Oncology Nursing Society 43nd Annual Congress May 17–20, 2018 • Washington, DC 1 Clinical Practice 1. Evaluation of a Standardized Titration Schedule to Be Utilized for the Administration of All Paclitaxel Infusions Carrie Patton, BSN, RN, OCN MemorialCare Todd Cancer Institute Long Beach, CA 2. Improving Communication in the Transfer of Care in Nursing Handoff: Perfecting a Culture of Nursing Collaboration and Patient Safety in the Outpatient Infusion Setting Stacy Farrell, MSN, RN, OCN Memorial Sloan Kettering Cancer Center Basking Ridge, NJ 3. Combating Chemotherapy Verification Fatigue: Nurse-Led Quality Improvement Interventions in Pre-Treatment Lab Evaluation Aya Sato-DiLorenzo, RN, BSN, OCN, BMTCN Beth Israel Deaconess Medical Center Boston, MA 4. Wake Up: A Prescription for Increasing Patient Safety in the Ambulatory Infusion Room Jennifer Foster, BSN, RN, OCN, ONN-CG Baylor Scott and White Hospital Temple, TX Nurse-Led Improvements and Collaborations in Outpatient Settings Friday, May 18 • 2:45–4 pm Note one action you’ll take after attending this session: ____________________________________________________ ________________________________________________________________________________
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Oncology Nursing Society 43nd Annual CongressMay 17–20, 2018 • Washington, DC 1Clinical Practice
1. Evaluation of a Standardized Titration Schedule to Be Utilized for the Administration of All Paclitaxel InfusionsCarrie Patton, BSN, RN, OCNMemorialCareTodd Cancer Institute Long Beach, CA
2. Improving Communication in the Transfer of Care in Nursing Handoff: Perfecting a Culture of Nursing Collaboration and Patient Safety in the Outpatient Infusion SettingStacy Farrell, MSN, RN, OCNMemorial Sloan Kettering Cancer CenterBasking Ridge, NJ
3. Combating Chemotherapy Verification Fatigue: Nurse-Led Quality Improvement Interventions in Pre-Treatment Lab EvaluationAya Sato-DiLorenzo, RN, BSN, OCN, BMTCNBeth Israel Deaconess Medical Center Boston, MA
4. Wake Up: A Prescription for Increasing Patient Safety in the Ambulatory Infusion RoomJennifer Foster, BSN, RN, OCN, ONN-CGBaylor Scott and White Hospital Temple, TX
Nurse-Led Improvements and Collaborations in Outpatient SettingsFriday, May 18 • 2:45–4 pm
Note one action you’ll take after attending this session: ____________________________________________________
Registered NurseMemorial Care, Long Beach Medical Center
Todd Cancer Institute
Disclosures
• None
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Clinical Practice (Patton) 2
Background
• Paclitaxel (Taxol)– A popular chemotherapy agent used in the treatment of a
number of cancers including:• Ovarian, breast, lung, cervical, pancreatic, and many others
– Classified as a: • Taxane• Plant alkaloid
– Natural derivative
Background • Paclitaxel is often associated with hypersensitivity reactions ranging
from mild to severe– Including:
• Generalized uticaria, facial flushing, shortness of breath, angioedema, and anaphylaxis
– Most reactions occur during the first or second infusions
78% within the first 10‐15 minutes
of initiation of the drug
Literature Review
A thorough literature review conducted revealed:
• Although limited, data was available for patients who had experienced a hypersensitivity reaction in regards to re‐challenge and desensitizing protocols.
• Scarcity of data existing regarding guidelines for administering Paclitaxel during initial infusions.
References• Huddleston, R., Berkheimer, C., Landis, S., Houck, D., Proctor, A., &
Whiteford, J. (2005, May/June). Improving Patient Outcomes in an Ambulatory Infusion Setting. Journal of Infusion Nursing, 28(3), 170-172. doi:10.1097/00129804-200505000-00004
• Weiss, R. B., Donehower, R. C., Wiernik, P. H., Ohnuma, T., Gralla, R. J., Trump, D. L., . . . Leyland-Jones, B. (1990, July 8). Hypersensitivity reactions from taxol. Hypersensitivity Reactions from Taxol, 8(7), 1263-1268
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Clinical Practice (Farrell) 1
Nurse-Led Improvements and Collaborations in Outpatient
SettingsStacy Farrell MSN, RN, OCN
Chemotherapy Infusion Nurse Memorial Sloan Kettering Cancer Center
Basking Ridge, NJ Regional Center
Disclosures
• The authors of this presentation have no actual or potential conflict of interest in relation to this program/presentation
• There is no underwriting or funding for this presentation
• All of the authors are clinical nursing staff members at Memorial Sloan Kettering Cancer Center, Basking Ridge, NJ Regional Infusion Unit
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Clinical Practice (Farrell) 2
Improving Communication in the
Transfer of Care in Nursing Handoff
Perfecting a Culture of Nursing Collaboration and Patient Safety
in the Outpatient Infusion Setting
Mary Wilson-Carnes BSN, RN, OCNTara Cheney BSN, RN
Rodwell Manalo BSN, RNHeidi Foss BSN, RN, OCN
SignificanceApproximately 300 million handoffs occur each year in the U.S.
