bluuebunny/crossref_metadata_2025 huggingface dataset:
Opioid-associated deaths in patients with cancer: A population study of the opioid epidemic over the past 10 years.
Authors: Chino Fumiko Ladd , Kamal Arif , Chino Junzo P.
Published: September 2018

230

Background: Over 40,000 Americans died due to opioid overdose in 2016; the epidemic is a top public health concern. Opioids are commonly used for cancer associated pain but it is unknown what risks for overdose exist in this vulnerable population. Methods: De-identified death certificate data was obtained via the National Center for Health Statistics. Death certificates contain 1 underlying cause of death and up to 20 contributing causes, as well as demographic data. All deaths due to opioids were included from 2006-2016; if present, cancer was noted as a contributing cause. Opioid death incidence was calculated from both the US and estimated cancer survivor population. Chi and R squared tests assessed for differences. Results: From 2006-2016, there were 895 deaths due to opioids in cancer patients compared to 193,500 in the non-cancer population. Opioid deaths increased from 5.33 to 8.97 per 100,000 people in the general population (significant time trend, p < 0.001, polynomial fit, R2 0.99). Opioid deaths increased in the cancer population from 0.52 to 0.66 per 100,000 (significant time trend, p < 0.001, linear fit, R2 0.24, slope = 0.018). Cancer patients who died due to opioid use were different from those who died due to opioids in the general population including: higher education (12.7 vs 6.9% at least a college degree), more women (38.5 vs 29.2%), fewer whites (82.3 vs 84.2%), more Hispanics (94.5 vs 91.3%), and fewer single patients (24.2 vs 48.1%) [all p < 0.001, except race p = 0.027]. Cancer patients also had older median age (57 years, IQR 50-65 vs median 42 years, IQR 31-51). 22% of opioid deaths were in lung cancer patients, followed by GI (21%), head & neck (12%), hematological (11%), and GU cancers (10%). Conclusions: Death from opioids as the primary cause noted on death certificates are 10 times less likely to occur in cancer patients versus the general population. There was a slight increase in opioid deaths in cancer patients; however, overall, there was not the sharp growth seen in the general population. Cancer patients at risk for opioid overdose are different than those at risk in the general population and care should be taken when planning effective treatment of cancer-related pain.
Restructuring of inpatient rounds to improve quality of care in patients with cancer.
Authors: Das Devika Govind , Williams Courtney , Godby Kelly Nicole , Rocque Gabrielle Betty , Cargo Pamela , Flood Kellie
Published: September 2018

232

Background: Traditionally, hospital units function as multidisciplinary teams which work in silos and communicate via notes in the Electronic Health System. This often leads to communication breakdown, frequently translating to adverse clinical outcomes and prolonged hospital length of stay. Our primary objective was to introduce Inter-Professional Team (IPT) rounds on the oncology unit and evaluate the impact on length of stay (LOS) within a Plan, Do, Study, Act (PDSA) cycle. Methods: The care transition team planned the IPT rounds structure and training curriculum which included team goals, post-rounds structure for addressing barriers to care progression, and member roles/scripting. Change in LOS and case mix index (CMI)-adjusted LOS post-IPT round implementation ( Do) in July 2017 was analyzed ( Study) using hierarchical linear models for patients with an admission to the oncology service from September 2016 to March 2018. Beta coefficients (β) and 95% confidence intervals (CI) were estimated and models were adjusted for calendar time. Results: Ten attending medical oncologists participated in IPT round implementation. Of 889 oncology admissions, median LOS and CMI-adjusted LOS pre-IPT round implementation (n = 464) was 4 days (IQR 2-6) and 3 days (IQR 1.8-4.7), while post-IPT round implementation (n = 425) was 4 days (IQR 2-6) and 2.9 days (IQR 1.9-4.4), respectively. Three common reasons for admission were septicemia (n = 96), hematologic complications (n = 42, e.g. anemia/neutropenia), and renal failure (n = 25). Adjusted models for LOS and CMI-adjusted LOS showed no significant difference post-IPT round implementation (β = 0.8 days, 95% CI -0.7-2.3; β = 0.5 days, 95% CI -0.3-1.3, respectively) when compared to pre-implementation. Conclusions: We did not observe decreased LOS in early outcomes. However, IDT rounds built on TEAMSTEPPS 2.0 elements with incorporation of key principles desirable in a patient care team. Next steps include further analysis to better understand cancer stages and diagnoses contributing to longer LOS. We also plan to evaluate patient satisfaction, educational needs, and readmission rates to restructure ( Act) IPT rounds to better serve the needs of our unique patient population.
Lessons learned from the investigation of a sustained increase in paclitaxel hypersensitivity reactions (P-HSR) at a large community oncology practice: A mystery not fully solved.
Authors: Enright Katherine , Bussey Heather , Carvalho Maritza , Yousef Mary , Mills Allan , Myers Jeffrey A.
Published: September 2018

