Haematology induction booklet was contributed by the following;
written by Dr Kaur
Reviewed by Dr Olivia Harvey
Updated by Dr Amir Shenouda
Select the booklet titles below to expand the table to view more information.
Haematology Ward Timetable
A normal week is set up according to whether you are covering triage and day case, or the haematology ward patients currently on C4 – outliers are reviewed by registrars and consultants.
| Day | Monday | Tuesday | Wednesday | Thursday | Friday |
|---|---|---|---|---|---|
|
AM |
Triage / Ward |
Triage / Ward |
Triage / Ward |
Triage / Ward |
Triage / Ward |
|
PM |
Triage / Ward |
Triage / Ward |
Triage / Ward |
Triage / Ward |
Triage / Ward |
Haematology has two FY1s with one starting on triage, and one on the ward. Each will cover the respective area for 2 months and rotate. The day starts at 09:00 and finishes at 17:00 for both.
It is best to liaise with each other when starting over where you’d like to begin – if one of you hasn’t taken the PSA yet. It’s recommended to start on the ward as triage has a greater number of prescriptions.
For annual leave you will need to ensure the ward and triage have adequate cover for the days you wish to take – I advise sorting this out between you within the first month, to ensure you both manage to take your allotted days of leave before the end of the rotation. Between the 2 of you there must always be 1 FY1 on the unit. There are also two trust grade doctors working on the ward: Dr Pamma (Oncology) and Dr Aurangzeb (Haematology and Oncology). There is also a 3rd doctor (Dr. Rehman) who covers triage.
Haematology - Triage
Triage Services
Both haematology and oncology patients have access to the triage service which runs from C4 09:00-17:00 Monday to Friday, and also on the weekend – however you only cover the weekday service. Furthermore, at 16:00 the triage service will refer any patients requiring in-patient assessment to the acute medical unit downstairs as this allows you to finish with the remaining patients till 17:00.
The triage service runs from a desk on C4 in between day case and the isolation unit.
Patients will phone through to the nurse sat beside you and run through a standard set of questions on their proforma, and make a decision where to go from there. These are both oncology and haematology patients. Occasionally they can give advice without needing to consult with you, or they will advise they need to consult with a doctor and will discuss with you on how to proceed. If this is the case it can include simply writing a prescription (e.g. laxatives), or a more in-depth review requiring a full history and examination in which you would call the patient in to attend the ward. Triage is allocated two corner spaces in the day case unit that have stretchers to assess patients on – as the rest of day case has chairs.
Common queries include side effects from chemotherapy such as nausea, vomiting, constipation, diarrhoea, a sore mouth or chemotherapy specific side effects. When assessing these presentations, it is about determining the severity.
Select the titles below to find out further information.
For example, with nausea they may have just finished their course of post-chemotherapy anti-emetics (usually dexamethasone + ondansetron) and require more as still feeling the side effects in which a prescription may suffice. However, if they are vomiting and not tolerating any food or fluids they will need to be admitted for intravenous fluids and anti- emetics.
With regards to mouth care, all patients should be on chlorhexidine QDS already. Other treatments that can be given include Difflam mouth wash (more analgesic), and Gelclair. Gelclair is 1 application TDS – not easily found in the BNF. When assessing patients post- chemotherapy, it is important to check for thrush as this is very common and will require treatment.
If patients are suffering from constipation – start by assessing how much of any laxatives prescribed they’ve had including those over-the-counter. Occasionally they may have 4 sachets of Movicol in a day – as the normal prescription is 2 sachets a day. Conversely, if a patient is suffering from diarrhoea it will be determining the severity such as the need for resuscitation with fluids and ruling out an infective cause with cultures given their immunocompromised state.
