses.

� To learn the policies, protocols and the standards for providing

nursing care to children with cancer.

� To learn the specific skills required for a pediatric oncology nurse in

relation to assessment, chemotherapy administration, care of central

venous access, supportive care, emergency management, counseling,

palliative care and end of life care.

� To learn the trends and other innovative approaches used in the

pediatric oncology unit.

� To observe the in service and educational programme conducted for

the nurses in the pediatric oncology unit.

5. CENTER VISITED FOR STF: Royal Children’s Hospital

Brisbane, Queensland.

MENTOR: Ms. Rachel Edwards

Nurse educator, Pediatric oncology

6. SHORT DESCRIPTION OF TRAINING:

INTRODUCTION

Royal Children’s Hospital (RCH) at Brisbane is a 168 bed multi-specialty

tertiary referral and teaching hospital for the State of Queensland.

PHYSICAL SET UP

The pediatric oncology unit houses two different wards - Banksia ward with

14 beds, Turner ward with 10 beds and a day care unit .The bone marrow

transplant unit which is attached to the Banksia ward has 3 beds. The unique

feature is that all the above patient care areas are considered as immune

compromised patient care areas and are restricted for entry of general public.

Children having infections or known to have had contacts with infected family

members are isolated appropriately from the non-infectious children.

The patient care area is child and family friendly, with well equipped play

room and parent lounges. The walls are decorated with beautiful paintings.

Relevant printed texts and pictures with information related to care of children

with cancer are displayed for staff (E.g. hand washing, safe handling of cytotoxic

agents, central venous access device management bundle etc...)

TEAM MEMBERS OF PEDIATRIC ONCOLOGY UNIT:

MEDICAL:

Medical director for pediatric oncology/hematology is the head of the unit.

The team of doctors functioning in the unit includes senior specialist (consultant),

Fellows (preparing to become senior specialist), registrars and resident doctors.

NURSING:

The executive nursing director is the head of the nursing services in the

hospital. The nursing directors in charge for pediatric oncology/hematology units

directly report to the executive nursing director. A team of nurses including nurse

practitioners, nurse educators, clinical nurse consultants, liaison nurses ,research

nurses, nurse unit managers, clinical nurse facilitators shift coordinators, staff

nurses ,nursing assistants, and bone marrow transplant unit nurse co-coordinators

work under the guidance of the nursing directors. As per the staffing policy in the

oncology ward the nurse patient ratio is 1:2. There are total of 25 staff nurses

working in the oncology day care unit.

ALLIED HEALTH:

Apart from the nursing team many other health professional also render care

to these children who are either admitted in the wards or visit the day care unit.

Social worker counsels the child and family after thorough assessment of the

family and social structures.

Welfare workers assess the financial need of the family and help them to access

to resources such as free accommodation or subsidized medical benefits.

Occupational therapist orients the child and family members about the disease

condition, investigations required and treatment modalities. They engage the

hospitalized children with meaningful activities.

Physiotherapist provides physical therapies as per the need of the child.

Speech therapist helps children with speech difficulties and feeding problems

Dietician assesses the nutritional status of the child and recommends the

appropriate dietary supplements required.

Music therapist provides solace and diversion to the child and family members by

singing and playing instruments of the family’s choice.

MISSELANEOUS

Many volunteers and nongovernmental organizations support the family

financially as well as provide diversion to children during hospitalization (E.g.

Leukemia foundation, Clown doctors, working wonders, Red kite, Make a wish

etc.).

PATIENT CARE IN DAY CARE UNIT

Every day (Monday to Friday) 25-30 children visit the oncology day care

unit to receive health care services. It was quite amazing to see the system of

patient care in the day care unit. The day care unit is designed in such a way that

the child register first, then the triage nurse carry out initial assessments such as

measuring the height, weight, vital signs, and collects necessary nursing history

and she ties the ID band to the child . Then the child along with family members

consult the doctor, blood samples are collected for investigation, dressing of the

central venous access is done or the port is accessed as per need. Once the blood

results are ready the child undergoes the recommended chemotherapy

administration. Bone marrow aspiration and intrathecal chemotherapies are done in

the minor theatre of day care unit under general anesthesia (GA) on Tuesdays and

Thursdays of the week. Followed by the painful procedures done under GA

children are wheeled to the recovery room and closely monitored until they are

conscious & stable.