233

Background: Trillium Health Partners (THP) is a large community oncology practice that has a culture of quality and safety. An investigation was triggered by a perceived increase in the rate of P-HSR during a weekly quality huddle in the chemotherapy suite. At the time THP had no formal hypersensitivity reaction tracking process. A retrospective review of P-HSR over the preceding 18 months identified an increase in reaction rates from a baseline of 1% to 4.5% that started 3 months prior to the raised concern. Methods: A systematic quality review was undertaken to identify triggers for the change and to identify steps to decrease P-HSR to baseline. There was no identified change in premedication, administration or compounding practice and no association with drug or lot number was identified. The increase in P-HSR was coincident with a change in the intravenous (IV) pumps and tubing system across the hospital. The change in IV pumps introduced several potential triggers including: a change in the options for priming the IV tubing which introduced a potential for variable concentrations of drug reaching the patient at the outset of the infusion, an interaction between drug and IV tubing, and a doubling of the IV tubing length which could result in incomplete delivery of the premedication. Results: Sequential practice changes were introduced to address each potential driver including i) a slow infusion protocol for first 2 cycles, ii) alternative tubing sets, iii) practice alert regarding potential for under-delivery of premedication. Over time P-HSR trended down towards the historic baseline, no single intervention had a sustained impact, although the practice alert regarding the administration of premedication seemed to induce the most change. A step wise withdrawal of interventions that were felt to be non impactful is underway. Conclusions: Although no clear cause for the increase in P-HSR was identified the systematic quality review resulted in improved standardization of nursing practice for chemotherapy delivery and the methodical approach also lead to the establishment of a more comprehensive hypersensitivity reporting system at THP.
Reduction of radiation safety incident reporting following implementation of the radiation oncology incident learning system (RO-ILS).
Authors: Nelson Carl , Roy Lori Ann , Wallace H. James
Published: September 2018

236

Background: The Radiation Oncology Incident Learning System (RO-ILS) was initiated nationally June 2014 and is free, web-based, and currently used in more than 425 U.S. radiation facilities. RO-ILS was implemented at University of Vermont Medical Center (UVMMC) in October 2016 to facilitate safer, higher quality care. This implementation of RO-ILS was reviewed in order to determine whether the conversion to a new reporting system at UVMMC impacted radiation incident reporting at our institution. Methods: Radiation safety reporting at UVMMC included radiation incidents submitted by radiation therapists, dosimetrists and medical physics. Prior to RO-ILS, safety/quality incidents were submitted via a specified reporting form and submissions were reviewed monthly by the Radiation Oncology Quality Committee. After implementation of RO-ILS, radiation safety incidents were entered in RO-ILS and reviewed by the UVMMC RO-ILS administrator. Radiation incidents reported prior to October 2016 were entered into RO-ILS with the initial safety incident date. Results: Between April 2014 and May 2018, 136 radiation safety incidents were reported. There was a median of 7 incidents reported per quarter, decreasing from 8 to 6 per quarter after RO-ILS was implemented. Similarly, the average incidents per quarter was 8 and decreased from 8.9 to 6.7 per quarter after RO-ILS was implemented. Radiation incident types reported prior to RO-ILS were 78% “Near Miss” events but after RO-ILS decreased to 34%, while “Operational/Process Improvement” incidents increased from 17% pre RO-ILS to 49% post RO-ILS. The rate of radiation incidents reported per new patient starting radiation (the most frequent process associated with reported radiation incidents) was 0.59% and showed no significant trends or shifts before or after implementation of RO-ILS. Conclusions: Following implementation of RO-ILS at UVMMC, reported radiation incidents per quarter and the proportion of “Near Miss” events decreased, while the percentage of “Process Improvement” submissions increased. Further training and awareness of RO-ILS is planned with the goal of increasing staff participation and more robust reporting.
Utilizing a two nurse timeout process to eliminate errors during chemotherapy administration.
Authors: Hooley Joseph , Karius Diana , Colvin Christina , Akins Patti , Best Carolyn , Brinker Allyson
Published: September 2018

237

Background: Chemotherapeutic agents are listed as high risk medications at Cleveland Clinic, and have long been included on the Institute for Safe Medication Practices (ISMP) List of High Alert Medications due to the heightened risk of causing significant patient harm if they are used in error. Following a series of significant adverse events involving chemotherapy administration in 2012 at Cleveland Clinic, a two nurse timeout process (modeled after surgical and procedural timeout practices) was established to eliminate interruptions and decrease the risk of error. Methods: A written protocol was established to formalize a two nurse timeout process which must be completed prior to administration of chemotherapy. In order to eliminate unnecessary distractions during order review and medication administration, nurses hand off their phone and/or pager and coverage is provided for the nurses who are checking in the chemotherapy. A designated distraction-free area is utilized chemotherapy verification and order review. Following comparison of the chemotherapy agents to the orders, the nurses proceed to the patient’s room with the chemotherapy and the order pulled up on a computer. A procedure stop sign is placed on the door and the door is closed to eliminate interruptions. During the in-room timeout process, each step in the chemotherapy documentation flow sheet is reviewed by both nurses. After proper patient identification, one nurse will read the chemotherapeutic agent label and the other nurse will program the infusion pump. The two nurses will then switch roles with re-verification of the label and the infusion pump. The tubing set-up is then verified and the infusion is initiated. Results: Since the two nurse timeout process was established in 2013, there have been zero serious chemotherapy errors resulting in patient harm. Conclusions: Results have shown that implementation of the chemotherapy timeout process has increased the safety of administration of chemotherapeutic agents. It has now been more than five years since the last significant adverse event involving chemotherapy has occurred at Cleveland Clinic.
Steroid tapering for patients with spinal cord compression or symptomatic brain metastases at Jackson Memorial Hospital.
Authors: Asher David , Farnia Benjamin , Ramey Stephen , Francis Sarah , Mehta Shahil , Richardson Angela , Manzano Glen , Samuels Stuart , Yechieli Raphael
Published: September 2018