Any patient that has a temperature spike at home will automatically be asked to come in to check their blood counts as there is a risk of febrile neutropenia and neutropenic sepsis. The Georgina Unit handbook (on the Hub – type in ‘Georgina Unit Haematology Handbook) includes the protocol for neutropenic sepsis whereby it is the same as sepsis 6 – however cultures may also need to be taken from any lines in-situ and the antibiotic of choice may be different. Refer to the Georgina Unit Handbook for current antibiotic choice.
Rashes can be quite specific to certain chemotherapy agents – if you are unsure it is always best to run through with a senior. Knowledge will build up with time and you are not expected to know lots of detail about each chemotherapy agent.
Bisphosphonates are commonly given to patients with myeloma and it is important to rule out osteonecrosis of the jaw should any patients present with jaw pain. Therefore, requesting an OPG and maxillofacial review should cover this as any dental work required is usually done under their team due to immunocompromised status.
Often during triage assessments, you are deciding whether to admit a patient or not, and there is always a senior available to run things by: Dr Pamma (oncology) and Dr Aurangzeb (oncology and haematology) are both very approachable. Another point-of-call for haematology advice would be the registrars and if necessary the consultant on-call (who carries a bleep) or the patient’s named consultant. All the consultants are approachable and would prefer to be contacted for advice if in doubt.
Haematology Day Case
Triage
Part of triage is also covering the day-case unit where patients attend to have their chemotherapy. This is nurse-led with appointments pre-booked. Occasionally nurses will present with queries about whether to proceed with a patient’s treatment today.
Getting a good background of the patient helps deal with these queries. For example, try to ascertain the following details:
- Diagnosis
- Any metastases
- What the chemotherapy is for (E.g. palliative)
- Baseline health usually
- Baseline health post chemo
- Latest development in management – g. Scans
Assessing the patient
After acquiring the above details, you can go and assess the patient to see where their health is currently sitting at. For example, if the nurse reports the patient has a cough – it might be a simple lower respiratory tract infection, or the patient’s primary is lung cancer and they usually have a cough but it is more troublesome than usual.
If patients have an infection usually chemotherapy is deferred by 7 days and treated in the meantime. FY1s cannot make decisions regarding chemotherapy. Once you have assessed the patient, you must discuss it with a senior who will advise you whether the patient needs their chemotherapy deferring or not. Speak to Dr Pamma for Oncology patients and Dr Aurangzeb for Haematology patients. The haematology consultants are also happy to advise.
Bloods
Other queries can include deranged blood results as all patients have pre-chemotherapy bloods the day before. It helps to assess the trend of the patient’s bloods with their latest investigations/letters rather than look at the last results. For example, between their last cycle and second cycle their ALP may have risen – however if you search for their latest CT staging scan it may have revealed new liver metastases. Deranged electrolytes are also very common and the aim here is to assess if patients are symptomatic and no ECG changes for those that are relevant – E.g. Hyper/hypokalaemia.
ECHO
Another common request from day case staff is signing for ECHO requests. Female patients with breast cancer treated with Herceptin need regular ECHOs to ensure their ejection fraction is preserved. Nurses will usually have filled out all the required details and need your signature to request the ECHO.
Haematology Ward
Ward Round
The ward round usually begins in the isolation unit and is led by registrars +/- the consultant on call that week. For these patients you will need to put a plastic apron on and wash your hands each time you enter a room. These patients are often neutropenic or receiving in-patient chemotherapy requiring a higher level of monitoring before they become neutropenic. Occasionally stem cell transplants are received here also.
As often haematology patients have widely deranged full blood counts – C4 is the only ward that is allowed to transfuse patients out of hours. All other wards can only do so in an emergency.
Documentation for ward rounds includes the following points:
- Clinical observations
- Check if afebrile and when last temperature spike was if had one
- Diagnosis
- Treatment – how many days into this
- Issues
- Bloods
- Fluid balance + weight
Bloods
Bloods from isolation will usually come back first as the nurses will take them from the lines in-situ in the early hours of the morning.
