bluuebunny/crossref_metadata_2025 huggingface dataset:
Re-evaluating the inpatient use of routine diphenhydramine transfusion premedication practices.
Authors: Wong-Sefidan Ida , Roeland Eric
Published: February 2017

164

Background: Routine diphenhydramine premedication to prevent allergic transfusion reactions is common practice despite lack of evidence. First-generation antihistamines are associated with a number of anticholinergic side effects such as sedation and cognitive impairment that impact patient care and increase cost. Because premedication should be evidence-based and patient-specific, the University of California, San Diego (UCSD) inpatient Bone Marrow Transplant (BMT) service implemented a transfusion premedication protocol, specifically addressing antihistamine use. Methods: To revise the protocol, a committee was formed. The committee reviewed evidence-based practices, challenges, pharmacology, and costs of antihistamines, and developed an inpatient BMT antihistamine premedication protocol that omitted pre-ordered diphenhydramine and offered cetirizine as a first-choice premedication. Antihistamine premedication was encouraged for high risk patients only. A retrospective comparison of antihistamine prophylaxis pre (2010-2011) and post (2011-2012) protocol implementation was completed. The number of antihistamine doses and transfusions was computed by a count from the electronic medical records. Results: Despite a 14% increase in transfusions, the number of BMT inpatient antihistamine premedication orders decreased by 26%. Diphenhydramine use decreased from 85.9% to 34.2%, while cetirizine use increased from 3.3% to 55.9%. Conclusions: The evidence-based, risk-stratified antihistamine premedication protocol decreased the use of diphenhydramine. Limitations include the retrospective design and lack of data comparing reactions in patients who did and did not receive premedication. Our institution plans to expand this study and complete a prospective evaluation of safely and rationally administered transfusion premedication with the goal to evaluate premedication-related toxicity and methods to improve the quality of life in our patients. [Table: see text]
Improving efficiencies in a hospital-based hematology outpatient service.
Authors: Rask Brittany A. , Zeldenrust Steven R. , Brandt Jessica , Hagan Heather , Witty Elizabeth , Larson Jennifer , Pederson Colleen , Herdahl Linda , Gallenberg DeWayne , Gronseth Daniel , Spaulding Tony
Published: February 2017

165

Background: The Hematology Hospital Outpatient service at Rochester Methodist Hospital provides ambulatory outpatient care to patients who would normally be hospitalized on our inpatient services due to cytopenias and need for infusion/transfusion support. A quality project was conducted to streamline our process and decrease wait times. Methods: This project was a part of a Mayo Lean Collaborative initiative to increase customer satisfaction and eliminate waste. The first step was to collect baseline measurements to capture the non-value added waiting time of our entire outpatient process. These benchmark times were collected from 65 patients over 4 days. We evaluated these wait times to identify gaps in care and factors contributing to delays in our process. Data collected "before and after" each implementation phase determined if the change was beneficial. Results: Through our data collection, one major area of opportunity we identified was the wait time for CBC results. At baseline, patients were waiting in a room for 61.9 minutes for lab results. A major contributor to delay was the lack of carriers to send blood samples through the tube system being stocked in the outpatient area. We also discovered that the time from when the sample was placed in the carrier to the time it arrived in our lab was significant. Through a process analysis it was identified that the CBC tubes were being sent to a central lab prior to their final destination in the Hematology lab. We were able to re-route our CBCs directly to the hem lab. Data collected after the intervention showed we were receiving results at 51 minutes, therefore, eliminating 10.9 minutes off of an appointment. We also identified additional opportunities such as pre-assigning rooms, scheduling, exam room organization, and communication that were able to be addressed. Conclusions: As a result of this lean collaborative project we reduced patient wait time by 20.1 minutes and increased patient satisfaction. We were able to order interventions sooner thereby increasing patient safety. By process analysis, we identified multiple areas in our process that could be shortened with no additional cost.
Patient barriers to participation in clinical trials at a community cancer center.
Authors: Ramakrishnan Geethakumari Praveen , Ackler Joann R. , Gooptu Mahasweta , Braitman Leonard E , Tester William J.
Published: February 2017