GUIDELINES, POLICIES, STANDARDS, & PROCEDURES:

The pediatric oncology unit has printed as well as online guidelines and

policies for patient care services. Standards for nursing care are

available in the unit exclusively for oncology nursing practice in

the State of Queensland. A record of all common procedures

carried out in the unit are available in the patient care areas.(E.g.

Central line dressing, heparin flush of central line, blood sampling

from central venous line, and needling a chemoport etc..)

CYTOTOXIC DRUG PREPARATION, STORAGE, ADMINISTRATION,

AND DISPOSAL

Cytotoxic drugs are prepared in pharmacy by the pharmacist in the low

pressure room under the biological safety cabinet. The pharmacist wears cytotoxic

specific personnel protective equipment and follows reverse barrier techniques.

After the counter checking by the senior pharmacist the syringes of loaded

medicine are put in to purple bag, labeled and sealed. Then it is brought to the

patient care area and stored at 2-8degree centigrade in the chemotherapy storage

refrigerator. In the clinical area two specially trained chemotherapy nurses check

the protocol, follow all the rights of medication administration, wear the PPE

(purple impermeable apron with full front cover and full sleeves, nitrile purple

gloves,N95 face mask, goggles, and inner shoes)to administer drugs. Most of the

time nurses wear clean purple gloves but follow aseptic non touch technique. All

the disposable items used for cytotoxic drug preparation and administration are

segregated into purple bins lined with purple colored alginate bags. Sharps are

discarded into disposable purple colored sharp containers .The urine, stools, and

vomitus of the child are considered as cytotoxic waste for 7 days following

chemotherapy administration and disposed with special care. The bedpans and

urinals are sterilized after each use by placing in to a sterilizer machine kept in the

dirty utility room.

CENTRAL VENOUS ACCESS DEVICE (CVAD) MAINTENANCE

BUNDLE

CVAD maintenance bundle consist of hand hygiene, scrub the hub, aseptic

non touch technique (ANTT), dressing, and patency. The oncology unit nurses are

specially trained to follow the bundle to prevent CVAD related infections. The

nurses who have completed the training successfully are recognized as CVAD

HERO. The CVAD HEROES are also trained to repair the damaged or broken

central venous catheters using the repair kit provided by the pharmaceutical

company. Nurses who have attended workshops on antibiotic therapy are called

ANTI BIOTIC CHAMPIONS.

STAFF DEVELOPMENT PROGRAMME AND SKILL TRAINING

Graduate nurse to work in the pediatric setting need to undergo a special

pediatric nursing course for one month. Then if she is interested to work in the

oncology unit she needs to undergo the chemotherapy course that consists of 3

modules and practical sessions for 3 months. After the successful completion of the

course the staff nurse is permitted to function independently in the unit. The

clinical facilitators train the new graduate nurses as well as the other nurses to

practice procedures like central line dressing on the Chester model available in the

wards. The clinical facilitators periodically assess the procedures done by the

nurses and gives evaluation. The oncology nurse educators are responsible for the

chemo course training and development of the nurses.

Every week on Thursday noon education meetings are conducted to share

the topic of interest with the oncology team members. Advanced workshops are

conducted once in 3 months for senior clinical nurses to upgrade their knowledge

and skills. CPR training is given to all the staff periodically by the respective nurse

educator. Every clinical area has a reading room with relevant study materials.

DISTRACTION PROGRAMME

An organization called Tender loving care for kids (tlc for kids.com)

recommends and supports the ‘Distraction Programme’, in the pediatric oncology

unit. The treatment room has distraction boxes which contain attractive play items

that divert the child’s mind during the procedure. Every child is given a gift after

the planned procedure in appreciation of the child’s cooperation.

RING THE BELL

Children those who have successfully completed the treatment ring the bell kept in

the day care waiting area. They write their comments with signature in the memory

making diary which gives a moment of hope to the other children and their

families currently on treatment.

