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| Volume
3, Issue 2, August 2005 |
| The Neutropenia SIG Newsletter is underwritten by a grant from Amgen Inc. |
| Make a Difference Through Performance Improvement  Colleen
Lemoine, APRN, MN, AOCN®New Orleans, LA clemoi@lsuhsc.edu The Neutropenia SIG sponsored two sessions at the Oncology Nursing Society 30th Annual Congress held in Orlando, FL, from April 28–May 1, 2005. "Acute Leukemia" and "Best Practices in Neutropenia Management: You Can Get There from Here" were instructional sessions. The "Acute Leukemia" session was offered on Thursday and again on Saturday. I was able to attend only the "Best Practices in Neutropenia Management: You Can Get There from Here" session that was offered on Sunday, and it was quite well attended. Following is a brief review of that session. "Best Practices in Neutropenia Management: You Can Get There from Here" highlighted three performance improvement efforts in which neutropenia management practices were vital. Kelly Sakalian, RN, MSN, CS, AOCN®, an oncology clinical nurse specialist at Providence Hospital in Southfield, MI, served as coordinator and presenter for the session. Other presenters included Rebecca Donohue, MSN, RNCS, FNP, AOCN®, a nurse practitioner at Acadiana Medical Oncology in Lafayette, LA, and Cheryl Lenhart, RN, BSN, HRM, a nurse manager at Western Pennsylvania Hospital in Pittsburgh. Kelly shared her institution's experience related to improving the management of patient's who present with febrile neutropenia (FN). The institution's multidisciplinary Oncology Performance Improvement Committee recognized FN as a serious hematologic toxicity associated with the risk of life-threatening infections and chemotherapy dose reductions and delays. The committee further recognized the importance of aggressive treatment, most often with IV antibiotics and hospitalizations, starting with the essential first step of prompt recognition. The committee established goals of reducing morbidity and mortality associated with FN and optimizing use of resources. A retrospective chart review was conducted to collect baseline data including admission type (direct or through the Emergency Department [ED]), primary diagnosis, time from admission to time laboratory specimens were obtained, time from admission to time antibiotics were ordered, time from admission to time of antibiotic administration, antibiotic choice, presence of a central line, absence or presence of fever, absolute neutrophil count, whether a colony-stimulating factor had been administered, whether cultures were obtained, presence of an infectious disease consult, and number of days on antibiotics. Thirty-nine charts were reviewed and, regardless of whether patients had been admitted through the ED or as direct admits, very little difference existed in time from admission to antibiotic administration (average in ED was 5 hours, 37 minutes; average for direct admits was 5 hours, 21 minutes). Based on this data, two hours was set as the desired maximum time from admission to antibiotic administration. To achieve the two-hour benchmark, three improvement strategies were selected that included developing a clinical pathway for FN; FN admission orders, which incorporated an antibiotic selection algorithm; and discharge instructions, which included a High Alert card for patients to carry and present on admission to make healthcare providers aware of a patient's need for immediate assessment for FN. Implementation of the strategies involved obtaining appropriate hospital approvals and providing widespread education to staff in the ED, admissions, and nursing. Following implementation of the plan, time from admission to antibiotic administration was monitored for all patients presenting with FN. Compliance with the pathway, admit orders, and discharge instructions was monitored, and education was ongoing. Close follow-up occurred with the ED staff and the ED Performance Improvement Committee. As a result of this follow-up, a process has been established with the ED to "fast track" patients with cancer. Finally, whenever the time from admission to antibiotic administration exceeded the two-hour benchmark, the case was reviewed to identify factors contributing to the delay. This successful performance improvement effort has driven practice changes that have resulted in improved processes and outcomes for patients experiencing FN. Lenhart presented the findings from her institution's performance improvement effort related to relative dose intensity (RDI). Cheryl pointed out that past oncology performance improvement projects had focused primarily on speeding up processes related to chemotherapy administration (e.g., mixing times, delivery times). When the nursing staff was introduced to the concept of RDI and the potential impact that decreased RDI can have on clinical outcomes, the staff became very motivated to evaluate RDI in their patient population and examine practices that might be contributing to decreased RDI. A benchmark of more than 90% was set for patients to adhere to their administration schedule (i.e., > 10% dose delays) and their dosing schedule (i.e., < 10% dose reductions). A data collection sheet was developed that captured information regarding biographical data, the prescribed chemotherapy regimen ordered, including drugs and dosages, laboratory values, dates, and cycles of chemotherapy; use of hematopoietic growth factors, delays or dose reductions; and reasons for and origination of dose delays or reductions. Although first-quarter findings looked positive, a number of challenges were encountered in the data collection process. Problems included difficulty in using the data collection sheets, leading to "guessing" and