238

Background: Metastases to the spinal column and brain for patients with cancer are common occurrences seen in oncology practices. Steroids play a critical role in symptom management upon patient presentation and proper tapering of steroids is necessary to minimize risk of recurrent symptoms. Within our institution, which is a tertiary care facility primarily for the poor and near-poor of a large urban environment, 78% of patients with spinal cord compression or symptomatic brain metastases do not receive appropriate tapering of steroids following completion of radiation treatment. This leads to unnecessary side effects from continued steroid use, ultimately leading to an inefficient use of resources, including time and money. Methods: Through the guidance of American Society of Clinical Oncology (ASCO) Quality Training Program, we created a process map, cause and effect diagram, and acquired preliminary diagnostic data. This data was acquired via electronic medical record (EMR) review including evaluation of inpatient notes, discharge summaries, medication orders and prescriptions, and outpatient clinic visit notes. We then completed several PDSA cycles including grand round presentation, tapering template incorporation into clinic, and template creation within our EMR. Results: We identified that a single physician primarily was responsible for the patients that appropriately received steroids. We utilized this physician's expertise to help create meaningful interventions. By the complete of our last PDSA cycle, we have reduced the percentage of patients who do not receive an adequate steroid taper form 78% to 20%. Conclusions: Practitioner education and incorporation of steroid tapering templates into an outpatient radiation oncology clinic can reduce the percentage of patients with spinal cord compression or symptomatic brain metastases, who do not receive and adequate steroid tapering regimen.
Clinical decision support to reduce laterality ordering errors for breast imaging procedures.
Authors: Hernandez Karen , El-Tamer Mahmoud , Gurman Jonathan , Moulder Robin , Nevrekar Reshma , Robinson Donna , Sarwan-Vega Kimberly , Granovsky Svetlana
Published: September 2018

241

Background: Data showed 46 modifications to breast imaging orders upon patient arrival to the Radiology Department, in a 4 month period (Sept-Dec 2014.) Upon further investigation, we found that patients were arriving in radiology, scheduled for exams for which the laterality needed to be modified prior to the exam. (The most frequent occurrence was a patient with a history of a unilateral mastectomy, arriving in radiology for a bilateral mammogram.) These laterality order errors were traced back to either the referring LIP requesting the exam, or to the referring office’s clerical staff transcribing the order. The ordering errors came from many different referring services. Methods: Our objective was to develop Clinical Decision Support in our Clinical Information System (CIS,) to offer an upfront alert of a potentially incorrect laterality when a user was entering or transcribing an order, prompting the user to confirm that the correct exam had been ordered before scheduling took place. The Health Informatics team developed a Medical Logic Module (MLM) in CIS which cross-checks the surgical history in the Clinical Documentation Operative Notes with the current CIS order; if a mismatch is found, the alert fires. Results: In the first 2 months (Dec 2016-Jan 2017), 110 alerts were generated. Fifty-seven alerts flagged users of incorrect orders which were corrected before being scheduled; 21 MLM alerts were acknowledged and comments entered explaining the need for the test; 32 alerts did not generate an order (and in most of these instances, the user backed out and entered the incorrect order again; upon the second time seeing the alert, they changed the order, resulting in many of the 57 changed orders referenced above). Conclusions: The MLM alert allows for immediate feedback to the user entering an order with a potentially incorrect laterality. Not only does this reduce the time and burden associated with investigating and modifying these orders upon patient arrival; more importantly, it ensures orders are entered correctly from the start, reducing the possibility of an incorrect exam taking place.
Medical error reporting, culture, and infrastructure.
Authors: Denny, DBA Diane , Shinners Caitlyn
Published: September 2018

