The cherry blossoms were in bloom, and the Washington, DC, Convention Center was a bustling hive of activity during the 38th Annual Congress of the Oncology Nursing Society (ONS), held April 25-28, 2013. Attendees were treated to a wealth of presentations in different formats. The following are some of the highlights from the ONS poster sessions.
Code Blue: A Model to Increase Staff Confidence
By participating in a simulated model for dealing with “Code Blue” emergencies, oncology nursing staff at UCLA Medical Center in Santa Monica, California, increased their knowledge and confidence in handling this situation.
“The potential for a Code Blue is high on oncology floors. Many of these patients are receiving highly toxic chemotherapy and are at the end of their lives. One year ago, the Code Blue simulated model was identified as a project that would help increase staff confidence. Although we have some experienced nurses, some of our staff members are young and are new graduates,” explained Deborah Lorick, RN, MSN/MHA, CMSRN, OCT. Lorick coauthored a poster describing results of the Code Blue project.
UCLA Medical Center in Santa Monica is a 266-bed combination community and academic center. The Oncology Unit has 26 beds and provides acute care for cancer patients. The experience level of the staff ranges from newly graduated to expert. Lorick noted that nurses experience anxiety and lack of confidence regarding resuscitations regardless of their level of experience.
Previous studies showed that simulation training that included “surprise” CPR training involving a simulated model resulted in a gradual and steady improvement in skills.
In the UCLA study, skills regarding what to do at the first “Code Blue” alarm and confidence were improved from pre- to postsimulation.
For this study, approximately 45 staff members were asked what they would do when they first heard the Code Blue alarm. Before the test, 27% said that they would wait for an experienced RN to help; after the test, only 13% gave that answer. Before the test, 27% said they would finish their current task of giving medications and then head to the room; after the test, 0% gave this answer. Before the test, 46% said that they would rush to the room and engage in action, whereas this percentage rose to 87% after the test.
Confidence was improved at all levels after participation in the simulated Code Blue. Pretest, 13% were “confident,” with the figure rising to 33% posttest; 34% were “somewhat confident” pretest, with the number rising to 67% posttest; 47% were “not so confident” pretest, and 0% gave this answer posttest. Prior to participation in the simulation, 6% were “totally lost,” with the percentage decreasing to 0% posttest.
The Code Blue simulation is given monthly at the UCLA Medical Center, Santa Monica, on a day shift and a night shift to nursing staff members who have not yet participated, Lorick said.
Lorick D, Queyquep M, Jakel P. Code Blue: journey to confidence. Presented at: 38th Annual Congress of the Oncology Nursing Society; April 25-28, 2013; Washington, DC. Poster 179.
Reducing Falls in the Outpatient Setting
At most hospitals and other inpatient facilities, procedures are in place for identifying patients at risk of falling, and there are guidelines for the prevention of falls. However, such procedures and guidelines are not routinely present in outpatient centers where cancer patients are treated, explained Sara Lantowski, BSN, OCN, of the Smilow Cancer Hospital at Yale-New Haven in Connecticut.
“We had a substantial number of reports of falls at our center, but we had no ambulatory fall screening or prevention plan in our outpatient setting. Since this was an unmet need, as well as a nurse-sensitive indicator of quality, we formed a committee to draft proposals for identifying patients at risk for falls and documenting them in our new electronic medical records system. The next steps are to implement prevention strategies and patient and family education,” said Lantowski.
The simple and easy-to-use Fall Risk Screening Tool that the committee developed includes 4 questions for patients:
- Do you use any assistive device to ambulate?
- Do you need any physical assistance with standing or walking (ie, walker, cane)?
- Do you have periods of forgetfulness or don’t know where you are at times?
- Have you had a fall in the last 6 months?
A “yes” answer to any of these questions indicates high risk of falling, she said.
With the use of this new tool, 80% to 100% of patients at Smilow are screened for risk of falls and are identified in the electronic medical record. The screening effort is led by patient care and medical assistants.
“Falls can result in injury, and providing patients with early education on fall risk and prevention would be expected to minimize falls in ambulatory oncology settings [and] the home setting and [would] potentially translate to fewer inpatient falls,” she stated.
The committee has developed an educational brochure for patients that includes steps for preventing falls during outpatient visits (wear nonslip footwear, bring walking assistive devices, wear clothes that allow you to walk freely, and wear your eyeglasses). The brochure includes safety measures for patients to take during outpatient visits, such as asking for help walking if needed, letting the staff know about a recent fall, not using an IV pole as a support, and alerting the staff if there is a slippery floor area or torn carpet.
The brochure also lists fall prevention tips for family members and other visitors who accompany patients on their outpatient visit.
Blasiak E, Lantowski S, Bursey C, et al. The ins and outs of fall prevention: improving awareness, providing education, and promoting early fall prevention in the outpatient oncology setting. Presented at: 38th Annual Congress of the Oncology Nursing Society; April 25-28, 2013; Washington, DC. Poster 178.
Screening Tool for Older Outpatients at Risk of Decline
Cancer is predominantly a disease associated with aging, and with the graying of America the number of older patients with cancer is expected to increase. Treatments for cancer, such as chemotherapy and radiation, can be associated with impaired physical and cognitive function. As more older patients enter treatment for cancer, it is important to identify who will be at risk for treatment-related decline in order to institute interventions that will allow them to return to pretreatment functioning level. To that end, investigators at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City developed and implemented a screening tool for outpatients aged 65 years and older and for identifying at-risk patients.