Patients bloods will be reviewed prior to seeing each patient. Some patients are likely to require blood components transfusing. I recommend keeping a separate sheet so you can write down a list of who and how many units before you call blood bank (Ext.2488), and request them in one go. Make sure each patient’s blood component has also been prescribed. Generally, keep platelets >10, and >20 if they have active bleeding/infection, and aim to keep haemoglobin >80. Some patients will have special requirements – ask your senior which patients do and update the handover word document accordingly to remind you.
Ward MDT
Haematology ward MDT runs on a Wednesday afternoon which includes all the consultants, registrars, specialist nurses, a psychologist and other healthcare professionals available to attend. The ward registrar will usually update this list after the ward round and will likely ask you to print it off prior to the MDT (print 12 copies). MDT is on the first floor, in the same area as biochemistry and microbiology laboratories. Explain to the help desk you are here for Haematology MDT in the haematology consultants’ office and they will let you through.
This meeting can generate more jobs for the ward patients – therefore, as the staff move on to discuss the outliers if needed you can excuse yourself to start on those jobs before the day finishes.
If you wish to work on your presenting skills the consultant may ask you to present the ward patients from this morning’s ward round. This is actively encouraged.
Ward jobs
Any patients that spike a temperature will need a sepsis screen due to risk with neutropenia – however they will not need repeat cultures if taken within the last 24 hours.
When updating the ward list it will have a column for the antibiotic/chemotherapy treatment they are on and how long until their next course. A common query from ward nurses can be if a patient is well enough to have their chemotherapy today – again this must be run past a senior.
Otherwise ward jobs are very similar to other departments which include referrals, TTOs and requesting/chasing scans and reviews. When patients are discharged and they need a follow-up clinic it is best to liaise with the ward clerk to book them in before they leave. Concerning TTOs, haematology patients are usually on a range of prophylactic antimicrobials (they are usually prescribed as 999 days), patients usually go home on these. If you are unsure, ask your registrar.
Sometimes you may be asked to call microbiology on-call. I suggest ensuring you write a quick note prior to calling regarding the antibiotics the patient is currently on, how many days they’ve been on each antibiotic and what the indications were.
Haematology Learning Opportunities
Teaching
Russells Hall Hospital (RHH) foundation teaching is organised by the postgraduate department in RHH. You will receive information about this through the postgraduate co-ordinator via email. On Tuesday mornings you will be expected to go to your teaching at RHH as you need to attend a percentage of this (the percentage changes yearly) to pass the Foundation 1 programme. After this, I would suggest contacting your EIS consultant or registrar to organise where and when to meet them.
The timetable for this teaching is sent out weekly by the postgraduate department by email, so check these! A timetable is also printed out on the education board in the postgraduate centre.
MDT
As explained above the MDT is a good opportunity to work on presentation skills and learn about the multidisciplinary approach to haematology patients – E.g. Specialist nurses and psychological support.
Journal Club
Journal club is an opportunity to expand on critical appraisal skills when reviewing papers with feedback from the registrars and consultants.
On-call
As one of the haematology FY1s you will either be rostered for general medical on-calls or part of the extra cover rota depending on what your colleague has. The Hub has the rotas for these.
Audits
The audit lead for the department is consultant Dr Gamage. Trust mandatory audits occur during the first rotation of FY1, therefore it is a good opportunity to do one for your portfolio requirement and present it at the Friday journal club meetings. There are also opportunities for different audits if you prefer in which you can liaise with Dr Gamage as above.
Grand Rounds
These are weekly on Thursdays between 13:00-14:00 in the education centre. These are lectures presented by different clinicians in the trust on useful and important topics.
Health and Wellbeing
Staff that are happy and thriving in their working environment will inevitably have a more enjoyable experience in the workplace, contributing to the provision of excellent health care for all of our patients. The Dudley Group recognises our commitment to staff wellbeing in a variety of ways.
Select the link below to find out more how the Trust can support you.
