Five current documents on one childhood-cancer ward. They do not agree on fever, on antibiotics, on who may visit, or on how a line is locked. The disagreement families take home is the one that can delay care.
Three different age bands (under 16 / 0–18 / 0–21) on one ward. A 17-year-old with a Broviac and fever sits in a gap.
Fever at home — come now, or wait until morning?
Highest risk
POL-CW-01: come to ER the same evening. No paracetamol before assessment. Door-to-antibiotic 60 minutes. Not ceftriaxone.
POL-CW-05: 38.0°C and well → paracetamol and clinic next working day. Door-to-antibiotic 90 minutes. Usual drug ceftriaxone. POL-CW-04 also sends night fever after an infusion to the day unit in the morning.
POL-CW-01 section 7 required the leaflet to match the FN pathway. It does not. Infectious Diseases has not countersigned POL-CW-05.
What counts as neutropenia?
Contradiction
POL-CW-01 and POL-CW-03: ANC below 500/µL.
POL-CW-02: for line decisions, ANC below 1000/µL. POL-CW-04 holds a cycle if ANC is 1000 or lower.
500 vs 1000 is a real clinical fork, not a wording quibble. The folder never says which number a night nurse should use.
Who is a child on Cedar Ward?
Contradiction
POL-CW-01 and POL-CW-03: 0–18 years.
POL-CW-02: under 16 (16–18 sent to adult haematology, whose protocol is not in this folder). POL-CW-04: 0–21.
First-line antibiotic
Contradiction
POL-CW-01: piperacillin-tazobactam. Penicillin rash → cefepime. “Do not use ceftriaxone as first-line.”
POL-CW-02 (line infection): vancomycin + cefepime. POL-CW-05 (what families are told): ceftriaxone.
Culture order, and whether to wait for the attending
Contradiction
POL-CW-01: peripheral culture first, then every lumen. Antibiotics after cultures. May run through the line. Do not wait.
POL-CW-02: line first. Peripheral optional if stable. Notify attending within 2 hours. Do not start antibiotics through the line until the attending has reviewed.
Heparin locks
Contradiction
POL-CW-02: no heparin on PICCs or Broviacs. Monthly heparin only on a sleeping port. POL-CW-01: no heparin as part of the FN pathway.
Same file POL-CW-02, discharge sentence: every central line goes home with a heparin lock. POL-CW-05: do not use saline alone — the line will clot.
POL-CW-02 disagrees with itself. The leaflet picked the discharge sentence and ignored the “no heparin” rule.
How many visitors when ANC is below 500?
Contradiction
POL-CW-01: two named caregivers. No children under 12.
POL-CW-03: well adult visitors, no cap on numbers. No children under 12. Overnight stay only with permission — while families are not told this at discharge.
Where is the spill kit?
Contradiction
POL-CW-04: Room 12 clean utility, top shelf, yellow. “Do not store the spill kit in the dirty utility.” Isolation gowns must not share that cupboard.
POL-CW-03: spill kit and isolation gowns live in dirty utility cupboard B.
ANC is not “white cells plus bands”
Error
POL-CW-05 tells families that the absolute neutrophil count is the white cells plus the bands. ANC is the neutrophils (and usually bands) as a subset of the white-cell count, not the white-cell count itself. A parent who hears “white cells 2.0” may think the child is not neutropenic.
Rewrite the leaflet in one sentence: “Neutrophils are the white cells that fight bacteria. Below 500, a fever is an emergency.” Owner: Nursing Education, countersigned by ID.
Warm compress for doxorubicin
Error
POL-CW-04 sends vinca alkaloids to a warm compress (usual) and anthracyclines (doxorubicin, daunorubicin) to a warm compress as well. Standard extravasation teaching is cold for anthracyclines, warm for vincas. A warm pack on a doxorubicin extravasation is the wrong pack.
Pharmacy to replace the anthracycline line with cold compress and antidote (dexrazoxane) per the current house extravasation card — not this paragraph.
Chlorhexidine 4% aqueous, no alcohol
Error
POL-CW-02 specifies 4% aqueous chlorhexidine and forbids alcohol. Line-insertion and dressing bundles usually use alcoholic 2% chlorhexidine and need a dry time. 4% aqueous is a surgical scrub concentration, not the usual CVAD skin prep.
Vascular Access to confirm against the product actually on the trolley and rewrite the sentence.
Influenza exclusion “3 days after the fever starts”
Possible error
POL-CW-03 lets a visitor return three days after fever begins, even if they still feel hot. Usual staff/visitor rules wait until 24 hours without fever, often with a 5–7 day floor. Measles (21 days) and varicella (crusted) in the same file look right.
IPC to replace with the current occupational-health influenza rule and to review the whole file — it is overdue.
Five moments of hand hygiene
Duplication
POL-CW-02 section 8 and POL-CW-03 section 6 are almost the same paragraph. When IPC updates the five moments, one file will be missed.
Keep the full text in POL-CW-03. In POL-CW-02, one line: “Hand hygiene as POL-CW-03.”
No live plants
Duplication
POL-CW-03 bans plants in protective isolation. POL-CW-04 bans plants in rooms where chemotherapy is given. Same ward, two owners, two sentences.
One plant rule, owned by IPC, pointed to from chemo safety.
When to come to ER — two lists
Duplication
POL-CW-01 and POL-CW-05 both list when a family should come in. The lists use different temperatures, different clocks, and different first drugs. This is duplication plus contradiction. The leaflet is the copy families actually read.
One ER list, owned by ID, pasted into the leaflet without rewriting the numbers.
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Infectious Diseases + Nursing Education — this week
Withdraw POL-CW-05 from the discharge pack until it matches POL-CW-01 on fever, paracetamol, door-to-antibiotic time, and first-line drug. A leaflet that is unsigned by ID is not a leaflet.
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Medical director, Cedar Ward
Pick one age band and one ANC cut-off for the ward, and put both in a one-page cover sheet that every policy points to. Until then, a 17-year-old with a line and ANC 700 has no home in this folder.
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Vascular Access
Delete one of the two heparin rules in POL-CW-02. Align the discharge lock with POL-CW-01. Confirm chlorhexidine product and concentration against stock.
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Pharmacy
Correct the doxorubicin extravasation compress. Confirm first-line FN drugs with ID so the leaflet, the line protocol, and the FN protocol name the same molecule.
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IPC
Review POL-CW-03 (overdue). Reconcile visitor numbers with POL-CW-01. Move the spill-kit sentence to POL-CW-04’s location. Shorten the duplicated hand-hygiene and plant rules to pointers.
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Quality
Give every Cedar Ward policy a single owner who must countersign the family leaflet. Re-run this folder through the standing orders in CLAUDE.md after the next edit.