“This was a multidisciplinary collaborative endeavor to identify and manage older patients at risk for age-related functional, cognitive, or physiological decline before they got treatment,” explained lead author Lorraine McEvoy, DNP, MSN, RN, OCN, nurse leader of Ambulatory Services at MSKCC.
“Patients come in with various comorbid conditions. Not all patients the same age are in the same condition. The nurse can screen for geriatric syndromes that are indicators for decline,” she explained.
Geriatric syndromes that signal potential age-related decline include dehydration, malnutrition, depression, pain, falls, incontinence, constipation, sleep deprivation, deconditioning, immobility, and delirium.
“The most profound indicator of decline turned out to be inpatient delirium,” McEvoy said.
In 2010, the authors implemented use of the 65+ Ambulatory Health Screening Tool at MSKCC’s outpatient services. This instrument consists of a list of questions to be answered by the patient or caregiver. If the patient is identified as at risk for decline, a “G” is placed next to that person’s name. The “G” triggers electronic nursing referral orders for a geriatrician to manage that patient, providing support services that can include nutritional support, pain management, social work, and case management.
The investigators of this National Cancer Institute–supported initiative are still collecting data. Quarterly electronic compilation of nursing quality data demonstrates substantial user compliance and effectiveness in identifying comorbid conditions, geriatric syndromes, and the initiation of multidisciplinary collaboration to support the overall treatment plan.
“The goal of this screening tool is to get older patients through their treatment and back to life in their pretreatment condition. This new tool has become a necessity, as our society is aging,” said McEvoy.
McEvoy L. Care of the older adult with cancer: a 65+ ambulatory health screening tool. Presented at: 38th Annual Congress of the Oncology Nursing Society; April 25-28, 2013; Washington, DC. Poster 182.
Measures to Preserve Fertility
Cancer patients are often at risk for impaired fertility related to their treatments. A quality improvement initiative at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City showed that education, developing an algorithm for discussions with patients, documenting those discussions, and supplying patients and providers with a list of referrals for fertility preservation specialists are an important aspect of oncology nursing that can improve the quality of care provided to patients.
The study included 26 patients with sarcoma or melanoma between the ages of 18 and 45 years treated at MSKCC over a 12-month period. All patients were eligible for fertility preservation options.
Meetings were conducted with physicians and nurses to identify barriers to discussing fertility, which included a lack of knowledge, undefined roles, the absence of a standardized work flow, no documentation system, and the difficulty of discussing fertility with patients with a poor prognosis.
At baseline, 69% of the oncologists discussed fertility risks associated with treatment, 54% explained fertility preservation options, and 54% referred interested patients to fertility specialists. Among the nurses, 0% discussed fertility, 0% discussed fertility preservation options, and 17% referred patients in response to an oncologist’s direction.
The research team provided education for oncologists and nurses regarding the need for discussion of fertility with the patient and options and referrals for interested patients. The team developed an algorithm for oncologists and nurses to use in discussions with patients, a method of data collection, and strategies for implementing improvements, as well as a list of fertility preservation resources and processes for making referrals and documenting care provided.
After a 3-month evaluation and follow-up of this initiative, dramatic improvement was seen among the nurses: 57% discussed fertility with patients, 71% discussed options, and 80% provided referrals.
Among the oncologists, after the education initiative, 60% gave patients referrals for fertility preservation options.
Clark R, Baldwin A, Frankel Kelvin J. Fertility preservation: standardizing education and patient referral. Presented at: 38th Annual Congress of the Oncology Nursing Society; April 25-28, 2013; Washington, DC. Poster 193.
Nurse-Led Symptom Management Clinic
A nurse-led interdisciplinary symptom management team has been implemented at the Billings Clinic Cancer Center in Montana, part of a top 100 hospital, according to Truven Health Analytics. The team was put together in response to the Commission on Cancer’s mandate for making palliative care services available and suggesting that interdisciplinary symptom management teams be developed. These teams would include a provider and a nurse trained in palliative care and hospice, a pharmacist, a social worker, a mental health clinician, and a chaplain.
“Palliative care is often thought of as end-of-life care, but it really relates to quality of life from the time of diagnosis,” said Alison Weber, RN, BSN, who presented this poster. “Palliative care encompasses psychosocial, spiritual, physical, and advanced care planning.”
Patients undergoing cancer treatment at the center were screened for distress, and the sources of distress were identified. The top 6 sources of distress were (in descending order) fatigue, pain, sleep, peripheral neuropathy, skin problems, and difficulty concentrating.
Assessment, triage, and protocols were developed for various symptoms. The team held weekly meetings. After the program was put in place, patients attended a weekly symptom management clinic.
Weber’s impression is that patients love the attention and care they get, and that their quality of life is improved.
When symptoms arise, the nurses identify which team members are needed for help in symptom management. For example, if the patient has taste changes, a dietitian might be called in; if the patient is in pain, a pain management staff member will be consulted. If symptoms do not resolve, then a provider is consulted; urgent care and even emergency care are provided if needed.
“This program has been ongoing for the past 4 years. Patients who engage with the nurse-led team seem to love it. They feel their complaints are heard and that they are given attention. The main challenge in implementing this type of interdisciplinary team is to get providers’ buy-ins. We need to convince providers that this effort provides added value,” said Weber.
She said that the information in her poster provides a model for cancer center personnel who want to implement a symptom management team, and she sees this approach gaining favor in the future. “This care is reimbursable for NPs and PAs, and it is billed as a clinic visit,” she said.
Weber A, Waitman K, Blaseg K, et al. A nurse-led symptom management clinic: serving cancer patients across the continuum. Presented at: 38th Annual Congress of the Oncology Nursing Society; April 25-28, 2013; Washington, DC. Poster 172.