17

Background: Clinical trials are fundamental to innovative oncology. Participation rates in trials have declined nationally to < 5%. Barriers to participation exist at patient, physician, and protocol levels. This study seeks to identify barriers to enrollment in clinical trials at a community cancer center serving a diverse patient population. Methods: We conducted a descriptive cross-sectional study, including 160 eligible patients offered enrollment in 27 clinical trials from July 2010-December 2012. A standardized questionnaire was delivered by mail or in person. Patients who enrolled (acceptors) and decliners were compared using Fisher’s exact test for nominal variables and t test for normally distributed continuous variables. Results: Fifty-seven patients (36%) (males: 10, females: 47) returned the questionnaire. Thirty-three (58%) were enrolled in a clinical trial. Mean age of acceptors was 57 compared to 64 for decliners (p=0.007). Stage IV disease patients were more likely to enroll (Spearman rho= 0.33, p=0.01). Among patients with family support, 66% accepted participation compared to 40% of those without [p=0.05]. Twenty-eight of 33 (85%) who felt trust in their doctor affected their decision enrolled. Of those “comfortable with randomization,” 86% enrolled compared to 29% who were not [p<0.001]. 74% patients would participate in a trial if maximal information could be gathered before making a final decision. Acceptors stated altruism, contribution to research, trust in doctor and hope for cure while decliners mentioned uncertainty in research, drug side effects, mistrust in pharmaceutical industry and depression as most important reasons for their decision. Conclusions: Our results confirm barriers among diverse patients treated at a community cancer center. Study limitations include small sample size and predominance of female gender. Factors influencing enrollment identified include age, family support, patient’s insight into conduct of randomized trials, perceived drug side effects and the doctor-patient relationship. Success lies in bridging knowledge and communication gaps, careful protocol design, and establishing trusting relationships.
Using a new patient process to improve breast care access.
Authors: Miller Eleanor , Colon Jonathan , O'Connor Nancy
Published: February 2017

171

Background: Access to timely care is of major focus in oncology. Clinicians and administration collaborated to improve the training and support for non medical staff involved in the new patient process at the breast center. The goal of the process was to improve upon the surgical triage of patient appointments for those with suspicious mammograms or newly diagnosed with breast cancer in less than one week, use the nurse practitioner clinics most effectively, and to triage other diagnoses and patients per updated guidelines, thereby increasing access to care. Methods: A new patient intake form was created with the assistance of IT and added to the electronic medical record as a tool for use by clinical and nonclinical staff. Clinicians and administration also met to update the new patient process forming a decision tree, which ultimately was developed into a manual. A series of in-services were held with scheduling and clinical staff for education and training. Education was also provided to refer patients with complex needs to the nurse navigator. Outcomes were measured by clinical and administrative staff. Results: Access to surgery clinics has improved for new breast patients since the process updates were implemented. Patients can be seen an average of 3.5 days sooner for both malignant and benign diagnoses. Access to the nurse practitioner clinic also improved by 9.4 days. Patients that are diagnosed within the health system can be seen within 3 days, and those that are diagnosed outside the system, within 7 days. Conclusions: It was the goal to improve access to the breast center by updating the intake and scheduling guidelines to see patients with a new diagnosis of breast cancer or other breast problems more quickly. Having guidelines that can be followed by clinical and non clinical staff promotes communication and collaboration, as well as a consistent approach among staff. In the future, the continued refinement of the new patient process and ongoing collaboration will further improve access to care.
Development of a quality assurance program at a community hospital breast center for elderly breast cancer patients who do not have axillary surgery.
Authors: Tito Elizabeth P. , Barthold Joseph , Lopez Marvin
Published: February 2017

173

Background: Sentinel lymph node biopsy (slnb) is the standard of care for patients with invasive breast cancer. Yet, in some patients, the nodal information will not change the treatment and the risk of a clinically relevant axillary event is low. It may be reasonable to offer observation of the axilla. However, this recommendation is outside national treatment guidelines. Our breast center developed a pilot program through which we offer elderly women with co-morbidities the option of avoiding axillary surgery for their invasive breast cancer and follow their outcomes. Methods: A pilot program was implemented to provide a structured method of evaluating and following elderly women with invasive breast cancer who did not have axillary surgery. Criteria for avoidance of axillary surgery were developed, cases were reviewed prospectively at multidisciplinary tumor board, data was collected and analyzed annually from 2010 to 2012. Results: Between 2010 and 2012, 282 patients had surgery for breast cancer at our hospital; 263 patents qualified for slnb by NCCN guidelines. Nineteen women did not have a slnb (Table). All cases were discussed at multidisciplinary tumor board. All women had negative axilla by exam and imaging prior to surgery. Patients were followed by annual axillary exams and imaging. One patient had a loco-regional recurrence (LRR) which was seen on axillary ultrasound. She died with disease from metastatic lung cancer. One patient, who refused radiation, developed an in breast tumor recurrence (IBTR). Conclusions: Breast cancer treatment is evolving at a rapid pace and becoming more conservative. This trend leads to practice changes before guidelines have been adjusted. Lacking a national registry, a system should be in place at hospitals to make these transitions in a safe, educated, data-driven process. Our pilot program provides a structure in which women who did not have sentinel node biopsies are evaluated, educated and followed. [Table: see text]
Time-to-simulation for radiation oncology patients in an academic department.
Authors: Kapadia Nirav S. , Lash Kathy Ann
Published: February 2017

