Nurse-Led Improvements and Collaborations in Outpatient

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: ____________________________________________________

________________________________________________________________________________

ONS 43rd Annual Congress

Clinical Practice (Patton) 1

Formation of a Paclitaxel Titration Schedule to Reduce

Hypersensitivity ReactionsCarrie Patton, BSN, RN, OCN

Registered NurseMemorial Care, Long Beach Medical Center

Todd Cancer Institute

Disclosures

• None



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.



Administration Guidelines• Manufacturer provided administration

guidelines include:– Pre-medications

• Corticosteroids, Diphenhydramine, H2 antagonists

– Subjective recommendation • “Administer slowly”

Strategy Review current

nursing practices

•Individual one‐on‐one interviews conducted with each AIC RN

Identify variations in administration

practices

•Attempt to correlate infusion practices with reaction rates

Standardize infusions

•Establish a titration schedule for all Paclitaxel administrations

Retrospective chart review was conducted

on all patients who received Paclitaxel in

the Ambulatory Infusion Center over a

14 month period

Retrospective Study Results

>10% reaction ratein patients receiving 3-hr

infusions

Significantly more reactions occurred when

tubing unprimed



PlanStaff Education

• New titration schedules to be followed regardless of infusion time, patient reaction history, or volume.

– 999 mL/hour (20 mL) Initial priming step over 1 minute

– 10mL/hour for 5 minutes (0.83 mL)– 25mL/hour for 5 minutes (2.08 mL)– 50mL/hour for 5 minutes (4.17 mL) – 100mL/hour for 5 minutes (8.33 mL) THEN

– 182 mL/hour for 2 hours and 40 minutes (3-hour Paclitaxel)

– 350 mL/hour for 40 minutes (1-hour Paclitaxel)

Pharmacy Labeling

Total volume infused is 15.41mL

in initial 20minutes

Study 3 month period of data collection

on EVERY Taxol infusion including: RN administering medication Date Pt Initials Cycle/Dose(mg) Pre-meds given Reaction Re-challenge with specific re-

challenge protocol Subsequent reaction w/re-challenge

Study Results

99%

1%

Total number of Taxol administrations

NO

YES

3 month data revealed a decrease in reaction rate to <1%

<1% reaction rateobserved in

(combined 1-hr and 3-hr infusions)



Project Takeaways

• Prime the line…EVERYTIME– Initial step of your titration schedule should always be to clear the priming volume from

the tubing– This ensures your titration schedule begins with the administration of the drug and not

saline or other priming solution.

• Slow and Steady– Titrating Taxol introduces the drug slowly to the body and allows for early recognition and

intervention in the event of a hypersensitivity reaction.

• Consistency is key– Standardizing administration practices not only decreases reactions but increases nursing

and patient confidence with infusion.

Special Thanks• Todd Cancer Institute

Memorial Care, Long Beach Medical Center• Project Co-Authors

– Nicolann Hedgpeth, DNP, RN, AOCNP– Kresta Grabau, BSN, RN, OCN– David Lu, PharmD-Student Intern

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


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



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)



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.

https://www.uptodate.com/contents/patienthandoffs/print?source=search_result&search+h

Methods• Pre and post surveys were conducted to evaluate nursing perceptions, safety,

information retention and efficacy of tools.

• A new systematic handoff tool and procedure were developed and implemented

Transfer of Care Handoff Form•Developed and implemented •Chairside report•Standardized and systems focused

• Transfer of Care Process • Changed from a huddle style report to a

one to one nurse handoff• In the presence of the patient• Interactive verbal and written

JCAHO Targeted Solutions for Hand Off

• http://www.jointcommission.org/assets/1/6/tst_hoc_persp_08_12.pdf• SHARE

– 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



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)



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



Nursing Implications• Improved patient safety and outcomes

• Enhanced nursing collaboration and satisfaction

• Improved the quality of communication in the TOC in nursing handoff

Effective handoff

Meet the Team• Tara Cheney BSN, RN ([email protected])• Stacy Farrell MSN,RN,OCN ([email protected])• Heidi Foss BSN, RN,OCN ([email protected])• Rodwell Manalo BSN,RN ([email protected])• Mary Wilson-Carnes BSN, RN, OCN ([email protected])



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


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

Disclosures

• I have nothing to disclose.



Our QI WarriorsCombating Chemotherapy Verification Fatigue

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



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.



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.



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



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.



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

[email protected]

Project Coach:

Meghan Shea, MDAttending Medical Oncologist, Beth Israel Deaconess Medical Center &

Instructor in Medicine, Harvard Medical School

[email protected]

References• Spath, P. L. (2011). Error reduction in health care: a systems

approach to improving patient safety. Jossey-Bass.• Zerillo, J. (2017). Oncology quality process improvement project

training. Lecture presented at Oncology Quality Process Improvement Project (PIP) in Beth Israel Deaconess Medical Center, Boston.


Clinical Practice (Foster) 1

Wake Up: A Prescription for Increasing Patient Safety in the

Ambulatory Infusion RoomJennifer Foster, BSN, RN, OCN, ONN-CGGenitourinary Cancer Nurse Navigator

Jennifer Havens, BSN, RN, OCN, ONN-CGLung Cancer Nurse Navigator

Baylor Scott & White Vasicek Cancer Treatment Center

Disclosures

• The presenter has no financial relationships to disclose



Preventing Allergic Reactions• A large number of cancer therapy infusions have the potential to cause

hypersensitivity reactions• Prevention of hypersensitivity reactions traditionally includes the use of H₁

antihistamines, i.e. diphenhydramine• Diphenhydramine is a first generation H₁ antihistamine that was introduced

in1945 (₁)– Traditionally has been the medication of choice for acute allergic

reaction/anaphylaxis– In studies utilizing chemotherapy/biotherapy, diphenhydramine is frequently

used in the prevention of infusion reactions– First generation H₁ antihistamines readily cross the blood brain barrier and

occupy approximately 75% of the H₁-receptor sites in the brain which correlateswith increased CNS related symptoms (₃)

Elderly Population and Antihistamine Effect

• Age is the greatest risk factor for developing cancer. In fact, 60% of people who have cancer are 65 or older (₂)

• People 65 and older often have multiple comorbities resulting in polypharmacy

• Impaired drug metabolism in this population leads to increased CNS symptoms

• Diphenhydramine is included on the Beer’s list

Patient Safety Concerns• Falls• Incontinence• Confusion (altered mental status)• Restless legs• Sedation, inability to report adverse reactions • Impaired driving (₁) • Hypotension• Urinary retention• IV dislodgement



But Why???

• 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)

Minimal or no CNS depression

Anticholinergic effects (dry mouth, blurred vision, urine retention)

Minimal or no anticholinergic effects

Other CNS effects (seizures, dyskinesia, dystonia, hallucinations)

Diphenhydramine Onset of Action Cetirizine Onset of Action

15‐60 minutes 15‐30 minutes

(₄)

(₁)



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”



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

Documents

Nurse-Led Improvements and Collaborations in Outpatient