Neutropenia

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today's expert is Rebecca Donohue, who will be talking with us about any and all questions you have regarding neutropenia. Welcome Rebecca!

 Rebecca Donohue 

Hi everyone.

 Rebecca Donohue 

Where is everyone from?

 oncnurse 

Massachusetts

 sfisher 

Rebecca Donohue

 sfisher 

Connecticut

 dfritz 

Colorado

 Rebecca Donohue 

Are there any burning questions about neutropenia?

 sfisher 

My burning question is in regards to the neutropenic diet. What is the latest thoughts on this based on some of the few studies that have been done?

 Rebecca Donohue 

There is actually no definite indication for a neutropenic diet. A recent study with transplant patients did not show benefit. However, the jury is still out on this one.

 dfritz 

We have tried to accommodate all patients in our outpatient infusion center, oncology and others. We are most concerned about neutropenic patients in with patients receiving antibiotics for a variety of reasons. We looked at CDC guidelines. ONS really has no guidance, even on the PEP card that I could find. Any guidance for us?

 Rebecca Donohue 

What I would recommend is that patients in for infection be kept at as much of a distance from neutropenic patients as possible. I realize that separate rooms are not always possible but this would be ideal. Also, remember good hand washing & cleaning of stethoscope between patients.

 Rebecca Donohue 

If different nurses can care for the neutropenic and the infected patients this would be good.

 Rebecca Donohue 

How do others handle this?

 dfritz 

At our facility in the inpt arena, we isolate even MRSA colonized patients. Our infection control nurse recommended (for Infusion Ctr) that we do a quick screen on these patients to see if there is any ACTIVE infection going on. If so, we MUST isolate them from others. It still makes us a bit nervous to have colonized patients in the same area. We also want to have ALL patients entering the Infusion Ctr to use the hand gel to reduce bacterial count. Any opinion on those measures?

 Rebecca Donohue 

This sounds like very logical thinking.

 Rebecca Donohue 

If you have an area for isolation this is ideal.

 AnnP 

I work on a med-surg-onc unit. We never have TB pts or meningitis, but nurses have pods and it is possible to have a MRSA patient with a neutropenic patient. Any suggestions for working within these parameters.

 sfisher 

In our infusion center there are separate rooms so infected patients can be kept away from neutropenic

 Julia 

I'm coming in late on this... do you do MRSA screening on all pts before they start coming to the infusion center?

 dfritz 

Unfortunately, it's a very small room, but it's away from the others.

 Rebecca Donohue 

Regarding med-surg unit the MRSA pt needs to be isolated. If possible have a different nurse caring for the neutropenic patient.

 sfisher 

We do nasal swabs on every patient admitted to the inpatient unit, which is something ID set up for the oncology unit.

 Rebecca Donohue 

Separate rooms are great.

 dfritz 

No, but most patients we see have been in the inpt area, which does MRSA screening 1. On admission, 2. On transfer to another nursing unit and 3. On discharge. That's a lot of nasal swabbing!!! Needless to say, there were some issues at some point in the past.

 Rebecca Donohue 

Regarding MRSA we do not screen before allowing into the infusion center. What are others doing?

 Julia 

Our infusion center is one big open room and unless they are admitted to the hospital, they aren't screened.

 Julia 

This sounds like a great idea and I can't believe we aren't doing it.

 Rebecca Donohue 

Nasal swaps are a wonderful idea, but we are an outpt clinic and this is not feasible.

 Julia 

We are outpatient as well, but knowing if they are MRSA/VRE would be very useful to know.

 AnnP 

To clarify, all patients have their own rooms and MRSA patients are isolated, but there is currently no way to avoid the same nurse caring for infected and immunocompromised. Any suggestions to reduce risk to the neutropenic?

 dfritz 

Just to reiterate, the only time we ISOLATE pts in the Inf Ctr is when they have ACTIVE infection, not just that they are colonized.

 sfisher 

I guess the question to ask is how many patients in those outpatient settings do get colonized just by being in the same setting?

 Rebecca Donohue 

To reduce risk universal precautions with special attention to hand washing & cleaning of all equipment is vital.

 dfritz 

The $64,000 question! (or maybe more)

 Julia 

Very true

 Rebecca Donohue 

That would be a great study.

 sfisher 

I agree with the universal precaution and not sharing unclean equipment.

 Julia 

But making sure when these pts get up to use the bathroom or get something to drink that they do proper hand washing as well.

 dfritz 

I have always been concerned about blood pressure cuffs and cleaning. How can one really get these clean? The sani-wipes or cavi-wipes really don't work on material.

 Rebecca Donohue 

This brings up the need to have a clean lab coat or gown for all patients.

 Julia 

We have virex that we spray.

 Julia 

But that is sometimes not feasible when you're going from patient to patient.

 annette 

Does anyone have procedures in place for the cleaning of equipment etc. after each patient?

 Rebecca Donohue 

Cleaning of the equipment would best be answered by the manufacturer -- just make sure it gets done according to institution policy.

 AnnP 

Each patient has his/her own cuff at our hospital. Disposable. They travel with the patient to procedures...

 Rebecca Donohue 

Actually make sure there is a policy.