176

Background: In 2011, one of the two clinical simulators in our department was decomissioned in order to enable the construction of a clinical magnetic resonance (MR) simulator. As result, our clinical simulator capacity decreased resulting in increased wait times for patients undergoing treatment planning. In turn, there was a perceived increase in the number of patients added onto the simulator schedule (add-ons) immediately following consultation. This created problems of workflow on the simulator and increased clinic wait times for previously scheduled patients. A clinical Lean team was formed with the intent of 1) quantifying the number of daily add-ons and 2) identifying predictors of add-ons so that the frequency of add-ons could be predicted and if possible, load-leveled. Methods: Over an eight-week period, frequency of simulator add-ons was correlated with de-identified patient data abstracted from the medical record using one-way ANOVA and student t-tests to assess the statistical hypothesis that a patient, disease, or provider factor increased the likelihood of a patient add-on. Interviews were conducted with the clinical staff to determine perceived frequency of add-ons, predictors of add-ons, and to evaluate the rationale for add-ons. Results: On average, 7.9 (range 7.3-8.7) simulations were performed daily in our department and 0.95 (0.7-1.4) patients were added onto the simulator daily. Patient demographics, day of consultation, inpatient vs outpatient status, treating and referring physician, as well as cancer diagnosis were examined. A statistical trend for add-on patients on Friday (p=0.064, vs. Monday) was found. One physician's patients accounted for 36% of the Friday add-ons over the eight week period. The physician was interviewed and her rationale for adding-on patients was determined. Conclusions: The mean number of add-on patients was determined to be acceptably low in our department and was on average less than one patient daily. A trend for an increased likelihoood of add-on patients with a particular Friday provider was noted and as such future efforts will be directed at mitigating the number of this physician's add-on patients.
Improving quality of care within the NCI Community Cancer Centers Program (NCCCP) network.
Authors: Castro Kathleen M. , Friedman Eliot Lawrence , Mack Nadesa , Siegel Robert D. , Eisenstein Jana , Prabhu Das Irene , Clauser Steven
Published: February 2017

178

Background: The National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP) was initiated to expand cancer research and deliver quality cancer care in communities. A program goal was support of quality care initiatives. Twenty-one community sites in 16 states participated in the network providing care to approximately 40,000 cancer patients/year. We describe strategies for implementation of a structured quality program within our network. Methods: Four components served as the foundation for quality efforts: 1) increasing multidisciplinary care (MDC) programs; 2) ASCO QOPI participation; 3) Commission on Cancer Rapid Quality Reporting System (RQRS) participation; and 4) expansion of genetic counseling/services. A Quality of Care subcommittee formed to guide quality efforts within the network. Clinicians from the network served as subcommittee leadership and each site designated a quality of care lead. The subcommittee met by teleconference monthly, developed goals, shared best practices, developed processes to accomplish goals and documented improvements in priority areas. Results: Strategies employed to improve quality included: assessment tool development, participation in national quality reporting initiatives, review and monitoring of network data, and network performance improvement projects. Conclusions: The NCCCP identified areas of needed quality improvement. In addition, the network developed implementation strategies and created benchmarks that measure program quality. Participants benefitted from the opportunity to interface with one another and set network goals, while adopting strategies to best fit their own practices and community sites. [Table: see text]
Large-scale fast-track diagnostics in a comprehensive cancer center.
Authors: Heintzbergen Sanne , van Harten Wim , Goedbloed Nicolette , van Wijngaarden Marja , Dernison Arthur , Boekhout Annelies H.
Published: February 2017

185

Background: In general, patients with a cancer suspicion visit the hospital multiple times before the diagnosis is completed. Using various “operations management” techniques a limited number of fast track diagnostic services were implemented in the Netherlands Cancer Institute (NKI) in 2006. Fast growing patient numbers and increasing process complexity, led to diminished service levels. To decrease the amount of patient visits and period of uncertainty, fast track diagnostics is implemented for 17 cancer types. The in benchmarks proven high efficiency, hardly any redundancy, and no capacity extension made this a large efficiency challenge. We report on the process of redesign, implementation, and first results. Methods: The throughput time (first visit to diagnosis conversation) was measured before redesigning the diagnosis process, and repeated after implementation of fast track diagnostics. In pre-measurement throughput time was retrospectively measured for 105 patients and 7 cancer types. The diagnosis process for 17 cancer types was redesigned by multidisciplinary teams. Input and process variation, slot use and constraints were analysed for all processes. In an eclectic approach, elements from lean management, theory of constraints, and mathematical analysis were used to organize slots for MRI, CT, PET, and echo with reservations turning into capacity available for short-term planning. Results: In premeasurement diagnosis was completed from 2 workdays onward to 58 (mean throughput time 13.3 workdays). It proved possible to design 15 of 18 tumors as a one-stop shop (Table). Through involvement of clinical and board leadership, massive communication efforts, commitment of physicians to reschedule their weekly activities was rather positive. In the post measurement the mean throughput time was 0.8 days (median 0 days). Conclusions: The involvement of physicians in redesigning and reorganizing their work was important: implementation of fast track diagnosis proved successful for 14 out of 17 cancer types. For 3 tumor types fast track diagnosis implementation is designed but not yet completed. Throughput time was considerably shortened after implementation of fast track diagnostics. [Table: see text]
Collaborating with Ontario cancer centers to ensure coordinated access to safe, evidence-based, high-quality IMRT treatment.
Authors: Murray Elizabeth , Bak Kate , Gutierrez Eric , Warde Padraig Richard
Published: February 2017