• Joint Commission Center for Transforming Healthcare reported miscommunication as “the leading root cause of sentinel events.”
(Joint Commission Perspectives, 2012)
• The World Health Organization (WHO) includes improved communication in handoff in its top five patient safety solutions
• Consequences of inadequate handoff:– Inappropriate, delayed or omitted treatment– Adverse events– Inefficiency – Patient harm and dissatisfaction– “Nurses may be found legally liable for failure to report necessary information
during handoff.” (Riesenberg, Leitzsch & Cunningham, 2010)
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Extended Operating Hours from 10-12 hours Need for end of day transfer of patient care at shift change
Background/Purpose
HuddleBrief Group Meeting
General
HandoffOne to OneSpecific
Question, Clarify, Confirm
Goals: Improve communication, patient safety and nursing satisfaction with the handoff process.
– Standardize critical content – Hardwire within your system
• Hand off tool • Expectations set about conducting successful handoff
– Allow opportunity to ask questions – Reinforce quality and measurement
• Use the forms • Consider looking at safety measures (i.e. NSI like falls)
– Educate and coach • Make successful hand off a priority at organizational level
Joint Commission Perspectives August 2012 Volume 32 Issue 8
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AFFIX PATIENT STICKER POD#:CODE STATUS: FULL DNR
HIGH RISK FOR FALLS: YES NO
ALLERGIES:
PRECAUTIONS:
DIAGNOSIS / TREATMENT C#___
Hx of REACTION IRB#__________
VITALS ht:______cm / wt:______kg
VS: _________________ ABNORMAL
OBTAIN POST VITALS PERFORM ORTHOSTATICS
ACCESS
PIV:_____ PICC HAI IP
MEDIPORT OTHER: ____________
LABS
ABNL POST
RE‐DRAW
________
PRE‐MEDICATIONS
CHEMO / BIO / PLAN / IMPLEMENTATION / EVALUATE
ASSISTIVE DEVICES
CANE WHEELCHAIR WALKER
OTHER: _____________________
NEURO
ORIENTED: PERSON PLACE TIME
MOTOR SENSORY DEFICIT: YES NO
PAIN
#____ / 10 REASSESS
GU / GI
I&O COMMENTS:
SKIN / MUSCULOSKELETAL
CARDIOVASCULAR
EKG ECHO/MUGA COMMENTS:
RESPIRATORY
O2 _____ OTHER:______________ PFTs
COMMENTS:
DISCHARGE / END TIME
CHAP EMAR Follow Up Task
Hand OffTool
Handoff Process Work FlowSending RN prepares for
Handoff:Completes Written
Handoff Form
Sending RN Verbally Reviews Written Handoff Form with
Receiving RN Questions Clarification
team?
Are there any more issues to
clarify with treatment
team?
Sending RN contacts treatment team for plan and contact information
Yes
No
Sending and Receiving Sending and Receiving RNs meet Patient in Treatment POD and
complete Verbal, Written and
Technologic Handoff
Barriers to Effective Handoffs• Communication barriers• Lack of standardization• Equipment issues• Environmental issues• Inadequate or misuse of time• Complex cases and high work loads• Inadequate training or education• Human factors
(Riesenberg, Leitzsch & Cunningham, 2010)
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Models used in Handoff• SBAR• S- Situation• B- Background• A- Assessment• R- Recommendation
• I PASS THE BATON• I- Introduction• P- Patient (identify the patient)• A-Assessment (V/S, symptoms etc)• S- Situation (current status)• S- Safety Concerns (falls precautions, allergies)• THE• B- Background (history, meds)• A-Action (action taken or required)• T- Timing• O- Ownership• N- Next Sandlin, 2007
Results
65%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Huddle Handoff
Does the Transfer of Care Tool Provide Adequate Information?