 Julia 

If they are neutropenic though they have their own

 Rebecca Donohue 

Gown should be furnished outside of each MRSA+ room -- put on when entering & removed when exiting.

 Rebecca Donohue 

Their own what Julia?

 dfritz 

In outpt, we have "dynamap" type units that travel from pt to pt. ISOLATION pts get their own, but I don't think neutropenic pts do. I'll have to check on that.

 AnnP 

We have an isolation cart outside the rooms and give teaching to the families on use of gowns, hand washing, and disposal of gowns. If only the MDs would follow the rules...

 Rebecca Donohue 

Yes, there was a study about the infections that can be caused by MDs ties.

 AnnP 

Ties and lab coats are now banned in Great Britain and Canada, I hear.

 annette 

Is there anyone from a private physician office and how do you handle infected patients?

 Rebecca Donohue 

Yeah good for them! We need to follow this.

 dfritz 

Could you reference that study, Rebecca?

 Rebecca Donohue 

I can add the reference to the transcript tomorrow.

 Rebecca Donohue 

I am at a private practice office.

 dfritz 

Thanks, I'd appreciate it. Sounds like an interesting study.

 Rebecca Donohue 

We have a large treatment room with no separate rooms.

 Rebecca Donohue 

Our nurses are great about keeping the infected & neutropenic patients as far from each other as possible.

 annette 

Our treatment room is large and we don't have any way to isolate patients other than putting them in an exam room to be treated. We do try to separate them.

 Rebecca Donohue 

If pts are neutropenic & just in for lab draws they do not necessarily go into the treatment room.

 AnnP 

Do other hospitals enforce a neutropenic diet that keeps fresh fruit, vegetables, and garnishes off the patient's trays?

 sheltbr 

I suspect we should all prepare for a future treatment room design that provides areas for infected patients before someone mandates it. What do you guys think?

 Rebecca Donohue 

Our local hospitals do not have a neutropenic diet unless specifically requested by the oncologist.

 Julia 

Ours either.

 AnnP 

Thanks.

 dfritz 

Yes, we do have pts on neutropenic diet when ordered by the physician. I think until more evidence is in, we won't change our practice.

 AnnP 

It seems the trend is actually away from neutropenic diets, but plants and flowers are still a no-no.

 Rebecca Donohue 

ONS PEP card on infection says there is no effectiveness established on neutropenic diet.

 sfisher 

We have a high population of leukemic pts and all neutropenic patients are on this diet...pretty blah!!! That's why I am hoping to eliminate it but the oncologists are not totally supportive of this.

 AnnP 

Right.

 Rebecca Donohue 

However basic principles of no raw seafood or meats/poultry is wise for the neutropenic pt.

 dfritz 

But the PEP statement could simply mean there hasn't been enough evidence generated, couldn't it?

 sheltbr 

Even if neutropenic diet is not evidence based- some things are good sense stuff like avoiding fermented cheeses, uncooked meats/ raw fish etc. Maybe that is a good compromise.

 Rebecca Donohue 

Avoidance of fresh plants & flowers is likely to be effective.

 sfisher 

We did have a patient that ate raw pistachio nuts and developed a fungal infection related to this while in the hospital.

 Rebecca Donohue 

Yes, “no effectiveness established” means there is inefficient data or of not good quality (related to the PEP card statement).

 Julia 

I think just instructing pt's to clean all fruits and veggies really well is effective too

 Julia 

And assuming the hospitals are cleaning everything as well.

 AnnP 

RE: pistachios pt: was this recently? There has been an outbreak in pistachios in the general population?

 annette 

We tell patients to avoid raw foods while neutropenic.

 Rebecca Donohue 

I usually tell them any fruits/veggies that can be peeled may be OK.

 sfisher 

If it was not so restrictive, some of it makes perfect sense in terms of safe handling of certain foods.

 AnnP 

How about well-washed fruits and veggies?

 Rebecca Donohue 

Any time there is a risk to the general population there is an increased risk to neutropenic pts.

 dfritz 

Sounds like y'all are still instructing them on elements in the neutropenic diet!

 Rebecca Donohue 

Again effectiveness not established regarding washing veggies.

 Rebecca Donohue 

We instruct regarding general precautions.

 sfisher 

Based on recent evidence in the general population with peanut butter, pistachios, tomatoes and spinach...what really works?

 dfritz 

So I've puzzled a bit on the "peeling" of fruits--is it OK if the pt peels it? Or should someone else peel it and let the neutropenic patient take it from the peeling?

 sfisher 

We peel the banana and give it to the patient.

 Rebecca Donohue 

The problem is there is no definitive studies b/c these would put the population at risk.

 Rebecca Donohue 

I think sometimes we have to follow common sense rules & have those that are most at risk be more cautious.

 sfisher 

I agree

 AnnP 

I think it is also important to educate the patient on good hand washing techniques so they can protect themselves in case there is a "breach."

 Rebecca Donohue 

Yes patient education is a major part of infection prevention.

 Rebecca Donohue 

Our patients are educated before there 1st chemo course & this is reinforced each time.