187

Background: In 2007, CCO identified variability in access to Intensity Modulated Radiation Therapy (IMRT) across the province. To ensure access to this technology, a three-year IMRT implementation Project was started in 2008, focusing on the development of: disease site guidelines and targets, cost-effectiveness analyses, a provincial quality assurance program, disease and discipline specific communities of practice and knowledge-sharing platforms. Methods: Needs assessments were conducted to identify educational and training needs in all disciplines. Systematic reviews were undertaken to establish disease site specific IMRT indications, set targets and conduct cost effective analyses. Educational courses and hands on expert-based coaching, were made available and a provincial IMRT quality assurance program was established. Results: The needs assessments identified a strong interest in educational and coaching opportunities. IMRT indication guidelines were developed for 10 disease sites and utilization targets were set for 6 disease sites. Results from two cost effectiveness analyses confirmed IMRT as a standard of care over 3D Conformal Radiation Therapy. 11 cancer centres received IMRT expert-based coaching, which included hands on-training, site visits, and educational support. Knowledge sharing and educational opportunities were provided to over 949 radiation therapists, oncologists and physicists. 13 cancer centres participated in external IMRT quality assurance testing for head and neck and prostate cancer. IMRT utilization has increased without affecting wait times or patient safety with no increase in incidents during this time period. All six disease sites have me their targets for 2012/13. Conclusions: IMRT knowledge and expertise across the province has grown along with a dramatic increase in the percentage of patients being treated for curative intent receiving IMRT. This jurisdictional implementation project was successful in making this treatment available to all Ontarians who would benefit. The lessons learned from this experience may be useful in the future rollout of other new technologies in Ontario and in other health care settings.
Disseminating team training across an academic cancer center and community-based satellites.
Authors: Gross Anne , Mann Susan , Weingart Saul , Kalfin Michael , Norden Andrew David , Buswell Lori A. , Constantine Michael , Fuller Frances , Briccetti Frederick , Thiele Jodi , Freter Rolf , Kostka Judith , Sherwood Geoffrey K. , O'Connor Janet , Bunnell Craig A.
Published: February 2017

188

Background: Dana-Farber Cancer Institute is the first cancer center to implement Team Training (TT). This program illustrates critical lessons about disseminating a quality improvement initiative across an academic center and its regional community-based satellites. Methods: We adapted TT principles to the needs of our satellite centers. This required recognizing different work flows and communication patterns, identifying hazards in routine communications, integrating satellite-main campus communication, and facilitating situational awareness when practicing at multiple sites. Key components included: support from executive leadership and Board of Trustees; previous success at the main campus; use of data and actual near-miss scenarios; development of workflows for critical communications; and workflows for shared care of patients at different sites. Results: Staff surveys demonstrated safer, more efficient, and more respectful practice environments. Higher scores were seen across most categories in comparison to main campus. We observed an increase in the number of chemotherapy orders without issues (81.7% to 91.9%) and a decrease in the number of missing (7.0% to 3.4%) or noncommunicated order changes (3.1% to 1.0%) when the patient arrived for treatment pre TT vs. post TT. Patient perception of teamwork, measured by Press-Ganey, showed a statistically significant increase at both the main and satellite campuses. Conclusions: TT improved communication, task coordination, perceptions of efficiency, quality, safety, and patient perception of care coordination, at both the academic main campus and our community-based satellite practices. [Table: see text]
Diabetes care management during cancer treatment.
Authors: Harper Gregory R. , Sharma Janelle , Habeck Cara , Coyne Cathy , Kincaid Hope , Hamadani Roya , Rivera Ada , Perilli Gretchen , Sully Nicole
Published: February 2017

