(Attach Label here or Complete Details)

Emergency Department
and
Rural Nurse Specialists

NAME: _________________________________________ NHI: ______________

GENDER: ____

DOB: ______________

AGE: ______

WARD: __________

Date:

Immunosuppressed Patients Clinical Pathway

(Haematology and Oncology Patients)
IS THIS PATIENT AT RISK? KEY QUESTIONS:
2. DOES THE PATIENT NOW HAVE (OR RECENTLY HAD)
ANY OF THE FOLLOWING?
q Symptoms or signs of shock

1. DOES THE PATIENT HAVE ANY OF THE FOLLOWING?

q Neutrophils known to be < 0.5 x 109/L

q Carries the immunosuppressed card
q Is immunosuppressed e.g. post-transplant, lymphoma,
myeloma, myelodysplasia or chronic lymphocytic leukaemia

YES to ANY answer in Question 1 PLUS

YES to ANY answer in Question 2 OR
Referred by specialist to follow pathway

q
q
q

Fever in last few hours

Rigors in last few hours
Other features of significant infection

NO to ALL answers in EITHER Question 1 or 2

e.g. well immunosuppressed patients presenting with injuries, or,
immunosuppressed patients without symptoms in Question 2

I
M
M
U
N
O
S
U
P
P
R
E
S
S
E
D

= MEDICAL EMERGENCY TRIAGE 1 OR 2 ONLY

IV antibiotics urgently required irrespective of current or recent oral

antibiotic therapy

EXIT
PATHWAY

If in doubt:
Administer IV antibiotics even if: apyrexial in ED and / or currently on oral antibiotics

Ask further questions later do not wait for: a new neutrophil count or the creatinine level

DOCTORS ACTION PLAN:

Within 10 minutes of arrival

Review patient
Prescribe all antibiotics
First-line
IV Piperacillin 4 g / Tazobactam 500 mg (Tazocin 4.5 g)
-- plus
IV Gentamicin 7 mg/Kg in 100 mL sodium chloride 0.9 % as a 30 min
infusion (based on ideal body weight)

Aminoglycosides should not be used for patients receiving high

dose methotrexate
Second-line Penicillin allergy / Rural Nurse Specialist patients/
Gentamicin contraindicated
IV Imipenem-Cilastatin 500mg (Primaxin) as slow IV bolus
Third-line
IV Ceftazidime 2 g as a 5-10 min infusion
If patient on long-term corticosteroids prescribe stat dose: IV
Hydrocortisone 100-200 mg

Within 30 minutes of arrival

Obtain IV access
Take cultures from a minimum of two sites including:
-- all existing lumens
-- plus a peripheral site
i.e. peripheral x2 or peripheral plus each existing lumen
Ask patient to provide MSU and sputum samples if available

Reasons for not following the pathway (mandatory)

Ref:

Issue 1 Authorised: Clinical Quality Improvement Team

NURSES ACTION PLAN:

Within 10 minutes of arrival

Ensure doctor reviews patient

Draw up all antibiotics while doctor obtains IV
access and blood samples

Within 30 minutes of arrival

Collect MSU and sputum samples if available

prior to antibiotics if possible
Administer antibiotics
Request bed for ALL patients
to allow time for the ward to make a bed
available

Within 60 minutes of arrival

Admit to ward

This pathway and treatment regime has been

developed through collaboration with the:
Haematology, Oncology, Nephrology, Infectious
Diseases, Pharmacology and Emergency Services

Sign overleaf
for actions completed
Time

Sign

Page 1 of 2

Designation

Dec 2013

P
A
T
I
E
N
T
S

Immunosuppressed
Patients
Clinical Pathway

(Attach Label here or Complete Details)

NAME: __________________________________________ NHI: ____________

GENDER: ____

DOB: ______________

AGE: ______

WARD: __________

INVESTIGATIONS AND INITIAL MANAGEMENT BY ED STAFF/RNS (within 30 minutes)

Action for all patients

Yes

No/NA

Comments / Variance

Time

Sign

Vital signs:
Set monitor to record Q15 min
IV Access:

Peripheral line:

Specify size and location of:

Location:

Peripheral line: 22G or 24G only

Size (circle):

Type of central line insitu

CVAD Type:

22G

24G

Apply green sticker when inserted in ED

Mark samples as:

Septic Screen blood samples:

URGENT

Haematology (1 tube)

Request:

Biochemistry (1 tube)

CBC + Diff, HEMO and Cultures

Blood cultures TWO sets

(Peripheral vein x 2 or
Peripheral vein PLUS one for each
lumen insitu if easily accessible)

Check Allergies

Antibiotics within 30 minutes (specify)

IV Piperacillin 4 g / Tazobactam
500 mg (Tazocin 4.5 g)

Do NOT wait for creatinine level for loading

dose. Gentamicin levels need to be taken.
Refer to WCDHB Gentamicin form. Dose
based on ideal body weight.

Gentamicin 7 mg/Kg in 100

mL sodium chloride 0.9 %

PLUS IV

or (penicillin allergy/Rural Nurse

Specialist/Gentamicin contraindicated)
IV Imipenem-Cilastin 500mg
(Primaxin)
or
IV Ceftazidime 2 g
IV sodium chloride 0.9 %
(via pump for CVADs)

Update PMS (inc. rapid assessment)

TRANSFER TO WARD (within 60 minutes)

Medical ward unless CCU considerations (i.e. not responding to resuscitation or an abnormal GCS)
Note:
Any patient who comes into the ED and is put on this pathway is required to leave the ED within 60 minutes
Discuss with Charge Nurse or Duty Nurse Manager ON ARRIVAL to facilitate
Action

Yes

No/NA

Comments

Time

Sign

Specialist team informed of patient

arrival:
Daytime: Oncology CNS
on 03 769 7561
After hours: On call oncologist
CDHB
Admit within 60 minutes
Handover using ISBAR format
Ref:

Issue 1 Authorised: Clinical Quality Improvement Team

Page 2 of 2

Dec 2013