misinterpretation of data, failure to capture exact schedule adherence, lack of access to original physician order for comparison of dose or schedule administered to dose or schedule ordered, and numerous caregivers completing sheets, leading to multiple methodologies and errors. Strategies were developed and implemented to address problems identified in data collection. These strategies included limiting the calculation of RDI to three specific RNs, selecting a single method for validating data on collection sheet, entering specific dates for chemotherapy regimens prior to a patient's first visit, and attaching a copy of the original physician order outlining the entire chemotherapy regimen, including dose and schedule, to the data collection sheet. Second-quarter findings were very disappointing, revealing that only 27% of patients received their chemotherapy regimen without delays and 82% of patients received their regimens without dose reductions. Problems identified during the second quarter included frequent cancellations, insufficient or nonuse of hematopoietic growth factors (HGFs), and a knowledge deficit about RDI. Strategies were developed and implemented to address problems identified in the second quarter, including revamping the cancellation process (patients needed to speak with the RN caregiver to cancel appointments; a patient was rescheduled for the next available day, not the next week; and the doctor's office was notified of the patient's cancellation and was asked to reinforce the importance of keeping appointments with the patient), advocating the use of HGFs, and providing educational sessions for RN caregivers to review principles of chemotherapy, strategies to prevent or manage pancytopenia, and RDI concepts. Although third-quarter results improved for patients staying on schedule, they decreased for the percentage of patients experiencing dose reductions. New problems were identified, including patients' lack of knowledge and caregiver complacency regarding patient cancellation and dose delays and reductions. A "Chemotherapy Information Sheet for First Visit" was developed, and patients were educated about the importance of receiving their chemotherapy the way the doctor ordered it without reductions or delays. Fourth-quarter results improved for adherence to schedule and dose, but management of myelosuppression continued to be less than adequate. In addition, not all RNs embraced their role as advocate and not all RN advocacy efforts were well received by physicians; however, tracking of blood counts was improved and resulted in earlier recognition of impending dose delays or reductions. A number of strategies were implemented so that improvements could continue, including education on the prophylactic use of HGFs, development of the advocacy role of the RN, creation of new data collection sheets that highlighted early myelosuppression to alert healthcare providers to the need for intervention, and the elimination of standing orders to routinely hold or reduce chemotherapy promoting an individualized approach to reductions and delays. Following a year of effort, a number of improvements had been realized: more than 50% compliance with chemotherapy schedule, 50% reduction in cancelled visits, 25% increase in HGF usage, and quarterly reporting to key physicians on cancellation rates and RDI percentages for their patients. Future directions for the project include reporting final RDI and "missed days" information in a patient's medical record and establishing parameters for initiating HGF usage in chemotherapy regimens. This project is a great example of the cyclical nature of performance improvement efforts. Ongoing monitoring often results in the identification of new problems and the effectiveness of improvement strategies must be continually evaluated. No time frame was set for how long it should take to "complete" any given performance improvement project. Processes can be continually tweaked until the best possible outcomes are achieved. Donohue described the performance improvement effort undertaken in her practice setting—developing and implementing a neutropenia risk assessment tool. Drawing on current evidence, including National Comprehensive Cancer Network, American Society of Clinical Oncology, and other guidelines; historical economic analyses that suggest it is cost effective to use colony stimulating factors for regimens associated with 40% FN; previously identified risk factors for neutropenia; and physician practice preferences, a prospective neutropenia risk assessment tool was developed. Risk factors included in the neutropenia risk assessment tool were chemotherapy regimens associated with 40% FN, age of 70 and receiving combination chemotherapy, bone marrow involvement or compromise, open wounds, previous FN, serum albumin of 3.5g/dl, and a first-cycle absolute neutrophil count of 500. Chemotherapy recipients were assessed using the tool and those with at least one identified risk factor were considered high risk for chemotherapy-induced neutropenia. A comparison was planned between clinical outcomes using the neutropenia risk assessment tool and outcomes prior to implementation of the tool. Outcomes to be compared included incidence of FN, IV antibiotics, hospitalization, dose delays, and dose reductions. Charts were reviewed for 35 patients who had been assessed using the neutropenia risk assessment tool and outcomes were compared to those of 50 historical cases who received care prior to the implementation of the neutropenia risk assessment tool. The findings indicated improved outcomes when using the neutropenia risk assessment tool. The project demonstrated that the use of a systematic neutropenia risk assessment tool may help practitioners determine which patients are at increased risk for chemotherapy-induced neutropenia. Kelly, Cheryl, and Rebecca did a great job communicating the positive impact that nurses can have on clinical outcomes-related to neutropenia. The impressive attendance at this session seems to indicate a high level of interest in neutropenia management strategies and a desire for insight into practical applications that incorporate these strategies into clinical practice. |