245

Background: Much work has focused on the importance of culture as a key factor in advancing the patient safety discussion. No assumption can be made that a culture of safety equates to embracing responsibility to report when errors and near misses occur. Underreporting exists. Without data, the opportunity to redesign care and address system failures is diminished. This research aimed to answer: what impact do various factors have on influencing the likelihood of reporting across a hospital network of oncology providers? Methods: The AHRQ Hospital Culture on Safety was used coupled with 15 custom questions of interest. Dependent variables (DVs) included: structure for reporting (definition, policy and ease), incentives to report, supervisor/employee relationship and management support. Independent variables (IVs) included number of errors reported and perceived frequency by which events are reported, influenced by tenure and extent of patient interaction. Higher scores associated with the IVs were posited to be positively associated with the errors reported as well as the reporting frequency. A principle component analysis was conducted as a variable reduction technique to affirm factors; the reliability of factors tested; and multiple regression analyses conducted to test the strength of relationships. Results: 2,103 surveys were completed. The 4 factors are found to weakly predict the DVs. Infrastructure had the greatest association in both models. Tenure and patient interaction influenced the likelihood of reporting. Conclusions: This research moves beyond culture in ascertaining factors pivotal in the underreporting of errors and near misses. An infrastructure promoting reporting must also exist ensuring staff know what, how, when, and why to report, linking data to action.[Table: see text]
Sustaining operational excellence in the oncology intensive care unit.
Authors: Barniak Sharon , Leahy Jennifer , Brash Jason , Wright Dana , McGovern Joanne
Published: September 2018

248

Background: In a high risk setting such as an oncology Intensive Care Unit (ICU), providing quality care and maintaining a culture of safety is vital to patient outcomes. Operational excellence built a foundational operating framework in the ICU, created process reliability and connected value streams through standardization, while increasing value to patients and employees. The purpose of this investigation was for the ICU and operational excellence teams to examine and eradicate defects. Five areas: Safety, Quality, Engagement, Innovation/Finance were determined to be most impactful and aligned with the unit’s key performance indicators. Metrics centered on patient safety and hospital-acquired complications (VTE, HAPU, VAE’s and CLABSI) became the focus of data collection and daily discussion. Methods: A multidisciplinary team designed and implemented a Lean Daily Management Board based on five predetermined metrics. The team met daily for a brief huddle to review a checklist confirming documentation adherence, patient outcomes, productivity, and employee engagement. Fallouts are addressed using a problem solving tool, displayed for awareness and corrective measures. Results: Initial data collected starting in January 2014, noted medication scan rate of 75%, fall rates at 1.32/1000 patient days, VTE 77%, HAPU 1/1000 patient days, VAE’s 1/1000 patient days, and CLABSI 0.3/1000 patient days. Continuing education and certifications among nurses were not defined at baseline. After implementation of the Lean Daily Management Board, 2015 data revealed an increase in medication scanning to 98.9% and 99.05% in 2017. Fall rates remain consistent at 1/1000 patient days and VTE prophylaxis climbed to 100% in 2015 and through 2017. HAPU’s decreased to 0.6/1000 patient days, and VAE’s were reduced to 1 in 2015, 0 in 2016 and 2017. CLABSI rates decreased to 0. Nursing certifications rose from 28% to 62% in 2017. Conclusions: Lean daily management empowered the staff to drive quality and safety in the ICU. Deficiencies fostered accountability and implementation of evidence-based patient care practices. Process improvement, positive patient outcomes, and increasing nurse engagement were achieved utilizing operational excellence.
Identifying potentially preventable emergency department (PPED) visits among patients with cancer in Ontario.
Authors: Yao Jane , Green Bo , Krzyzanowska Monika K.
Published: September 2018

25

Background: Cancer patients (pts) often visit the emergency department (ED) when symptoms and side effects occur. Growing evidence suggests that some treatment-related toxicities can be managed proactively in outpatient clinics, improving patient experience and optimizing acute care utilization. Understanding PPED visits is crucial to developing and evaluating such improvement efforts. Our objectives were to quantify the extent of PPED visits in Ontario among cancer pts and identify the best measure of PPED for province-wide quality improvement. Methods: By linking Activity Level Reporting to the Discharge Abstract Database and the National Ambulatory Care Reporting System, we identified cancer pts who had ED visits or hospitalizations up to 30 days after receiving chemotherapy and/or radiotherapy from April 1, 2014 to March 31, 2015 in Ontario. Episodes were stratified as ED Only or Indirect Admission (ED visit leading to hospitalization). We mapped the presenting Canadian Emergency Department Information System (CEDIS) complaints against the PPED metric proposed by Panattoni et al (JOP, 2018) that combined the CMS preventable visits typology with the STAR PRO tool (Basch et al, JCO, 2016) which found 49.8% were considered potentially preventable (PP). Results: We identified 43,593 ED visits (67% ED Only& 33% Indirect Admissions) among 64,407 pts. The most common presenting CEDIS complaints were pain (20%), fever (13%) and shortness of breath (SoB, 7%) among chemotherapy pts, and pain (19%), SoB (11%) and general weakness (9%) among radiotherapy pts. By applying the CEDIS-based PPED definition, which includes 17 presenting complaints, 50% of ED Only and 68% of Indirect Admission visits were considered PPED. Conclusions: We were able to adapt the PPED algorithm for the Canadian context, which can aid cross-jurisdiction comparisons. We found a substantial proportion of PPED visits. While common presenting complaints had face validity for being PP and a similar proportion of visits were PP compared to the US-based definition, further validation of this approach against healthcare records and in other jurisdictions would be helpful as these metrics become increasingly used for quality improvement.
Oral chemotherapy education sessions at an academic and community cancer center.
Authors: Roberts Daniel Aaron , Doolin Jim , Cibotti Christina , Hartwell Rebekah A , Yenulevich Mary , Trillo Kelsey , Hamdan Ayad , Rodrigues Christopher , Smith Morgan Brittany , Dowling Holly , Tocci Noah Xavier , Devlin Scott M , Shea Meghan , Zerillo Jessica A.
Published: September 2018

