2.3 Scope of Satellite Practice

Delivery of Chemotherapy
Delivery of Chemotherapy within the scope of satellite practice is to be based on the delivery of selected maintenance chemotherapy and elective chemotherapy.  Specific guidelines pertaining to administration of these selected chemotherapeutic agents include guidelines for route of administration, appropriate precautions, and monitoring requirements; these guidelines are detailed in Section 2.2.1.

Calculation of Dose
The dose will be calculated in the tertiary centre. However, the prescribing physician or Advanced Practice Nurse/Nurse Practitioner in the satellite centre should re-calculate the dose prior to prescribing based on weight and height in reference to current protocol and stage of protocol.  If this re-calculated dose differs by more than 10% in either direction from that calculated by the tertiary centre, consultation with the tertiary centre is mandatory.

Note: Tertiary centres are responsible for supplying the current does/m² and anticipated dose adjustments specified by the protocol.

Management of Specified Oncologic Emergencies
There must be 24-hour availability of:

1. The designated pediatrician, or the designated backup pediatrician, trained and aware of the protocols surrounding the management of pediatric oncology emergencies, most notably Fever and Neutropenia. It is acknowledged that pediatricians on the regular call roster may be responsible for the initial management of patients presenting with F/N and the Satellite’s Lead Physician must accept responsibility for ensuring the appropriate training and maintenance of competency in these matters of all staff who may be engaged in the regular on-call schedule.
2. Specialized nursing care for hospitalized patients in a pediatric in-patient setting, expertise in the management of central venous catheters, and understanding of common problems in this patient population.
3. Transfer to the tertiary centre in case of emergency, as specified in the guidelines.
4. Routine blood counts and chemistry, using micro-technology and cultures with appropriate access to necessary expertise – e.g venous access personnel and blood bank technicians who can prepare specialized products.
5. On-call X-ray technician and Ultra Sound technician.
6. Blood products of all types (including irradiated products) within reasonable time limits.
7. Practice guidance documents for Central Venous Catheters (CVC’s), and Fever and Neutropenia should be kept on site in the Emergency Room or the location in which such after hours patients are seen in the particular satellite institution.

With regard to the management of patients experiencing treatment complications or deteriorating health status: Patients experiencing treatment complications whose clinical status deteriorates while being managed in the Satellite context MUST be transferred promptly to the appropriate tertiary centre according to the recommendations outlined in the clinical practice document, When to Consult the Tertiary Centre.

Effective Pain Management
Effective Pain Management particularly management of terminal pain should be carried out according to standards of practice.^{1 2 3 4} 
Particular emphasis has been placed on Chronic Pain Management and its variants including neuropathic pain. Inability to control such pain requires consultation with the tertiary centre.

Clinical Communication between Centres
Clinical communication between centres occurs via Initial Data Transfer; dictated physician referral letter; Shuttle Sheet as follows:

1. The initial data transfer from the tertiary centre⁵ will include a physician’s dictated referral letter, an “Initial Data Transfer Form”, completed by the designated tertiary nurse coordinator for the case and sent to the designated nurse in the pediatric oncology satellite program. Both documents are to be faxed via a secure fax with a copy sent by mail.  In addition to these documents, a copy of the treatment schema should be sent for reference and the roadmap or treatment plan should be sent as appropriate.
2. The Psychosocial Communication Tool will be completed by most responsible allied health professional (e.g. Child Life Specialist, Interlink Nurse, Psychologist, Social Worker), and sent within 3 days of referral to the Satellite Site as part of the standard referral process.
3. Routine communication between the tertiary centre and the satellite centre will include a copy of the section of the protocol pertinent to the next satellite visit from the tertiary centre and a shuttle sheet from both the tertiary centre and the satellite centre.

Note: The Shuttle sheet is used to share information between shared care partners.  In 2008 transmission of the shuttle sheet will be converted from a paper based tool to an electronic web based tool developed by eCHN. The contents have been carefully selected to serve the needs of the pediatric oncology network for clinical, research and service analyses.  The satellite centres and the tertiary hospitals depend on the information in the shuttle sheet and this must be complete and accurate and available in a timely fashion.

The procedure for completion of the shuttle sheet is as follows:

1. The child’s visit to the tertiary centre immediately prior to his/her transfer to the satellite program will be documented on the Initial Data Transfer sheet and faxed with appropriate documents by the tertiary staff to the satellite nurse coordinator as soon as possible, but within 24 hours.
2. Each subsequent visit to the tertiary outpatient clinic or the inpatient areas that occurs immediately prior to transfer back to Satellite care will be documented on a Shuttle Sheet and sent via web based technology to the Satellite centre nurse coordinator as soon as possible, but within 24 hours.
3. Every visit to the satellite centre outpatient clinic including one in which the patient is subsequently admitted, will be documented on the shuttle sheet and sent to the shared care tertiary partner nurse coordinator as soon as possible, but within 24 hours of each contact with satellite staff.
4. Each Satellite Centre inpatient discharge will be documented on a shuttle sheet and sent via the web based technology to the shared care tertiary partner as soon as possible but within 24 hours of discharge or within 48 hours if discharge occurred on a weekend.
5. The satellite ambulatory clinic nurses will maintain regular contact with tertiary caregivers and will provide comprehensive and accurate data as specified in these guidelines (Section 6.5.1), to ensure clinical accuracy and continuity of care of the child/family.
6. Information will be flowed from the designated tertiary centre case coordinator to the designated clinic nurse(s) in the satellite clinic, rather than the pediatrician.

Note: A small but significant number of patients, not formally referred to the satellite centre, show up at the emergency room of satellite hospitals and other community hospitals with bleeding or fever/neutropenia.  Since this often happens after hours, and information is not readily available, consideration will have to be given to the creation of a minimal data set to be retained by the parents for patients who live in a geographic area that suggests that they may make use of the satellite centre or local community hospitals on an ad hoc basis.  This is NOT intended to encourage ad hoc arrangements, but to facilitate care under emergent/urgent circumstances.

¹  McGrath, PJ, McAlpine L. Psychologic perspectives on pediatric pain. The Journal of Pediatrics, 122(6): Part I and II, 1993.
² Kuttner, L. (1996). A Child in Pain: How to Help, What to Do. U.S.A.: Hartley & Marks Publishers, Inc.
³ AMA Pain Management: Pediatric pain management. Retrieved from http://www.ama-cmeonline.com/pain_mgmt/module06/03pain/index.htm January 24, 2007
⁴ Pain Management Staff Development & Education University of Michigan Health System. Retrieved from http://www.med.umich.edu/pain/pediatric.htm 
⁵ It is anticipated that over the next few years that new electronic tools will be used to communicate patient specific information between shared care partners. The initial data transfer sheet will be the next document on the agenda.

Reviewed by the POGO Satellite Manual Review Scope of Practice Working Group, 2016.

Published: September 22, 2016.