The 2015 Annual Congress of the Oncology Nursing Society (ONS) marks the 40th anniversary of the organization. Presentations and events included the new and the “tried and true.”
New this year was a research track for sessions presenting the latest findings for nurse scientists, the streaming of 4 different main-stage lectures, and ePoster sessions that allowed multimedia versions of over 25 poster presentations.
With more than 3100 registrants at the meeting, held in Orlando, Florida, attendees had many opportunities to gain new knowledge and meet new people. Below are some of the highlights of the ONS poster sessions. Subjects included reducing life-threatening infections associated with central line catheters, improving pain assessment using auditory cues, adapting a business strategy to reduce waste and improve efficiency, boosting enrollment in clinical trials, and progress made in implementing survivorship care plans. We hope you will find these summaries of interest and helpful in your everyday practice.
VAD Champion–Driven Central Line–Associated Bloodstream Infections Prevention Project (Poster 12)
Staff nurses at Stanford Cancer Institute got together to assess how to reduce the incidence of central line–associated bloodstream infections (CLABSIs), one of the most deadly infections that can develop in immunocompromised patients with cancer and can occur due to a single practice deficit in central line (CL) maintenance. The nurse-driven initiative also increased awareness of evidence-based CL maintenance care.
“We observed inconsistent practices among nursing staff and a high rate of CLABSIs persisting in the hematology/oncology unit at our magnet-designated hospital, where more than 90% of patients have a CL,” said Andrea Plati, MSN, RN, OCN, a coauthor of this poster. “We used old-fashioned thought processing to determine what our practices were, whether we were doing proper infection control processes, and we evaluated our staff practices in a 38-bed unit.”
“A lot of hospitals do this with a computer. Our hypothesis was that if we retrained our staff on a live patient under the supervision of 1 of 4 VAD [vascular access device] champions, we would reduce the rate of CLABSI. Retraining involved competency in inserting peripheral central catheter and CL dressings,” she continued.
Ikuko (Koko) Komo, MSN, RN, OCN, was lead author of this poster but could not attend the ONS meeting.
The project was initiated early in 2014, and by the summer the rate of CLABSI was reduced from 2.37 to 0.81 per 1000 CL days. In the last quarter of 2014, there were zero CLABSIs.
Hands-on education was conducted if practice deficits were observed. Nursing staff were included in discussions regarding findings in audits. To have a more accurate assessment of compliance rates, the number of monthly CL audits conducted by VAD champions to assess compliance with the CL maintenance bundle was increased from 5 to 30, per recommendations by the Centers for Disease Control and Prevention.
“This is a unique initiative driven by nurses. Performing these interventions on a live person having peer supervision makes a difference. We have a great team of female and male nurses who work with very sick patients,” Plati said.
Pain Assessment in Inpatients (Poster 42)
The nurse’s role in assessing patients’ pain and improving pain control can be helped by using a simple and inexpensive kitchen timer, according to Sandra Rudolph, RN, OCN, Barbara Ann Karmanos Cancer Center at the Detroit Medical Center.
Although the institutional policy at Karmanos is that patients should be reassessed for response to pain medication within 60 minutes of administration, this standard was adhered to only 47% of the time. Studies show that pain assessment and documentation improve pain management, and it is optimal to reassess within 60 minutes of receiving pain medication.
“It’s not clear why the adherence at our institution (and others) was so poor, but some studies suggest that auditory cues can be an effective reminder to reassess pain,” she said. “We found a simple solution to a big problem.”
Each RN working on the project received a “dollar store” kitchen timer and was educated on how to use it within 60 minutes (but not less than 30 minutes) after pain medication was given. Nurses were instructed to set the timer 15 minutes before the hour was up, allowing the RN enough time to reach the patient at the desired time. Once the “beep” occurs, the nurse assesses and documents the patient’s pain response on a visual analog scale from 0 to 10 (10 being most severe pain). The unit manager documented adherence and counseled staff who were not meeting the standard set.
Adherence by RNs went from 47% to more than 93.5% over 9 months after the intervention was instituted. Moreover, patient satisfaction increased from 87.5% to 90.9% during the same period.
Complex interventions have been introduced at other centers to rectify the problem of failure to reassess a patient’s pain after medication, but this simple intervention was able to stimulate nurses’ recall, Rudolph said. “Using the kitchen timer retriggered how we did things. This reassessment often led to changes in treatment. We were able to tell the doctor that the patient’s pain was not at an optimal level and the medications needed to be addressed,” she said.
LEAN Approach Improves Efficiency (Poster 78)
Problems such as missing orders, consents, and/or laboratory results were causing significant delays in the flow of patient care at the Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Hospital, New Brunswick. A multidisciplinary team collaborated to address these problems, using a LEAN approach.
Borrowed from industry, the LEAN approach is now being adopted at healthcare centers. Its goal is to drive out waste, improve flow, and only include steps/tasks that add value and serve the customers’ needs.
“We were experiencing delays in starting treatment that averaged about an hour. After patients signed orders, it took about 90 minutes from time of check-in to time of chemotherapy dispensed. If policy was not adhered to, the time increased by 68 minutes, and these delays occurred in about 33% of patients,” explained lead author of this poster, Carla Schaefer, BSN, RN, OCN.