254

Background: Oral chemotherapy is becoming more widely utilized within oncology. Concerns regarding poor adherence and toxicity may be addressed by providing patient education. Methods: We developed and implemented a pharmacist-led initial education session for patients newly prescribed oral chemotherapy in both an academic medical center gastrointestinal oncology clinic and an affiliated community oncology cancer center. We provided an education packet including drug-specific information, clinic contact telephone numbers, and a drug schedule calendar. Standardized teaching and documentation templates were used. Patients completed each education session with the MOATT teaching tool for patients receiving Oral Agents for Cancer V1.2. Assessment of compliance with the ASCO/ONS Chemotherapy Administration Safety Standards on Oral Chemotherapy Education was assessed through use of Quality Oncology Practice Initiative (QOPI) quality measures where applicable and compared to historical QOPI data from the academic medical center from 2015-2017. Results: Thirty-one patients were newly prescribed oral chemotherapy and received the initial education session from November 2017 through May 2018. Based on a monthly report generated of new oral chemotherapy prescriptions, after a seven-month run-in, the rate reached 100% of patients at both sites for the most recent month. When comparing the intervention cohort to the historical QOPI cohort using a one-sided P value of 0.017 with bonferroni correction, there was improvement in safe handling/storage (pre: 19%, post 100%, P = 0.0001), drug-drug and food interactions (pre: 31%, post 100%, P = 0.0001), and plan for missed doses (pre: 37%, post: 97%, P = 0.0001). A trend toward improvement was found for schedule/start date discussion (pre: 87%, post: 100% P = 0.018) and side effect/toxicities (pre: 87%, post: 100% P = 0.018). Conclusions: Implementation of an oral chemotherapy education session in both an academic and community setting was feasible and improved adherence to QOPI measures of oral chemotherapy education and ASCO/ONS standards for oral chemotherapy. Further data regarding time to clinical outcomes is forthcoming.
Trends in aggressive inpatient care at the end-of-life for stage IV lung cancer patients.
Authors: Mrad Chebli , Abougergi Marwan S , Daly Robert Michael
Published: September 2018

26

Background: Metastatic lung cancer patients are treated with palliative intent. Aggressive inpatient care at the end-of-life is seen as a marker of poor quality care. However, national trends and factors related to aggressive inpatient care at the end-of-life for these patients have not previously been evaluated. Methods: A total of 3,030,866 hospitalizations of metastatic lung cancer patients were identified in the National Inpatient Sample database between 1998 and 2014. Longitudinal analysis was conducted to determine trends in aggressive inpatient care at the end-of-life and multivariate logistic regression was performed to determine associations with age, race, region, and hospital characteristics. Results: From 1998 to 2014, in-hospital mortality for metastatic lung cancer patients decreased from 17% to 11%. However, the proportion admitted to the intensive care unit during the terminal hospitalization increased from 12.9% to 26.4%. Reflecting this aggressive end-of-life care, mean total charges for a terminal hospitalization increased from $29,386 to $72,469, adjusted for inflation. Among patients who died in the inpatient setting, the intensive care unit stay translated into higher total costs (+$18,461 CI: $17,460 to $19,463). Promisingly, palliative care encounters for terminal hospitalizations increased during this period from 8.7% to 53.0% and were correlated with a decrease in aggressive care at the end-of-life. A multivariable model showed variation by patient and hospital characteristics in aggressive inpatient care utilization. Conclusions: Among patients with metastatic lung cancer there has been a substantial increase in intensive care unit use during terminal hospitalizations, resulting in high cost for the health care system.
Enhancing safety and delivery of oral chemotherapy utilizing lean methodology.
Authors: Fernandez Debbie , Hulen Kathy , Scott Leigh Anne , Bambara Kelsey , Creamer Gayle , Wright Jeff , Tsue Terry , Neiberger Adam , Hoffmann Marc Steven
Published: September 2018