 Rebecca Donohue 

I still like to teach pts to sing “Happy birthday” to themselves when washing their hands…

 dfritz 

Is there a good DVD/computer based/web site that has a good, brief explanation for patients? I know that "Phil" has done a lot to educate patients, but DVDs seem to be a good way for most patients to learn.

 Rebecca Donohue 

“Happy birthday” allows the correct amount of time for effective washing!

 AnnP 

Only if they sing it slowly enough!

 Rebecca Donohue 

There is an ONS site: cancersymptoms.org that may help re: pt education.

 dfritz 

Is there a DVD/video that can be accessed on that site?

 Rebecca Donohue 

American Cancer Society may also help.

 annette 

Thanks for all the information. Have a great day.

 Rebecca Donohue 

ONS site has lots of info on neutropenia – check it out.

 Rebecca Donohue 

I'm not sure about any DVDs.

 dfritz 

We seem to have such restrictions nowadays on what vendors can supply to us in terms of pt support. If it has their name on it, we seem to be unable to use it.

 Rebecca Donohue 

This is true, however, many can provide if it is for pt or nurse education -- ask them.

 dfritz 

I'm disappointed that this has to be the case as vendors with their larger budgets can do more visually appealing productions.

 Rebecca Donohue 

We need to deal with what is unfortunately.

 dfritz 

Generally, they are trying to get folks to buy their product, so most of their productions mention their product at some point during the segment. Yes, that's reality.

 dfritz 

Do we see any new drugs/products on the horizon to assist us in managing neutropenia?

 Rebecca Donohue 

I'm not aware of any. Does anyone else?

 sheltbr 

I just heard yesterday that some docs are not prescribing growth factors for breast adjuvant therapy pts because of increased risk of MDS and AML. Truth????

 Rebecca Donohue 

I am not aware of studies indicating this risk.

 sfisher 

Does anyone know of evidence-based information that states definitively the time frame from temp spike in a neutropenic patient and time to hang first antibiotic? We try for 1 hour.

 sheltbr 

My colleague pulled up one study over 8 years with 900+ pts but I wondered if they stratified for the regimens with Cy or adria where there is increased risk.

 Rebecca Donohue 

There have been studies that indicate the antibiotic needs to be within 1 hour.

 Rebecca Donohue 

What did this study recommend?

 dfritz 

Sheltbr, do you have a reference for that study? I'd be interested in looking at it.

 Rebecca Donohue 

When a patient presents with neutropenic fever at our office we try to give a dose of antibiotics before sending to the hospital. What about other outpt clinics?

 Rebecca Donohue 

How are others dealing with neutropenia -- proactive or reactive?

 dfritz 

It seems that no one ever gets CSFs on the first cycle. Once they're in the hospital for neutropenic fever, or we see how LOW their ANC goes, then it is used on subsequent cycles.

 sheltbr 

Responding to request for reference of AML/ MDS risk: I do not have a ref now, but we just did a key word search in a hurry to respond to comment in our clinic. I could get and send to Laurl for posting.

 Laurl at ONS 

Yes, please, thanks!

 dfritz 

Thanks, that would be great.

 Rebecca Donohue 

CSFs are recommended for all patients receiving chemo with > 20% risk of FN -- NCCN & ASCO.

 Rebecca Donohue 

Studies have shown that the risk is greatest during the 1st course.

 dfritz 

Yes, I wish the evidence/standards were followed.

 Rebecca Donohue 

Evidence is strong that CSFs prior to the 1st course of chemo significantly reduces the risk of FN complications

 dfritz 

Don't you mean after the first course?

 Rebecca Donohue 

We have a risk assessment tool with the initial plan of care to try to prevent missing a pt at increased risk.

 Rebecca Donohue 

Sorry, yes 24 hrs AFTER the 1st course

 Laurl at ONS 

It's about five minutes before our time is up—as you continue to ask questions ( don't stop!), please don't forget to take a moment to cut and paste this URL into your browser and take our very brief survey at the end of the chat- we'd love to hear what you think of these chats! The URL is http://research.zarca.com/k/RsTUTRsSUWsXYTXRsPsP

 dfritz 

Whew! I thought maybe there was some new study I had missed! Thanks for all the suggestions.

 Rebecca Donohue 

Also, don't forget the flu/pneumonia vaccines for chemotherapy patients.

 AnnP 

Our oncologists don't usually want them to have these. Do you know why?

 dfritz 

One oncologist told me that when the immune system is suppressed, you're just wasting the vaccine. But if they are not neutropenic, it should be OK.

 Rebecca Donohue 

Timing is important. The pt needs to have adequate immune response for them to work.

 AnnP 

Thanks.

 Rebecca Donohue 

We give the vaccines just before the next course of chemo when the counts have recovered.

 Laurl at ONS 

Well, UNFORTUNATELY, it's about time to end! This has been a great discussion - many thanks for your participation! Please come to our next chat, tomorrow night at 6pm Eastern, if you'd like to continue the discussion, and tell your co-workers and friends! Thank you for your time Rebecca!

 dfritz 

Thanks!

 Rebecca Donohue 

Goodbye and thanks everyone!

 sfisher 

Thanks

 AnnP 

Thanks to all.