189

Background: Cancer treatment negatively affects glucose control and puts patients at risk for hospital admissions. A one year medical record review at Lehigh Valley Hospital revealed that 75.4% of diabetic patients receiving treatment in the cancer center had at least one emergency department (ED) and/or inpatient (IP) admission—13.2% had a diabetes code present among the top 3 discharge diagnoses. We implemented a program in which a certified diabetes educator (CDE) and nurse practitioner worked with oncologists and primary care providers (PCP) to coordinate care for these patients. Methods: Cancer patients with diabetes or treatment related hyperglycemia were referred to the Diabetes Oncology Program for care management (CM). CM included patient assessment, education, care plan development, collaboration with PCP, and follow-up during treatment. A clinical practice guideline was developed for infusion nurses to treat hyperglycemia. Diabetes medications were modified during cancer treatment in collaboration with the PCP. CM ended at the conclusion of the course of treatment or with end of life care. Program evaluation consisted of patient and provider surveys, and analysis of ED/IP admissions. Results: In a preliminary analysis of 98 patients that received CM, 74 ED/IP admissions occurred between the first appointment with the CDE and the end of CM; 11 admissions (14.8%) were for diabetes or hyperglycemia related diagnosis. At baseline, participant mean FACT-G scores were slightly lower than published normative data for cancer patients. Significant improvements from baseline to 2 months post program enrollment were found among participants in diabetes empowerment and satisfaction with diabetes treatment scores. Provider survey responses at baseline found that PCPs are more satisfied with oncologist communication than oncologists are with PCP communication. Final results of the patient and provider surveys and program impact on ED/IP admissions will be presented. Conclusions: Patient empowerment and satisfaction with treatment may be improved by focused diabetes care management. Final data analyses will indicate if this improvement is achieved along with reductions in ED/IP admissions for diabetes related diagnoses among cancer patients.
Building clinical volumes, research capacity, and quality care in testicular cancer.
Authors: Nichols Craig R.
Published: February 2017

198

Background: Developing consistent, evidence-based, personalized and cost appropriate management of germ cell tumors is challenging for two reasons: these are uncommon diseases and successful management requires nuanced input from many disciplines with specialized interest in germ cell tumors. We speculated model combining a working tumor board and a true multidisciplinary clinic would improve volumes, research contributions, consistency and personalized care for patients with germ cell tumors. Methods: Beginning in March 2011, we developed a multidisciplinary clinic model, flow and communications with the following principles in mind. 1.) embed electronic capacity to capture clinical and biological datasets to serve as a template for research collaborations with national and international colleagues, 2.) coordinate clinical operations around a mandate for expert pathological and radiographic review, 3.) develop and apply evidence-based clinical guidelines, 4.) build an “open-source” operation and accept cases for electronic review and deliberation from patients and providers who desired expert oversight from an experienced team. Results: Our current clinical volumes have grown to an average of two new cases/week along with 1-2 outside reviews. Ongoing follow-up patients average 10/week. RPLND volumes have increased markedly to more than 20/year. All cases undergo pathology and radiology review. Adherence to published guidelines is superb with few deviations. Imaging schedules have been scaled down to approximately one third of previous radiation exposure. Research contributions have increased with the development of international collaborations, publications and new investigator-initiated studies. Conclusions: Our results demonstrate that purposeful coordination and consolidation of expertise and interests can result in the development of regional and national resources for management of rare malignancies such as testicular cancer. These high functioning clinics result in cost-effective, evidence-based management and high patient satisfaction.
An academic medical center's journey to a survivorship care plan.
Authors: Korber Susan
Published: February 2017

210

Background: Cancer clinicians are challenged by the need to give patients an initial treatment plan and a summary of their care at the end of the treatment period. Both are essential elements in the care continuum and the summary is now a required standard for accreditation by the Commission on Cancer. By 2015, each patient’s Survivorship Care Plan should be a collaborative document shared with the patient, their primary care and/or referring provider. A well-written plan includes a road map for the patient and their PCP to use as the patient transitions from active care into surveillance. Our academic medical center, part of the Lifespan system, began exploration of the transition process in 2007. The goal of our multidisciplinary group was to develop a patient and PCP friendly record of the treatment experience and recommendations for follow up. Methods: Two oncology staff nurses at The Miriam Hospital developed an early home-grown tool in 2008, a simple one page document in layman’s terms. From 2009 to 2010 we participated in a national Breast Cancer Registry Pilot Program using ASCO templates and assessing patient and staff perspectives on the use of treatment plans and summaries. Lessons learned from both experiences was to "keep it simple." At the urging of the CoC we moved on to the Journey Forward website and tried to utilize plans for breast and colorectal patients. We have now formed a partnership with our state Department of Health and have developed a template for use by all cancer programs in our state. Results: Our state will be the first to offer to all cancer programs the ability to download a user friendly one page template for a Survivorship Care Plan. Clinicians enter demographics, the patients’ providers, simplified disease information, treatment given and surveillance suggestions. A list of community references is included on the second page. The Department of Health will have this available on their website for download into each cancer center’s electronic system. Conclusions: Development of a user friendly summary of patient treatment and future surveillance needs is possible with a collaborative effort between clinicians and engaged public health officials. Understanding the value of a simple, single page form available online has been essential.
Science of quality: Communication, decision making, and behavior.
Authors: Harrison Deb , Hoverman J. Russell , Mikan Sabrina Q. , Olson Kevin Donald , Taniguchi Cynthia , Arlen Aimee Ginsburg , Ash-Lee Susan
Published: February 2017