266

Background: An oral chemotherapy safety event prompted analysis of related workflows utilizing lean quality improvement methodology. This analysis identified high variation in prescription processing, lack of standardized safety checks, inefficient use of pharmacy time, and inadequate data collection. Our goal was to create an oral chemotherapy protocol that could ensure patients have the right oral chemotherapy agent, at the right dose, at the right time, with independent and efficient safety checks by nursing, pharmacy, and providers. Methods: Multidisciplinary teams participated in two kaizen workshops. utilizing lean methodology. Primary workshop objectives were (1) develop safety standards for oral chemotherapy similar to those for intravenous chemotherapy; (2) make workflows more efficient; and (3) have workflows that enable data collection and process control. The first workshop standardized oral chemotherapy prescription processing though a single workflow in the EMR. This enabled robust data collection and established a platform for safety interventions. The second workshop developed standardized safety checks for and integrated those into the EMR workflow. Given the rarity of serious safety events, a validation measurement was not feasible to track in 30-day PDCA cycles. Consequently, surrogate measures of utilization of the EMR prescribing algorithm and reduction of non-clinical pharmacy interventions were used to assess progress. Safety data were collected and correlated to surrogate outcomes for long-term impact assessment. Results: Interventions resulted in the following outcomes: 100% reduction in oral chemotherapy order defects reaching pharmacy; 97% improvement processing oral chemotherapy though a single EMR workflow; 23% reduction in oral chemotherapy processing time; In spite of a 51% increase in oral chemotherapy volume, no serious safety events have occurred in the last year. Conclusions: Comprehensive quality improvement in our oral chemotherapy process increased safety and efficiency while developing data collection systems for continuous improvement. Multidisciplinary workshops with key stakeholders using established lean methodology were critical to success.
Reducing opioid utilization after urologic oncology surgery.
Authors: Stevenson Kerri , Kee Jessica , Van Zyl Elizna , Dugala Anisia , Shah Jay Bakul
Published: September 2018

269

Background: Multiple sources have reported on widespread abuse of opioid pain medications among Americans. For many patients, the first encounter with these addictive substances happens when they are prescribed opioids for acute pain management after surgery. Unfortunately, 6% of opioid-naïve patients become newly addicted to opioid medications after surgery. As a high-volume surgical department, we aimed to reduce our reliance on opioid medications to manage post-operative pain by 50% from a baseline morphine equivalent daily dose (MEDD) of 95.1 to a target of 47.5 MEDD. Methods: We retrospectively reviewed daily opioid use, pain scores, and anxiety scores for inpatients recovering from surgery for urologic cancers at our institution over 4 months. We generated process maps, Ishikawa diagrams, and Pareto charts to identify causes contributing to excess opioid use. We designed opioid-sparing pain regimens (using varying combinations of acetaminophen, ketorolac, gabapentin, and local anesthetic) and we identified key drivers required to reliably decrease excess opioid use. Initial interventions were aimed at educating providers and nurses on availability and efficacy of non-opioid medications and later interventions sought to facilitate adoption of the novel pathways. Results: Over the course of this QI project involving 443 patients, the median opioid use per patient decreased 46% from 95.1 to 51.5 MEDD. This reduction in opioid requirements after implementation was successfully achieved across multiple surgery types ranging from robotic prostatectomy (55.1 MEDD) to open radical cystectomy (50.6 MEDD). There was no increase in 24- or 48-hour post-operative pain score associated with use of opioid-minimizing pathways (3.03 vs. 3.04 and 2.92 vs. 2.96, respectively; p > 0.05 for both). Similarly, there was no change in anxiety score at 24- or 48-hours after surgery (0.15 vs. 0.12 and 0.48 vs. 0.30, respectively; p > 0.05 for both). Conclusions: We decreased opioid use after surgery by 46% without compromising pain control. In the nationwide effort to combat the opioid epidemic, health care providers can play a pivotal role as gatekeepers by decreasing reliance on opioids in the post-operative period.
Development of a virtual cancer care network for distance oncology treatment.
Authors: Passero Vida Almario , Liman Andrew D. , Rai Hema , Harrold Laurie , Hotchkiss John , Speerhas Lucy , Allen Kaneen , Veraldi Kristen , Tokarsky Joyce , Couch Myra , Tan Jocelyn , Kies Kara , Shields Jenna
Published: September 2018

270

Background: The VA Pittsburgh Healthcare System (VAPHS) Virtual Cancer Care Network was launched in January 2018 as the next step after we had established an electronic consult service where 555 hematology electronic consults were completed at VAPHS in FY17. The clinical video telehealth (CVT) clinic allows veterans from central Pennsylvania to receive their anticancer therapy at the VA in Altoona, Pennsylvania where the oncology pharmacy, nursing, telehealth, and supportive oncology staff are on site, while the patients continue to follow regularly during treatment via CVT visits with their oncologist located 93 miles away at the VA in Pittsburgh. Methods: A chemotherapy pharmacy and nursing infusion clinic were created at the VA in Altoona. CVT visits started in January 2018. Data including zip code and clinic visit details were examined through descriptive statistics. Results: A total of 89 CVT visits for 27 patients were completed from January 2018 to May 2018. All patient visits were follow-ups while patients were receiving active treatment. 16 patients received intravenous treatments, and 11 received oral anticancer therapy. 100% of the patients were male. Median age was 73 (range 56-89). The most common diagnosis was prostate cancer (26%). The majority of the patients were receiving therapy for palliative intent. 100% of patients chose VA Altoona rather than VAPHS as their treatment clinic location. Five oncology physicians and one oncology clinical nurse specialist completed the clinical video telehealth visits from VAPHS. Total commuting distance averted was 14,828 miles. With an average commuting speed of 60 mph and a travel cost per mile of 0.5 dollars, the total commute time saved for veterans was 247 hours, and the total mileage costs saved was $7414. Appointment compliance was 100%, and there were no missed opportunities. Conclusions: Implementing the Virtual Cancer Care Network has decreased the travel time and costs for veterans who previously would have travelled from central Pennsylvania to VAPHS for their oncology treatment. The integration of CVT technology has improved patient access to oncology care and maintains the patients’ primary relationships with their oncologists.
Impact of technology-based access to a multidisciplinary tumor board on treatment planning for patients with cancer in developing countries.
Authors: Jotwani Amit Kumar , Jain Rashie , Shelometh Spoorthi
Published: September 2018

