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Intravesical BCG clinical care pathway
AcknowledgmentsThe WA Cancer and Palliative care Network wish to recognise Fremantle Hospital for their collaboration in the development of this document.
Disclaimer
All information and content in this material is provided in good faith by the Department of Health, Western Australia and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the Department of Health, Western Australia and their respective officers, employees and agents, do not accept legal liability or responsibility for the material, or any consequences arising from its use.
The Local implementation, training and evaluation of clinical staff remains the responsibility of the employee authority.
1
Intravesical BCG clinical care pathway explanatory notes
Intravesical therapies are the mainstay of treatment for non-muscle invasive bladder cancer. BCG, including maintenance treatment is the current gold standard for high risk disease, though optimal regimes remain undefined. This care pathway was developed to assist in the delivery of intravesical BCG induction and maintenance treatment by providing clinicians and nursing staff with a clear framework for treatment delivery utilising best practice principles.1, 2
The diagram below is a 12 month schedule for BCG induction and maintenance with suggested cystoscopic surveillance. It fulfills current guidelines for BCG and maintenance administration though other maintenance schedules exist. 3, 4
Induction BCG treatment
Week 1 2 3 4 5 6 7 8 9
Maintenance
Month 3 4 5 6 7 8 9 10 11 12
GA cystoscopy and biopsy
Flexible cystoscopy
Flexible cystoscopy
GA cystoscopy and biopsy
Patients should be screened to exclude urinary tract infection prior to commencing each cycle of BCG, as per shown in the algorithm on page 3. Once clearance to proceed has been obtained, regular surveillance cystoscopies should be undertaken during maintenance regimes, and this should be documented in the scheduling chart shown on page 4.
2
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Intravesical Bladder CancerConsultant ____________________________
Ward ____________________________
Aims of Intravesical BCG clinical are pathway
The patient will receive Intravesical therapy at weekly intervals with managed side-effects and a cystoscopy performed at defined intervals
Risk factors
Any urinary bladder operation (eg. TURBT), cystoscopy +/- biopsy performed within last 2 weeks
Using the Clinical Pathway
The Clinical Pathway is a guide that should be altered to meet the patient’s needs as required Record and code variations from the pathway on the variance page. If required, variance documentation may be expanded further in the integrated notes
Complete the signature register only on the FIRST occasion of caring for the patient
Signature register
Print Name Initial Desig Print Name Initial Desig
© Fremantle Hospital & Health Service – Permission to use
Surname UMRN
Given names Birthdate Sex
Address
Algorithm
Consultant ____________________________
Ward ____________________________
Patient label
3
Algorithm
Consultant ____________________________
Ward ____________________________
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Medical Officer to review MSU growth results & sensitivities, and contact Microbiologist or Infectious Diseases physician for further clarification of urine culture and susceptibility results if required. Contact GP to organise antibiotic therapy and repeat MSU.
* LUTS – Lower Urinary Tract Symptoms
No
Yes
Yes
Yes
No
No
Urine M/C/S (MSU) form given by nurses for collection at hospital pathology on the Monday prior to intravesical commencing.
Treatment area nurse to review MSU results day prior to intravesical treatment day.
MSU - Scanty, Light Growth or Mixed organism.
Leukocytes less than 100 x 10^6/L.
Is this result following a repeat MSU?
Treatment cannot proceed Repeat MSU Inform patient Record variance.
Contact Urology Registrar to consider dose reduction or repeat MSU.
Treatment may proceed at reduced dose.
Severe LUTS*.
MSU - no growth & may include:
Isolated pyuria Contaminants.
No symptoms to mild/moderate LUTS*.
Treatment can proceed.
MSU - moderate to heavy growth.
Treatment cannot proceed.
Inform patient to see GP for antibiotic therapy and not to come in for the intravesical treatment.
Arrange a repeat MSU 3 days post completion of antibiotics. Record variance.
Inform booking clerk of treatment delay.
Is this 3rd positive MSU?
Stop pathway. Contact Urology Registrar or Urology Consultant for management plan.
Contact Medical Officer.
Clearance to proceed algorithm
ME
DIC
AL
4
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Cystoscopy Scheduling Chart
Cystoscopy Date Range Required Date Request Sent
Date Procedure Scheduled
Signature
GA cystoscopy/biopsy(Post Induction) Recorded on cystoscopy
booking form Patient informed
Flexible cystoscopy(First)
Recorded on cystoscopy booking form Patient informed
Flexible cystoscopy (Second)
Recorded on cystoscopy booking form Patient informed
Flexible cystoscopy (Third*)
Recorded on cystoscopy booking form Patient informed
GA cystoscopy/biopsy (Post maintenance completion)
Recorded on cystoscopy booking form Patient informed
High Grade Non-muscle Invasive Bladder Cancer patients require a follow up General Anaesthetic (GA) cystoscopy and bladder biopsy at a minimum of two weeks post therapy. These should take place following completion of the induction course and then following completion of the maintenance course.