22

Background: Addressing advance care planning (ACP) early in metastatic disease is a challenge for providers across oncology. Providing a systematic method to engage providers and patients in these discussions offers opportunities to improve end of life outcomes, improve patient quality of life and engage in shared decision making that supports effective transition to appropriate palliative care and hospice. Methods: A multidisciplinary group of oncology providers developed a framework for ACP which included defining a target population for early introduction, utilizing a standard patient-centered measurement tool (Values Assessment), reviewing practice workflow to schedule ACP conversations, and incorporating documentation elements embedded in the electronic health record. The model included physician referral of patients to a nurse practitioner or social worker who scheduled meetings with patients to assess values, assist patients with advance directives (AD), and explore patient end-of-life wishes based on disease. Seven cancer center sites of service engaged in the pilot study for a 90-day period to test tools, workflow and effectiveness of implementation methods. Documented values assessments, code status, and advance directives were pilot outcomes measures. Results: All sites in the pilot study implemented the framework and participated for 90 days. Workflows were validated to support scheduling of ACP conversations. Use of the values assessment tool was slow to be incorporated in ACP process as was physician referral for introduction. Conclusions: Engaging in a systematic approach to gather and assimilate information provides an opportunity to comparatively assess adoption of an ACP program. Providers are not inherently experienced in basic ACP introduction or deeper ACP discussions. Communications training, including conversations for values assessment and ACP, is in development for use with pilot and new practices engaging in the program, which supports program scalability. [Table: see text]
Improving patient safety: Factors leading to radiation therapy events in a large academic institution.
Authors: Walker Gary V. , Johnson Jennifer , Edwards Timothy , Hayden Sandra E. , Riley Beverly A. , Sittig Dean F. , Gillin Michael , Ibbott Geoffrey , Buchholz Thomas A. , Das Prajnan
Published: February 2017

224

Background: The purpose of this study was to elucidate the factors associated with radiation therapy (RT) treatment events and near misses at a large academic institution. Methods: All RT patient events and near misses/good catches were prospectively collected using an electronic incident reporting system from April 1, 2011-April 30, 2013. The event origin was categorized according to the step in the treatment process (simulation, physician prescription, dosimetry/physics, treatment delivery and other). The incident database was linked to the RT delivery (record and verify) database which contains date of treatment, radiation beam duration, number of fractions, and type of treatment. A treatment record was defined as a unique site description and date/time. Results: There were 224 reported RT events or near misses/good catches analyzed, of which there were 59 RT treatment delivery events associated with 105 treatment records, including 0 level I (most severe), 18 level II, 35 level III (least severe), and 6 level IV (near misses/good catches) among the 13,899 patients and 468,489 treatments. The remaining 165 RT events occurred at the other steps of the treatment process. The overall rate of RT events and near misses was 161.2 per 10,000 patients. The rate of RT treatment delivery events and near misses was 42.4 per 10,000 patients and 2.2 per 10,000 treatment records. Logistical multivariate analysis showed that treatment on Tuesday (Odds Ratio = 2.50, 95% CI 1.67-3.73, p<0.001), first day of treatment (5.16, 95% CI 3.32-8.02, p<0.001), number of fractions (continuous) (0.98, 95% CI 0.96-0.997, p<0.03), intensity modulated radiation therapy (IMRT) (2.87, 95% CI 1.44-5.74, p=0.003), electron only fields (2.00, 95% CI 1.27-3.14, p=0.003), and radiation beam duration (continuous minutes) (1.03, 95% CI 1.02-1.04, p<0.001), were associated with RT treatment events and near misses, while age, proton treatment, number of fields and after hours treatment were not. Conclusions: Treatments delivered on Tuesdays, on the first day of treatment, with fewer fractions, with IMRT, with electron only fields, and with longer radiation beam duration were associated with an increased risk of RT treatment events.
Chemotherapy safety initiative.
Authors: Tomaro Maria , Silverman Paula , Miano Wendy Rowehl , Wakeling Amy , Gonzalez Kathleen
Published: February 2017

226

Background: The 2006 Institute of Medicine report "Preventing Medication Errors," stated that “medication errors harm at least 1.5 million patients every year…” Chemotherapy (CT) has a narrow therapeutic index and safety margin which can and does lead to fatal errors. University Hospitals Seidman Cancer Center (UHSCC), an National Cancer Institute (NCI) designated Comprehensive Cancer Center, dispensed 10,500 CT doses in 2012 and has taken an active approach to enhance CT safety. Methods: In the last quarter of 2012, a nurse coordinator (NC) for chemotherapy orders and a Chemotherapy Safety Governance Committee (CSGC) was conceptualized. The NC’s role would be to incorporate CT safety best practices into order set development. The charter for the CSGC includes 1) to establish cancer CT standards and operating procedures across the adult and pediatric oncology population; 2) to develop and oversee cancer CT order set infrastructure applicable to our hybrid electronic/paper current state; and 3) to lead performance improvement initiatives related to CT safety. Leading organizations involved in oncology practice and medication safety standard-setting (ASCO, Oncology Nursing Society, Institute For Safe Medication Practices, National Comprehensive Cancer Network, Journal of Cancer Research) were reviewed for recommendations for standards for CT order sets. Results: Thirty standards for a CT order template were identified by the NC. A comprehensive gap analysis was completed to compare the current inpatient and ambulatory CT order sets to these standards. Results of the gap analysis were brought to the CSGC, a multi-disciplinary group of cancer and quality clinicians and leaders over 6 meetings. Consensus was achieved on the application of these standards to CT order sets. Our new orders will adopt 100% of all identified standards for CT orders. Conclusions: The gap analysis led to the development of a CT order set template that maximizes safety by applying best-practice standards. This template is designed to be applicable to electronic and paper-based order sets and with minor variation, appropriate to all disease-based order sets. This template is currently being utilized to revise 330 electronic and 398 paper CT order sets at UHSCC. [Table: see text]
Developing a culture of safety in systemic cancer treatment at the system level.
Authors: Hertz Sherrie , Kaizer Leonard , Krzyzanowska Monika K. , Simanovski Vicky , Vu Kathy
Published: February 2017