Using LEAN tools, the multidisciplinary team set out to identify the root cause of the delays and design future processes as well as a control plan to sustain these processes. They focused on improving chair utilization; reducing patient delays, thus shortening the duration of patient visits; decreasing the time from check-in until medication dispensing; and improving policy compliance, which mandates signed orders 24 hours prior to treatment appointment. The team’s overriding goal was to improve efficiency, shorten the treatment visit, and increase patient satisfaction.
The project took 7 months to complete. Process changes were implemented as follows: vital signs were assessed chair-side instead of in a separate room; an additional fax line was installed to receive lab results 24 to 48 hours in advance to be entered into the electronic medical record (EMR); signed treatment orders were audited daily for compliance, with reminders sent to noncompliant attending physicians; checkouts were done chair-side to ensure that patients received all follow-up appointments and prescriptions for lab work prior to discharge; and bundled scheduling was instituted via the EMR, allowing lab orders and return visit information to be signed simultaneously with the chemotherapy regimen, eliminating the need to call the provider for further orders.
Significant improvements have been observed in the percentage of patients with orders as per policy and the average number of daily patients, and these process changes have had a positive financial impact as well. Press Ganey scores for patient satisfaction have shown the most improvement, Schaefer said.
Nine months from the start of the project, the percentage of patients with orders as per policy improved from 67% to 89%; the number of patients checked out improved from 75% to 93%; the average number of patients treated improved from 62 to 76; and savings to the hospital were estimated to be about $499,300. Press Ganey scores for “wait time in treatment area” improved from 78.7% to 87.5%.
“As a result of this process, we are doing more with less,” Schaefer said.
“Nurses and the health care team can utilize the LEAN approach as a quality assurance method to focus on process improvement and change management to assure better patient outcomes, improved quality care, and patient satisfaction,” the authors wrote.
Nurse Dyads Improve Clinical Trial Recruitment (Poster 77)
A strategy that utilizes a dyad of disease-specific clinical trial nurses (CTNs) and disease-specific nurse navigators (NNs) is boosting enrollment in clinical trials at the Billings Clinic in Montana.
“A strategy of using these dyads can help identify patients who want to enter clinical trials, enhance patient care, and increase enrollment in clinical trials,” said lead author Kathy Wilkinson, RN, BSN, OCN.
Since the strategy was introduced, the average number of patients enrolled in clinical trials increased from 10 patients per month to 18 patients per month, she said. NNs referred 87% of patients they navigated to research in the first 7 months of this year.
The process goes like this: patients are referred to an NN; the NN sends an email notification about the patient to the CTN; the CTN reviews and identifies a potential clinical trial for that patient; the CTN notifies the physician and NN about the potential clinical trial; then the physician discusses the clinical trial with the patient.
The Billings Clinic has won many accolades, including the safest hospital in the nation according to Consumer Reports, and the top hospital in Montana according to U.S. News and World Report. The community cancer center has 9 disease-specific NNs and 5 disease-specific CTNs. This structure enables close collaboration between NNs and CTNs.
The 5 disease-specific CTNs are responsible for the following cancer types: breast; central nervous system, genitourinary, radiation; gastrointestinal, hematologic, lymphoma; gynecologic, lung; and head and neck, melanoma, sarcoma, unknown primary. The disease-specific NNs work in these areas: breast, genitourinary; central nervous system, head and neck, melanoma; gastrointestinal, sarcoma, unknown primary; gynecologic; hematologic, lymphoma; and lung.
Advanced Practice Provider–Led Transition-to-Survivorship Visits (Poster 85)
A survey of cancer patients treated at Stanford Cancer Institute showed that advanced practice provider (APP)-led transition-to-survivorship visits provided added value to patient care by increasing patients’ knowledge and understanding of their past treatment and future health recommendations. APPs included both nurse practitioners and physician assistants.
The APP-led transition-to-survivor visits were instituted at Stanford in 2012 for breast cancer, acute leukemia, and lymphoma survivors. Patients were eligible if they achieved complete remission after intensive chemotherapy, surgery, and/or radiation. The transition-to-survivor visits include Likert-scale previsit assessments of common survivor symptoms and survivorship care plans (SCPs).
Participants completed a clinic-designed survey on Survey Monkey (94%) or paper (6%) immediately after their transition-to-survivorship visits. Anonymous responses were collected from November 5, 2012, to February 11, 2014.
Of 104 patients, 80 surveys were evaluable. These showed that 98% (78 of 80 patients) found the standardized assessment form helped in their communication about symptoms; 98% (78 of 80) received an SCP. Of those who received an SCP, 75 (96%) found that it increased their knowledge about their past treatments and future health-related recommendations. In addition, 93% were “confident” or “very confident” that their healthcare provider would be responsible for each aspect of their healthcare.
The transition-to-survivor visits and the SCP led to a high level of patient satisfaction (98%). Moreover, 71% (52 of 73) said that they would like future cancer survivorship visits.
Of 70 breast cancer survivors, 94% (66) were less than 6 months from end of treatment, and 70% (49) rated the 1 to 3 months’ posttreatment period as the optimal time to receive an SCP.
Lead author was Kelly Bugos, BS, MS, RN, ANP-BC, Stanford Cancer Institute, Palo Alto, California.
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