The Neutropenia SIG Newsletter is produced by members of the Neutropenia SIG and ONS staff and is not a peer-reviewed publication. |
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| Special Interest Group Newsletter August 2005 |
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Bookmark the Neutropenia SIG Web Site I would like to introduce myself as your new SIG Virtual Community Web page administrator. The Web page contains lots of helpful information and can be very useful. One of my goals as your Web page administrator is to post current and helpful information for all of you to take advantage of. When you enter the SIGs Virtual Community, you can sign up to receive e-mail notification whenever a new posting or announcement occurs. To get started, I posted an announcement about the new National Comprehensive Center Network (NCCN) guidelines on neutropenia. I also posted links to several Web sites that have guidelines relating to neutropenia management or infection prevention (NCCN, Centers for Disease Control, and Infectious Diseases Society of America). It's just a start, but it allowed me to see how easy it is to add announcements and links. I'd like to add links to other useful Web sites, so please let me know if you have suggestions. My next goal is to either post articles or a reference list on neutropenia topics. Some excellent journal articles on neutropenia have been published in the past few years, and I'd like to make those easy to identify and access. I also thought that posting a reference list on neutropenia would be a good idea. The challenge is to identify such a list and get it peer-reviewed. I'll work on developing this concept, and I may be looking for people to assist with this project in the future. This could be a long-term project, but I think it would be useful if we could work toward having a comprehensive reference list, perhaps divided into topic areas such as dietary restrictions, prevention of infection in the inpatient setting, neutropenia precautions in the outpatient setting, use of growth factors, maintenance of chemotherapy dose-intensity, etc. I would appreciate any input from you regarding this idea and would encourage any SIG members to submit recommendations for posting. I recently had a chance to read an excellent article in the May issue of the Oncology Nursing Forum (Vol. 32, pp. 565–579) on prevention of fungal infections in neutropenic patients. The title is "Prevention of Systemic Mycoses by Reducing Exposure to Fungal Pathogens in Hospitalized and Ambulatory Neutropenic Patients," by C. Smith and S. Kagan. It's very thorough and cites a vast amount of evidence. I encourage everyone to review it, and I put an announcement about it on the Virtual Community. Perhaps one of you could write an article review for the next newsletter? Let SIG Coordinator Arlene Davis, RN, MSN, AOCN®, or SIG Newsletter Editor Bonnie Wivell, RN, BSN, OCN®, know if you're interested. If you've never been to the SIG Virtual Community, see the SIG membership benefits article for instructions on how to access it. Please take advantage of this great tool that ONS has made available to us. I will make as much information as possible available to you via this communication vehicle, but it is up to you to use it to its fullest potential. Remember, once you access the Web site, sign up to receive notification when new items are posted. Again, I welcome input or suggestions from the membership, so please feel free to contact me.
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Inga
Aksamit, RN, MBA, OCN® |
| Special Interest Group Newsletter August 2005 |
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I’ve Got a Question; Do You Have the Answer?
Elizabeth Butler, RN, BSN, OCN® Subject: IV Tubing Changes for the Neutropenic Patient Marci Schafer, RN
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Subject:
Oral Care in the Neutropenic Patient |
| Special Interest Group Newsletter August 2005 |
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Message
From the Editor  Bonnie
M. Wivell, RN, BSN, OCN®Lakewood, CO BnJsAbode@aol.com The focus on neutropenia and nursing care definitely has moved to the forefront. More and more performance improvement projects are being initiated, and this information is being disseminated via multiple avenues—the most recent being instructional sessions at the ONS 30th Annual Congress held in May in Orlando, FL. An upcoming event has me very excited—the ONS State-of-the-Knowledge Summit. It is being planned to address all aspects of neutropenia management and the role of oncology nurses in this process. I am honored to be attending this summit as a representative of the Neutropenia SIG. I believe that this is an opportunity for us to make some major advancement in our progress toward establishing national standards for care of neutropenic patients. A preplanning meeting was held at Congress to discuss the specifics for the summit. The planning team members decided to meet and further discuss the objectives and outcomes for the summit. Unfortunately, the planning was not complete for the Summit to occur on the originally scheduled dates of July 8–9, 2005. Hence, it is being postponed to a later date in 2005. I will update you with the outcomes of the summit as soon as possible.