PALLIATIVE CARE TEAM

Palliative care team plans and organizes the care for children referred under them.

They provide care to children admitted in the ward as well as make home visits

along with the community health nurse working for that area. The family is given a

home care kit with necessary medical supplies to continue the care at home. This

kit includes a syringe pump to administer necessary medication as continuous

infusion through subcutaneous line. This assistance helps family members in

adequate symptom management such as pain, nausea and vomiting. The parents

and siblings are given adequate counseling and support. Palliative care guide is

available for parents as well as for health professionals.

EDUCATION MATERIAL FOR FAMILY AND CHILD:

Every family is given a “Going home book’, to help them to learn about cancer

and home care.

A magnet sticker with information about danger signs and contact numbers in case

of emergency is given to the family at the time of discharge.

Organizations such as Leukemia Foundation, Children Oncology Group(COG)

has made lot of attractive teaching materials with the interest to equip the child and

parents with adequate knowledge to enable them to cope through the treatment

process.

SCHOOL VISITS:

The Liaison nurses make school visits to meet the teachers and the classmates of

children who are on chemotherapy or just completed treatment and rejoined the

school. The Liaison nurse educates the teacher and children in simple terms to

ensure the safety of the children when they are attending the school.

RCH SCHOOL:

According to the policy of the state of Queensland, RCH has a higher secondary

school to continue the education for the hospitalized stable children as well as their

siblings. The teachers are very friendly with the students and teach in a play way as

well as use variety of AV aids.

CLINICAL TRIALS

In collaboration with the Children Oncology Group (COG) based in United States

currently more than 44 clinical trials are going on in RCH. The aim of these

clinical trials is to improve the cancer treatment and the survival rate of children

with cancer in the future. All the team members play a vital role in conducting the

clinical trials.

RCH TUMOUR BANK:

The tumor bank collects and stores leukemia samples and solid tumor specimens.

These samples are given free of cost to the multiple research centers in the world to

carry out the clinical trials to ensure disease specific treatment for cancer in the

future.

7. PLANS TO IMPLEMENT OBJECTIVES ON RETURN TO CMC

� To share the new ideas obtained from RCH with colleagues during the in

service education programme.

� To encourage the unit staff nurses to read the pediatric oncology related text

books given by the friends from RCH and to conduct periodic in service

education programmes.

� To apply the innovative ideas to modify our patient care area as child

friendly to some extent possible.

� To formulate policies, procedures and protocols related to chemotherapy

handling (preparation storage, administration, safe disposal and spill

management) in consultation with other team members.

� To write down the procedure for central venous access device (Peripheral

line, PICC line, Hickman line, and chemo port ) management

� To improve the skills of nurses related to CVAD care by providing them the

opportunity to practice on the manikin

� To enhance the existing educational and counseling programme for child

and family members (Training of the OT along with the chemo nurses to use

teaching materials)

� To assist in planning an ideal pediatric oncology unit for the future pediatric

specialty hospital

� To prepare orientation programme for new staff nurses joining the pediatric

oncology unit.

� To prepare a course for training of pediatric oncology nursing in line with

the hospital policies.

� To educate and train pediatric oncology unit nurses in all the above aspects.

CONCLUSION:

It was a wonderful opportunity for me to observe and learn the system of

functioning in the oncology unit at RCH. I was amazed to see the rich resources

such as manpower, patient care related materials, infrastructure and the financial

assistance rendered to the children with cancer. This experience was an eye opener

to learn about the cytotoxic safety measures. Though it is not possible to practice

all that I have observed I am sure that I will try my level best to apply some of the

ideas that I have learned to improve the quality of care to children in our hospital.

All the team members of the pediatric oncology unit at RCH were very caring and

friendly throughout my stay and sincerely supported me in achieving my learning

objectives. In the nursing show case conducted by nurses in RCH I was given an

opportunity to present about nursing experiences from India and also about the

heritage of CMC, Vellore. I was fortunate to have fellowship with Mr. Brain Lee,

senior member of friends of Vellore. I also had an opportunity to visit the

Queensland University of technology-school of nursing.

Menaka Raghuraman Date: 12.04.2014