271

Background: The developing countries account for 70% of cancer associated mortality in spite of significantly lesser incidence than the developed world. The main reason for poor outcomes is acute shortage of trained oncology medical professionals. We conducted a prospective study on impact of Onco.com multidisciplinary tumour board (MTB) opinion on the treatment plan for patients. Onco.com provides online access to senior experts in oncology from India and United States wherein the patients can avail unbiased, evidence based treatment opinion through technology. Methods: We prospectively evaluated the impact of treatment plan provided by multidisciplinary team of oncologists on the treatment received by patients who opted for secure online opinion on onco.com. A total of 335 patients from 13 countries received online MTB opinion from July 2017 till April 2018 were included in the study. A multidisciplinary tumour board was constituted through an automated system by matching expertise of the oncologists as per patient’s condition. The experts had access to cutting edge scientific journals and international clinical practice guidelines (NCCN, ESMO, Uptodate.com) while giving opinion for the patient. The opinion was delivered in 3 days. Results: Of the total 335 MTB reports evaluated, 68 had stage I or II disease, 104 had locally advanced disease and 163 patients had metastatic/relapsed disease at presentation. Online access to multidisciplinary team of expert oncologists lead to a better treatment plan for 81.5% patients, while significant 14.6% patients received drastic changes in their existing treatment plan. Conclusions: The results demonstrate that technology can help us bridge the gaps in access to trained expert oncologists across borders for developing countries and help them receive better treatments. A longer follow up is needed to evaluate impact of online MTB opinion on clinical outcomes for patients.[Table: see text]
Decreasing time to treat using visual management tools.
Authors: Rothacker Andrew , Cummings Chad W. , Tullio Katherine , Ibsen Alison , Monteleone Emily Elizabeth , Bottles Rebecca
Published: September 2018

277

Background: Time between positive cancer diagnosis and first treatment (TTT) has lengthened significantly nationwide over the last decade. Decreased TTT has been shown to positively impact patient outcomes such as anxiety and stress, and in some situations, overall survival (OS). As such, TTT (measured in median days) is a major initiative for disease programs at our large academic medical center. Impacting TTT is challenging given the usual sources of data, which are retrospective. Further, engaging the teams around the data was difficult. The need to illustrate patient delays in real-time was identified. Methods: A patient database was created, along with a dashboard, using a visual software package to track patient activity. Information is extracted from the database into a dashboard, including the patient’s appointments, treatments, and barriers to care. The dashboard was constructed with graphics of historical TTT by month, TTT distribution by treatment type, TTT by provider, and a graphic of the most common barriers to treatment. Additionally, the dashboard identified patients who were not scheduled for treatment, and were represented by a symbol on an x/y-axis graph. The x-axis represents the unique patient, while the y-access represents the days from diagnosis, with the symbol incrementing each day the treatment is not scheduled. Results: The dashboard is used weekly to huddle with clinical and non-clinical teams. Patients with no scheduled treatment are easily identifiable on the dashboard, with a focus on minimizing all patient’s TTT. Patients with extended schedule are actively engaged to reschedule and reduce their TTT. The breast cancer program began using the dashboard in July 2017. The surgical TTT was 30 days (n = 34). Post-implementation of the dashboard and multi-disciplinary huddles, it was found in April 2018 the TTT was 26 days (n = 36). Conclusions: Combining real-time data with simple data visualization tools allows teams to identify barriers to care easily. The visual tools identify outliers and allow teams to communicate on scheduling challenges of each patient. In conjunction with the multi-disciplinary huddles, the dashboard allows teams to track progress of each patient to ensure timely scheduling and coordination.
Implementation of oral chemotherapy management program in the large integrated health care system and its impact on patient safety.
Authors: Yoo Jessica , Nhean Salin , Vogel Prabha , Rybkin Igor I. , Kostoff Diana
Published: September 2018