Does the Transfer of Care Tool Provide Adequate Information?Huddle n=20Handoff n=16
Huddle Handoff
RN Perception of Safety 55% 93%
RN Ability to Ask Questions 55% 93%
RN Retention of Information 41% 100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Huddle versus Handoff RN Survey
Pre n = 20Post n= 16
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Nursing Implications• Improved patient safety and outcomes
• Enhanced nursing collaboration and satisfaction
• Improved the quality of communication in the TOC in nursing handoff
References• Arora, V., & Farnan, J. (2017). Patient Handoffs, from https://www.uptodate.com/contents/patient-handoffs#!• Eggins, S., & Slade, D. (2015). Communication in clinical handover: improving the safety and quality of the
patient experience. Journal of Public Health Research,4(3). doi:10.4081/jphr.2015.666• Goldenhar, L. M., Brady, P. W., Sutcliffe, K. M., & Muething, S. E. (2013). Huddling for high reliability and
situation awareness. BMJ Quality & Safety, 22(11), 899-906. doi:10.1136/bmjqs-2012-001467• Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-off
Communications, Joint Commission Perspectives®, August 2012,32(8). Joint Commission on Accreditation of Healthcare Organizations, from http://www.jointcommission.org/assets/1/6/tst_hoc_persp_08_12.pdf
• Koenig, C. J., Maguen, S., Daley, A., Cohen, G., & Seal, K. H. (2012). Passing the Baton: A Grounded Practical Theory of Handoff Communication Between Multidisciplinary Providers in Two Department of Veterans Affairs Outpatient Settings. Journal of General Internal Medicine, 28(1), 41-50. doi:10.1007/s11606-012-2167-5, from https://www.ncbi.nlm.gov/pubmed/22868947
References• Riesenberg, L. A., Leisch, J., & Cunningham, J. M. (2010). Nursing Handoffs: A Systematic Review of
the Literature. AJN, American Journal of Nursing, 110(4), 24-34. doi:10.1097/01.naj.0000370154.79857.09, from https://www.ncbi.nlm.nih.gov/pubmed/20335686
• Sandlin, D. (2007). Improving Patient Safety by Implementing a Standardized and Consistent Approach to Hand-Off Communication. Journal of PeriAnesthesia Nursing, 22(4), 289-292. doi:10.1016/j.jopan.2007.05.010, from http://www.jopan.org/article/S1089-9472(07)00169-4/fulltext
• Søndergaard, E., Grøne, B., Wulff, C., Larsen, P., & Søndergaard, J. (2013). A survey of cancer patients’ unmet information and coordination needs in handovers – a cross-sectional study. BMC Research Notes, 6(1), 378. doi:10.1186/1756-0500-6-378, from http://www.biomedicalcentral.com/1756-0500/6/378
• Streeter, A. R., Harrington, N. G., & Lane, D. R. (2016, December 08). Communication Behaviors for an Effective Patient Handoff. Communication Currents, National Communication Association, from https://www.natcom.org/communication-currents/communication-behaviors-effective-patient-handoff
• Ulrich, B., & Kear, T. (2014). Patient safety culture in nephrology nurse practice settings: Initial findings. Nephrology Nursing Journal, 41(5), 459-475, from http://www.prolibraries.com/anna/?select=session&sessionID=3102
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Clinical Practice (Sato‐DiLorenzo) 1
Combating Chemotherapy Verification Fatigue: Nurse-led Quality Improvement Interventions in
Pre-treatment Lab Evaluation
Aya Sato-DiLorenzo, RN, BSN, OCN, BMTCNUnit Based Educator
Ambulatory Hematology/Oncology & Bone Marrow Transplant Beth Israel Deaconess Medical Center
Team Hematology‐Oncology Team Hematology/Bone Marrow Transplant
Planning
“orders approved by nurses but halted by pharmacy”Define near-misses
Reduce the number of near-misses by fifty percent over three months
Aim statement
Tools Used to Analyze Baseline Processes and Barriers
Process Map
Cause-and-Effect Diagram
Staff Survey
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Process MapTo understand baseline nursing processes
Unit-Based Nursing SurveyTo understand existing barriers as identified by staff nurses
The survey was created and analyzed in Survey Monkey
Cause and Effect DiagramTo categorize each existing barrier and visually present its influence on the system.
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Brainstorming Sessions by Nurses
Ideas on post-it notesGroup discussions
Selecting InterventionsEach idea on a post-it notewas placed in one of the coordinates within a priority/pay-off matrix according to its potential effectiveness (low to high impact) and perceived ease (difficult to easy).
Ideas organized in priority/pay-off matrix
easy & high Impact interventions are encouraged.