High Grade Non-muscle Invasive Bladder Cancer patients on maintenance intravesical therapy require follow up flexible cystoscopy third monthly.
Ongoing cystoscopy surveillance thereafter is to be determined by the patient’s Urologist.
*Determined by length of time of the maintenance course.
5
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Induction treatmentConsultant ____________________________
Ward ____________________________
Category Pre Admission
Date:
Vari
ance Week 1 of 6
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained and patient understands UTI symptoms, MSU collections and GP follow up of abnormal results with antibiotics explained BCG patient handout Bladder cancer information booklet. Patient aware cystoscopy/biopsies will be carried out post induction; third monthly whilst receiving maintenance; and on completion of maintenance.
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults Nursing admission complete Medical admission complete Consent signed
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted (pages 14 and 15)
4 Treatment & Assessment
TPR recorded TPR recorded
5 Medications & Pain Management
Usual medications Assess for analgesia requirements
BCG instillation as per protocolDate instillation givenUsual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet and fluids Usual diet Encourage oral fluids after treatment
7 Hygiene Education provided on Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination &
Safety Patient educated on safe voiding technique - sitting to void and double flush Patient educated on use of bleach tablet after toileting
No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sit to void and double flush)Patient educated on use of bleach tablet post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM AM PM
This pathway is a guide and should be altered to meet the patients needs as required
6
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Induction treatmentConsultant ____________________________
Ward ____________________________
Category Week 2 of 6
Date:
Vari
ance Week 3 of 6
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted (pages 14 and 15)
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted (pages 14 and 15)
4 Treatment & Assessment
TPR recorded TPR recorded
5 Medications & Pain Management
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet Encourage oral fluids
Usual diet Encourage oral fluids
7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination
& SafetyNo voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM AM PM
This pathway is a guide and should be altered to meet the patients needs as required
7
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Category Week 4 of 6
Date:
Vari
ance Week 5 of 6
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults Refer to Pre-Admission Clinic for GA cystoscopy and biopsyBooking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
4 Treatment & Assessment
TPR recorded TPR recorded
5 Medications & Pain Management
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet Encourage oral fluids after treatment
Usual diet Encourage oral fluids after treatment
7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination
& SafetyNo voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM AM PM
This pathway is a guide and should be altered to meet the patients needs as required
Induction treatmentConsultant ____________________________
Ward ____________________________
8
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Category Week 6 of 6
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults GA cystoscopy and biopsy booking date recorded on Cystoscopy Scheduling Chart of this pathway
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
4 Treatment & Assessment
TPR recorded
5 Medications & Pain Management
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet Encourage oral fluids after treatment
7 Hygiene Pre procedure genital Chlorhex wash8 Elimination
& SafetyNo voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM
This pathway is a guide and should be altered to meet the patients needs as required
Induction treatmentConsultant ____________________________
Ward ____________________________
9
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Category Maintenance treatment: 1 of 10
Date:
Vari
ance Maintenance treatment: 2 of 10
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults Refer to Pre-Admission clinic for GA cystoscopy and biopsyBooking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted (pages 14 and 15)
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted (pages 14 and 15)
4 Treatment & Assessment
TPR recorded TPR recorded
5 Medications & Pain Management
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet Encourage oral fluids after treatment
Usual diet Encourage oral fluids after treatment
7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination
& SafetyNo voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM AM PM
This pathway is a guide and should be altered to meet the patients needs as required
Maintenance treatmentConsultant ____________________________
Ward ____________________________
10
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Category Maintenance treatment: 3 of 10
Date:
Vari
ance Maintenance treatment: 4 of 10
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults Flexible cystscopy booking date recorded on Cystoscopy Scheduling Chart of this pathway
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted (pages 14 and 15)
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted (pages 14 and 15)
4 Treatment & Assessment
TPR recorded TPR recorded
5 Medications & Pain Management
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet Encourage oral fluids after treatment
Usual diet Encourage oral fluids after treatment
7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination
& SafetyPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on safe bleach tablet usage post toileting