230

Background: Chemotherapy ordering, preparation and delivery involve multiple providers and complex systems where high impact errors may occur. Cancer Care Ontario, a provincial agency responsible for continually improving cancer services in Ontario, Canada employs a comprehensive systematic approach to build a culture of safety for systemic treatment. Methods: A comprehensive strategy is applied at 77 systemic treatment hospitals in the Province. A multi-pronged approach is used that includes: 1) system planning, organization and funding, 2) engagement of health care providers working at the regional and local levels, 3) guidelines implementation and, 4) quality measurement. Results: Institutions are organized into regional networks, according to four levels of service complexity based on quality standards, planning, funding, coordination and health human resources. A customized, system-wide incident reporting system is available. Quality improvement is undertaken in several ways. Regional clinical and administrative leaders foster engagement with local providers and work is facilitated by a provincial multidisciplinary community of practice, an annual Safety Symposium, and local improvement projects with funding support. In this way, collaborative sharing and learning occurs across the Province. Comprehensive evidence-based guidelines have been produced addressing safe labeling, administration, handling and the use of computerized prescriber order entry systems. Routine performance management together with guideline concordance measurement, public reporting, planning for improvement and re-evaluation strategies, has produced system improvements. Conclusions: A comprehensive, evidence-based and systematically applied approach to providing systemic cancer treatment can produce a culture of safety that is coordinated and standardized across multiple providers and provider sites.
Reducing inappropriate PSA-based prostate cancer screening in men age 75 or older with a highly specific computerized clinical decision support tool.
Authors: Shelton Jeremy B. , Ochotorena Lee , Bennett Carol J. , Shekelle Paul , Goldzweig Caroline
Published: February 2017

233

Background: The value of PSA-based screening for prostate cancer is a topic of intense debate, however the Veterans Health Administration's (VHA) national clinical policy is to use age as a proxy for life expectancy and avoid screening in men ≥ age 75. To facilitate this we developed and implemented a highly specific computerized clinical decision support (CCDS) reminder to remind providers of current guidelines, at the moment of entering an inappropriate PSA order. Methods: We defined screening PSA as: any PSA ordered on men excluding those a) with a diagnosis of existing malignant prostate disease or “elevated prostate specific antigen”, b) who are using either enhancers or suppressors of testosterone, or d) who had a PSA of 2.5ng/ml or greater on either of the two most recent PSA tests. We measured PSA-based prostate cancer screening rates using this definition and on a monthly basis from 07/2011 to 07/2013. Using an interrupted time-series design, we turned the reminder on from 6/2012-8/2012 and then again from 1/2013-4/2013. Results: There were a total of 24,705 men eligible for screening during the two year period of analysis and 1,524 men who were screened. The mean screening rate during the 12 months prior to the study period was 7.8% among men, and during the 12 months of the intervention period it was 4.3%. During the 12 month baseline period the screening rate declined by 29.3%. During the two periods when the CCDS tool was turned on the screening rate feel by 59.7% and 29.8%, whereas during the two periods when it was off, it rose by 84.3% and 18.4%. Conclusions: The overall reduction in screening rate before and after the intervention period is likely substantially confounded by the secular event of the May, 2012 release of the USPSTF grade D recommendation against all PSA-based screening and its substantial media coverage. Despite this, the striking correlation between rate of change in screening rate and the turning on and off of the CCDS tool, suggests that this highly specific CCDS tool was able to reduce inappropriate PSA-based screening, even in an era of significant public discussion of the merits of PSA-based prostate cancer screening.
Use of electronic medical record queries to support clinical decision quality assurance.
Authors: Nielsen Michelle , Senthelal Senti , Lian Jidong , MacPherson Miller , Medlam Gaylene , Larsen Tessa , Tsao Jonathan , Radwan John , Finlay Marisa , Yuen Jasper , Wang Yongjin , Rauth Sarah , Wan Jonathan Fung , McGowan Thomas
Published: February 2017