Chosen Interventions
Two-RN lab check during verification.
Utilization of "display the last day lab results" function in EMR to limit lab display to the most recent results only.
Practice champions from each treatment area initiated these interventions and encourage their peers to follow their lead.
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Study the Results
Interven
tions
Study Sustainability
Post‐intervention Follow up surveillance
Unit-Based Follow Up Survey
Barriers to full success identified by nurses• Returning to past habits.• Primary nurse telling the second verifying nurse that pre-
treatment labs have been verified.
The survey was created and analyzed in Survey Monkey
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Key Conclusions
Our nurse-identified-and-led interventions were successful in reducing the number of near-misses.
Identification of latent failures and interventions to correct them may be necessary to engender sustainable changes.
Further interventions are needed to sustain a low occurrence over time.
What’s Next?
A project by clinical nurses with the aim to improve provider-nurse communication.
Clinical guidelines by pharmacy addressing toxicity monitoring for treatment regimens frequently used at our institution.
A project by nursing leadership to improve the clarity of chemotherapy orders.
Three TakeawaysChoose your interventions wisely. Do not jump into conclusions without careful analysis of contributing factors.
Not gaining the result you were looking for does not mean a failure. It is your opportunity to dig in deeper.
Engage your colleagues and find solutions that are supported by many.
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How to Reach Us:Project Leader:Aya Sato-DiLorenzo, RN, BSN, OCN, BMTCNUnit Based Educator
Ambulatory Hematology/Oncology & Bone Marrow TransplantBeth Israel Deaconess Medical Center
• Patients complained of and nurses noted increased adverse side effects from diphenhydramine during the first two cycles of treatment (traditionally paclitaxel) and the physicians would often switch the patient to cetirizine at the nurses’ request
• Nurses questioned, “Why use diphenhydramine?” –because that is how the drugs causing hypersensitivity were studied, and that is “always how it has been done”
Second Generation H₁Antihistamines
• Emerged in the 1980s• Examples: terfenadine, astemizole, loratadine,
cetirizine, and levocetirizine• Developed to decrease the side effect profile of
antihistamines (₃)• Second generation H₁ antihistamines occupy
approximately 20% of H₁-receptors in the brain which correlates with less cognitive dysfunction (₃)
Comparison of First and Second Generation H₁ Antihistamines
First Generation AntihistamineSide Effects
Second Generation AntihistamineSide Effects
CNS depression (somnolence, impairedcognitive and psychomotor performance)
Other CNS effects (seizures, dyskinesia, dystonia, hallucinations)
Diphenhydramine Onset of Action Cetirizine Onset of Action
15‐60 minutes 15‐30 minutes
(₄)
(₁)
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Implementation• RNs requested review of current practice by
pharmacy/physician group• Pharmacist completed literature review comparing efficacy of
various premedications (antihistamines)– Limited data available– Cetirizine thought to be acceptable option
• Physician buy-in• Order sets were updated to reflect the change from IV
diphenhyradmine to oral cetirizine as a premedication for: paclitaxel, cetuximab, and rituximab
ResultsSwitch from diphenhydramine to cetirizine in the ambulatory infusion setting demonstrated:• No rise in the number of hypersensitivity reactions• No increase in the required wait time after premedication
(does not effect time for scheduling infusion chair)• Decreased incidence of CNS-related effects, reduced
patient reports of adverse side effects, diminished need for one-on-one nursing care, and overall improved patient safety
Key Takeaways• No increased frequency/severity of reactions with use of
cetirizine vs. diphenhydramine and no effects on the length of infusion chair time (premedication wait time)
• Nurses noted decreased safety concerns and that patients verbalized fewer antihistamine related complaints with the switch to cetirizine
• Nurses can impact safety by being patient advocates by speaking up and questioning the “status quo”
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References1. Banerji, A., Long, A. A., & Camargo, C. A. (2007). Diphenhydramine
versus nonsedating antihistamines for acute allergic reactions: A literature review. Allergy and Asthma Proceedings, 28(4), 418-426. doi:10.2500/aap.2007.28.3015
2. For Older Adults. (2016, April 20). Retrieved from https://www.cancer.net/navigating-cancer-care/older-adults
3. Kay, G. (2000). The effects of antihistamines on cognition and performance. Journal of Allergy and Clinical Immunology, 105(6),
622-627. doi:10.1016/s0091-6749(00)79554-64. Mahdy, A. M., & Webster, N. R. (2008). Histamine and antihistamines.
Anaesthesia & Intensive Care Medicine, 9(7), 324-328. doi:10.1016/j.mpaic.2008.04.016