Patient educated on safe voiding technique (sitting to void and double flush)Patient educated on safe bleach tablet usage post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM AM PM
This pathway is a guide and should be altered to meet the patients needs as required
Maintenance treatmentConsultant ____________________________
Ward ____________________________
11
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Category Maintenance treatment: 5 of 10
Date:
Vari
ance Maintenance treatment: 6 of 10
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults Refer for flexible cystoscopyBooking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway
Proposed flexible cystoscopy Booking date recorded on Cystoscopy Scheduling Chart of this pathway
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
4 Treatment & Assessment
TPR recorded TPR recorded
5 Medications & Pain Management
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet Encourage oral fluids after treatment
Usual diet Encourage oral fluids after treatment
7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination
& SafetyNo voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM AM PM
This pathway is a guide and should be altered to meet the patients needs as required
Maintenance treatmentConsultant ____________________________
Ward ____________________________
12
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Category Maintenance treatment: 7 of 10
Date:
Vari
ance Maintenance treatment: 8 of 10
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
4 Treatment & Assessment
TPR recorded TPR recorded
5 Medications & Pain Management
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet Encourage oral fluids after treatment
Usual diet Encourage oral fluids after treatment
7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination
& SafetyNo voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM AM PM
This pathway is a guide and should be altered to meet the patients needs as required
Maintenance treatmentConsultant ____________________________
Ward ____________________________
13
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Category Maintenance treatment: 9 of 10
Date:
Vari
ance Maintenance treatment: 10 of 10
Date:
Vari
ance
1 Education & Discharge Planning
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
Procedure explained Educated on follow up arrangements and bookings Booking clerk informed of any variance
2 Consults Proposed GA cystoscopy and biopsy booking date recorded on Cystoscopy Scheduling Chart of this pathway
Refer to Pre-Admission clinic for GA cystoscopy and biopsyBooking form and consent sent with patient and recorded on Cystoscopy Scheduling Chart of this pathway
3 Investigations & Clearance to Proceed
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
Pre treatment MSU clear Y / N Clear to proceed Y / N If N = Clearance to proceed algorithm completed and Variance charted
4 Treatment & Assessment
TPR recorded TPR recorded
5 Medications & Pain Management
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
BCG instillation as per protocolDate instillation given ________________
Usual medicationsAssess for analgesia requirements
6 Diet & Hydration
Usual diet Encourage oral fluids after treatment
Usual diet Encourage oral fluids after treatment
7 Hygiene Pre procedure genital Chlorhex wash Pre procedure genital Chlorhex wash8 Elimination
& SafetyNo voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
No voiding until 1-2 hours post treatmentPatient educated on safe voiding technique (sitting to void and double flush)Patient educated on use of bleach tablet post toileting
Special Needs & Team Messages
Sig
nat
ure
s Medical
Allied Health
Nurse AM PM AM PM
This pathway is a guide and should be altered to meet the patients needs as required
Maintenance treatmentConsultant ____________________________
Ward ____________________________
14
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Integrated Variance Report
Date & Time
Pathway Day
Variance Description & Action Taken
Positive/ Negative
Variance Code
Signature
The variance report should record any unexpected variations to care.
Variances should be reviewed regularly as part of local clinical Governance process.
15
Surname UMRN
Given names Birthdate Sex
Address
Patient label
Integrated Variance Report
Date & Time
Pathway Day
Variance Description & Action Taken
Positive/ Negative
Variance Code
Signature
Code A Patient Code B Clinical Code C Hospital Code D Community
A1 Suspicion of bladder perforation
B1 Medical decision C1 Delay in test results D1 Delay in transport availability
A2 Allergic reaction B2 Altered dose of intravesical agent
C2 Delay in OR/Procedure
D2 Delay in home care/ community/ family support
A3 Poor tolerance of intravesical agent
B3 Altered frequency of intravesical agent
C3 Cancellation of procedure
D3 Equipment/ supplies not available
A4 Unable to catheterise B4 Other C4 Other D4 OtherA5 MSU positive growth
delaying treatmentA6 Taken off pathwayA7 Pre treatment MSU
not providedA8 Other
16
Notes
References1. Department of Health, Western Australia. Guidelines for the administration of intravesical cytoxic
and immununotheapeutic drugs within the hosiplta setting. Perth: Healthnetworks Branch, Department of Health, Western Australia; 2010
2. British Association of Urological Nurses (BAUN) Section of Oncology (2005) Guidelines for the administration of Intravesical therapies. Bathgate, UK: Fitwise Management Ltd.
3. European Association of Urology (2010) Guidelines on Non Muscle Invasive Baldder Cancer. Accessed online 7/1/11 <http://www.uroweb.org/gls/pdf/TaT1%20(non-muscle%20invasive)%20bladder%20cancer%202010.pdf>
4. Lamm, D, et al. Clinical Practice recommendations for the management of non-muscle invasive bladder cancer. European urology supplements 7 (2008) 651-666: Elsevier
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© Department of Health 2011