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Background: Oral chemotherapy is a progressively growing portion of antineoplastic agents. Although convenient for the patient, it creates a unique challenges for the drug complacency and safety. To address these issues variety of programs and solutions were proposed, ranging from the smart pill bottles and mobile phone applications to telemedicine monitoring programs. This presentation describes development and implementation of the integrated monitoring program within a large health care system and assess impact of this program on patients safety and compliance. Methods: This is a retrospective, quasi-experimental study that compared outcomes of the patients treated with capecitabine, before and after implementation of OCMP (Oral Chemotherapy Management Program) in the Henry Ford Health System. The primary outcome was incidence of all grade and specifically grade 3-4 toxicities commonly associated with capecitabine. Secondary outcomes included emergency department (ED) visits and hospitalizations due to toxicity, adherence rates, and number of clinical interventions. Results: The incidence of adverse effects of Any Grade was significantly lower in the post-OCMP group compared to pre-OCMP group (70.3% vs 58.9%; 95% CI, 0.39-0.94; P = 0.03). All grade and grade 3-4 nausea, vomiting and diarrhea along with grade 3-4 hand-foot syndrome were significantly lower in the post-OCMP group, as well as decreased ED visits (18.9% vs. 8.6%; P = 0.005) and hospitalizations due to toxicities (17.1% vs. 6.3%; P = 0.002). The study also found higher adherence rates in the post-OCMP group. In the post-OCMP period, more than 50% of the patients required clinical interventions by OCMP nurse, mostly for side effect management. Conclusions: Administration of capecitabine on OCMP reduced rate of higher grade adverse events, most likely due to early intervention. OCMP implementation was associated with decreased rate of ED visits and hospitalizations due to the side effects. Patients who were managed by OCMP had higher adherence rates to the prescribed oral chemotherapy.
Engaging support staff to redesign and improve the process to communicate with outside physicians.
Authors: Kadish Sarah , Malins Ashley , McCleary Nadine Jackson , Bullock Taneisha , Malouf Alexia , White Kimberly , Gauthier Stephanie , McLaughlin Bridget , Johnson Danielle , Krier Gina , Brady Lauren , Wagner Andrew J.
Published: September 2018

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Background: Communicating with a patient’s primary care physician and other specialists is a key component of collaborative patient care across organizations. This includes identifying and maintaining a current list of care team members and distributing consult and progress notes. Recently, after transitioning to a new EMR, referring physicians noted a reduction in notes about their patients seen at the Dana-Farber Cancer Institute. The process in the new EMR was more burdensome than the automated system in the legacy application: physicians were now required to populate a recipient list, manually attach a note, and arrange for mailing of a printed letter if no fax number was available in the directory. The system did not require notes to be sent, and consequently many physicians chose not to adopt this new administrative work. Methods: A multidisciplinary team was formed to reduce the administrative burden of sending notes from providers and to enhance communication with outside physicians. All adult medical, surgical and radiation oncology exam appointments were in scope. A standardized process was developed in which at each exam visit clinic assistants worked with patients to update the care team list and asked patients which physicians should be sent copies of the note. The clinic assistant prepared the outgoing communication, added the patient’s identified recipients and PCP, and set the communication to automatically send upon the provider completing his/her documentation. The clinical assistants were trained on each clinical floor and held daily debriefs with the project team during the first week to address any issues. Providers were educated on how to change the recipient list or the outgoing communication if desired. Results: In the five months after implementation, the percent of exam appointments with notes sent increased from 42% to 79% (P < 0.001) without significant impact on the time to place patients in exam rooms. Conclusions: Redesigning workflow through engaging support staff can improve communication and coordination with external providers, while reducing the administrative work assigned to providers.[Table: see text]
Results from a pilot of an innovative 4R Cancer Care Delivery Model in early breast cancer: Impact on timing and sequencing of guideline recommended care.
Authors: Weldon Christine B. , Trosman Julia Rachel , Perez Claudia B. , Kulkarni Swati , Khan Seema Ahsan , Hansen Nora M. , Nelson Valerie , Stein Jennifer , Simon Melissa A. , Spagnoli Cathy , Tepper Jennifer , Pearson Kay , Gradishar William John
Published: September 2018

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Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (Trosman JOP ’16). 4R = Right Info / Care / Patient / Time. It enables patient and care team to manage timing / sequencing of interdependent care with an innovative multimodality personalized 4R Care Project Plan. We piloted 4R at 3 centers (academic, community, safety net) and assessed impact on timing / sequencing of guideline based care. Methods: 4R Plans were administered to breast cancer patients stage 0-III Sept ’17 – Aug ’17. Clinical data for 185 patients who received 4R (4R cohort) were compared with a historical control cohort of comparable patients who received care pre-4R, Jun ’16 – May ’17. We used simple frequencies and Fisher’s exact test in analyses. Results: We improved timing / sequencing of 7 guideline recommended metrics (Table). Significant improvements were shown for care lacking in the control cohort. 4R improved rate of patients receiving genetic test results and fertility in a timely manner. Neoadjuvant therapy rate doubled, but low sample size precluded statistical conclusions. However, timing / sequencing of care needed prior to neoadjuvant therapy (eg fertility, flu shot) were significantly improved. Conclusions: The 4R model significantly improved timing / sequencing of guideline recommended care in early breast cancer. An ongoing 4R pilot at 12 additional cancer centers across the U.S. is continuing to accrue patients and focusing on other guideline-recommended metrics. [Table: see text]