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| Special Interest Group Newsletter August 2005 |
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Message
From the Coordinator  Arlene
Davis, RN, MSN, AOCN®Gainesville, FL arlene.davis@med.va.gov I hope that a number of you were able to participate in the Web conference "Clinical Implications of the Newly Released NCCN Myeloid Growth Factor Guidelines in Oncology." Presenters were Jeffrey Crawford, MD, the panel's chairman, and Barbara Wilson, RN, MS, AOCN®, a member of our SIG. If your schedule did not allow you to participate in this conference, be assured that you haven't missed out. The Web cast will be archived on the ONS Web site and will be available for six months. The program also will be distributed to all ONS members via a CD-ROM as a supplement to the Oncology Nursing Forum. You also may download your own copy of the new guidelines by accessing the National Comprehensive Cancer Network (NCCN) Web site at www.nccn.org and then clicking on "New Guidelines: Myeloid Growth Factors in Cancer Treatment" at the top of the page. These new guidelines incorporate the most recent evidence supporting the use of colony-stimulating factors (CSFs) for the management of chemotherapy-induced neutropenia. Dr. Crawford explained that the risk threshold of neutropenic events (severe neutropenia, dose delays, or dose reductions) was redefined from greater than 40% (American Society of Clinical Oncology recommendation) to greater than 20%. Besides the chemotherapy regimen, NCCN stated that individual patient factors need to be considered in determining risk as well. Dr. Crawford reviewed the parameters for first- and/or subsequent-cycle use of CSF. For high-risk patients (risk > 20%), first- and subsequent-cycle CSF use is recommended when treatment intent is curative or prolonging survival. For intermediate-risk patients (risk 10%–20%), first- and/or subsequent-cycle use of CSF should be considered when treatment intent is curative. For low-risk patients (risk < 10%), first- and/or subsequent-cycle CSF use is not recommended unless treatment intent is curative and the patient is at risk for neutropenic complications, including death. Wilson then reviewed the role of nurses in assisting with risk assessment, recommending and anticipating the use of CSF for high-risk patients, and educating patients on neutropenia risks, prevention of infection, and the use of CSF. An audience poll revealed that 72% of the attendees currently do not use a written documentation tool to determine patient risk. Wilson strongly urged that nurses use a neutropenic risk assessment. Discussion ensued regarding the fact that individual risk factors listed in the guidelines are not weighted according to their contribution of increasing risk. Reflecting on this Web conference, I realized that it has taken time for standards of care to be published regarding the use of CSF in the medical management of neutropenia associated with cancer therapy. Sadly, studies to determine an evidence base for nursing strategies aimed at reducing infection in patients with have not kept pace. With lack of evidence to support our actions, we may be implementing interventions with uncertain benefit. These reflections bring me back full circle to one of our strategic goals, namely to establish national guidelines that will facilitate consistent, quality nursing care and promote optimal outcomes for patients with neutropenia. We hope to accomplish this goal by promoting and sponsoring nursing research and institution-based performance improvement projects leading to evidence-based practice in caring for neutropenic patients. We are making progress. Some of our members are conducting nursing research and developing performance improvement projects that focus on nursing care of patients with neutropenia. At times, progress seems slow, but most worthwhile achievements require a lot of work and endurance. With all of us working together, we can achieve our goals.
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| Special Interest Group Newsletter August 2005 |
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Notes From National
New Chemotherapy Guidelines Are Available Apply for Nursing Awards and Scholarships New Chemotherapy and Biotherapy Update Course Is Online Don't Miss This Leadership Opportunity New Core Curriculum Is Available Now Check Out the Redesigned Evidence-Based Practice Resource Area ONS Foundation Offers Symptom Management Research Funding Visit the Hematologic Toxicities Resource Area Clinical Practice Guidelines for Palliative Care Are Available
The Clinical Practice Guidelines for Quality Palliative Care can be downloaded at no charge at www.nationalconsensusproject.org. To learn more about the guidelines or the National Consensus Project for Quality Palliative Care, contact Project Coordinator Ken Zuroski at 412-787-1002 or kenz@hpna.org. Interested in Reviewing the Latest in Oncology-Related Resources? Consider Becoming an Oncology Nursing Forum Reviewer Reviewers are valued volunteers who contribute their professional knowledge and clinical expertise to the Oncology Nursing Forum and are credited for their reviews. Reviewers can keep the media once reviews are complete. To learn more about serving as a reviewer or to request an application, call 412-859-6271 or e-mail pubONF@ons.org.
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Learn
More About the Impact of Clinical Trials on Quality Care |
| Special Interest Group Newsletter August 2005 |
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Membership Information SIG Membership Benefits
A great way to stay connected to your SIG is to join its Virtual Community. It’s easy to do so. All you will need to do is
All members are encouraged to participate in their SIG’s discussion forum. This area affords the opportunity for exchange of information between members and nonmembers on topics specific to all oncology subspecialties. Once you have your log-in credentials, you are ready to subscribe to your SIG’s Virtual Community discussion forum. To do so,
As an added feature, members also are able to register to receive their SIG’s announcements by e-mail.
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| Special Interest Group Newsletter August 2005 |
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Neutropenia SIG Officers
Know someone who would like to receive a print copy of this newsletter? To view past newsletters click here. ONS Membership/Leadership Team Contact Information Angie Stengel, Director of Membership/Leadership Diane Scheuring, Manager of Member Services Carol DeMarco, Membership/Leadership Administrative Assistant The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability. Oncology Nursing Society
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