239

Background: Clinical Treatment Decisions in radiation oncology direct the patient’s treatment plans. There is a need for Clinical Decisions to be peer reviewed preferably in real time before the patient plan is completed. Traditional peer review of clinical decisions which ensure high quality patient treatments can be challenging in a busy radiation oncology clinic. Leveraging Electronic Medical Records (EMR) to query standard patient staging and demographics data per disease type allows for efficient peer review of the clinical decision. Methods: Through the use of EMR system (Aria, Varian Medical Systems, Palo Alto CA), data is entered into the radiation oncology chart by the primary radiation oncologist during a patient’s work up. Tools within the EMR have been configured to automatically query patient charts and summarize the data. A second Oncologist runs the query, reviews the data and peer reviews clinical decision for radiotherapy including treatment intent, dose and target contours. The radiation oncologist can then discuss modifications with the original oncologist, or indicate to the dosimetrist to continue planning. Those clinical decisions that are uncertain are escalated to review in a traditional peer review setting. Results: The EMR queries have allowed a shift to real time peer review of clinical decisions. The summary of disease specific staging and demographics data has added to efficiency in clinic in both the oncologists’ ability to complete a timely peer review and the lowering the amount of planning rework. Traditional peer review setting is then used to discuss the controversial and complex cases that would receive the most benefit. Conclusions: The ability to leverage electronic medical record data has made the peer review of clinical decisions in our institution more efficient and therefore the majority can be completed in real time.
Usability evaluation of HemOnc.org, a collaborative online hematology/oncology reference.
Authors: Yang Peter C. , Cowan Andrew , Warner Jeremy
Published: February 2017

244

Background: With an ever-growing body of medical knowledge, open access to accurate information is critical to quality care. HemOnc.org is a free online collaborative wiki created by health care professionals to record, access, and share information about chemotherapy treatment regimens and drugs. As of June 2013, the site contains referenced information for 931 regimens and 316 drugs. The site receives >7,000 visits/mo and has had >425,000 total page views from around the world (29% from outside the United States). We conducted a survey to evaluate the usability of the site. Methods: The survey was open May 1 to May 31, 2013. Participants were invited by site announcements, social media, and emails to hematology/oncology fellowship programs. Usability was assessed by 100-point scales (higher = better). Other data were collected via multiple choice questions with optional free text entry. Results: There were 139 respondents; demographics are shown in the Table. They felt that the site was useful (median 90, interquartile range (IQR) 76-99.5), usable (median 85, IQR 69-98), and recommendable to colleagues (median 87, IQR 72-99). Although 100% of users reported using other references (e.g. textbooks), 70.5% reported accuracy issues with these references (Table). Conclusions: HemOnc.org provides a new way to access and share curated knowledge. No resource is 100% accurate, but the open and transparent nature of the site allows users to actively correct errors and inconsistencies. Feedback has been positive, suggesting that an unmet need for information is being satisfied. Our goal is to improve collaboration, foster greater knowledge sharing among the oncology community, and improve quality of care through open dissemination of accurate information to a widespread audience. [Table: see text]
Concordance with best-practice guidelines for systemic treatment computerized prescriber order entry systems.
Authors: Hertz Sherrie , Gilks John , Kaizer Leonard , Yurcan Marta , Kukreti Vishal
Published: February 2017

245

Background: In 2012, Cancer Care Ontario, released evidence-based guidance for the key features, functionalities, and components of a Systemic Treatment Computerized Prescriber Order Entry (ST CPOE) system to ensure safe, high-quality care. Concordance measurement indicators were developed alongside the guidelines and a survey was then conducted to understand the current state in a meaningful and practical manner in the province of Ontario. Methods: A self-assessment survey was distributed to 22 hospital groups, including cancer centres and both academic and community hospitals, using four different ST CPOE systems in Ontario. 52 items were assessed on a four-point Likert scale, and descriptive hospital data was collected. Composite scores were calculated by category (regimen and protocols, functionality, useful alerts, audit logs, system integration, usability) and overall. Local and provincial results were analyzed. Results: Twenty-one (21) responses were received, with the majority (17) of surveys being completed by pharmacists. 48% had been using a ST CPOE system for more than 5 years and 38% for less than one year. 81% responded that they did not, or did not know if, they had local/institutional indicators for monitoring their systems. The mean total concordance score overall was 79% (range 65% to 92%) of a potential 208 total points. The highest mean score was in the category of audit logs (92%) and the lowest in system integration (69%). Approximately half (48%) had a multidisciplinary ST CPOE advisory group. While 16 hospitals were using the same ST CPOE system, there was distinct variability in responses from these sites, indicating the effects of tailored implementations and/or discrepancy in level of knowledge of system functionalities. Conclusions: Current concordance with best practice guidelines for ST CPOE systems in Ontario is incomplete and variable. While ST CPOE systems have potential to improve safety in the chemotherapy delivery, differences in system functionalities and their implementation have been identified. This study will be used to inform specific areas of strength, set benchmarks and potential areas for improvement.