bluuebunny/crossref_metadata_2025 huggingface dataset:
With quality and safety for all: Risking optimal care with VIP patients.
Authors: Blackburn Sandra
Published: February 2017

142

Background: The person deemed a VIP is generally considered differentiated from the average person by virtue of fame, notoriety (positive or negative), or success through talent, tenacity or simple luck. Because society often views VIPs as special, this can generate strong feelings ranging from excitement and awe to resentment in those who encounter a VIP. VIPs and/or their entourage may request or demand special attention. The unique factors associated with caring for a VIP can jeopardize patient safety and optimal care of the VIP patient. Methods: Typology associated with the labeling of VIP patients will be used as a framework. For example, an objective VIP patient is someone who is indisputably famous or notorious. These individuals are typically in the public eye such as a famous actress, professional athlete, elected official or rock star. Persons who are subjectively designated as a VIP are usually labeled by a person of power or authority such as a hospital administrator or the Development office and they are largely unknown until they are so designed as a VIP in a specific facility. They may be the brother-in-law of the hospital CEO or a major benefactor who has a low or unknown public profile. Both objective and subjective VIPs pose problems because of the expectations placed on staff whether implied or explicit. Results: This presentation will review typical operational problems and named syndromes that are associated with the medical care of the VIP patient. These syndromes typically outline how the whirlwind of activity and expectations surrounding a VIP patient can cause a flummoxed staff to make decisions that can lead to worse care for the patient. Conclusions: For example, ‘Chief Syndrome’ is a demand, request, or intentional substitution for the “top person” in a department to provide care to the VIP patient. Problems can result if the top person, or chief, has been behind an administrative desk for the past five years and they are not as practiced as a usual provider who sees patients daily. Other cautionary notes and preventable actions that can lead to sub-optimal care of the VIP patient will be presented.
Hardwiring advance directives into an electronic medical record.
Authors: Childress Susan B. , Buckley Tyler , Badke Andrew , Horyna Amy , Howell Julie , Gren Lisa , Beck Anna Catherine
Published: February 2017

146

Background: Patient preference at the end of life has been extensively researched and documented. Advance Directives (AD) have been shown to make a difference for patients in the areas of quality, cost, and patient satisfaction. Organizations struggle with meeting federal laws and accreditation expectations due to our complex systems. Literature supports “hardwiring” AD documentation into the EMR and providing “one click” accessibility to AD’s. Changing EMR vendors provides a unique opportunity to optimize access to AD’s, both through patient education /endorsement, review of providers’ role, and engagement of IT. Methods: Huntsman Cancer Institute at the University of Utah identified an opportunity to improve the process of obtaining AD's during a change to Epic as an EMR. MD/RN champions brought a team together that included pastoral care, social work, medical records, and IT. The group used national "Decision Day" efforts as a platform for kicking off the project. Notable barriers to implementation included AD’s from previous EMR not migrating, inadequate systems for RN and SW consultation, lack of triggers to engage provider support, and MD order sets requiring major revisions Accessibility on the banner from any view was deemed best practice. Audits were created to give feedback to hospital staff and the quality department. This effort was also identified as a priority quality goal for the entire institution. Results: There have been significant improvements in assessing patients, obtaining AD's, and providing easy access to these records. Conclusions: EMR systems do not always come with processes in place to address the need to obtain AD's, scan or enter them into the EMR, and provide easy access during critical decision points in patient care. Collaboration with the IT team in identifying institutional requirements and workflow is critical as an organization identifies the need to improve AD system flow or begins planning for transition to a new EMR.
Meeting patient and provider eTechnology needs: A provincial approach.
Authors: Redwood Erin , Smith Richard , Garay Chanson Robert , Truscott Rebecca , Umar Shama , Kaan Melissa , Kraetschmer Nancy , Lee Gemma , Kukreti Vishal
Published: February 2017

153

Background: Cancer Care Ontario is the government agency responsible for improving cancer services across Ontario, and for implementing standards such as quality care, benchmarking and system navigation. In this role, a provincial information management and information technology (IM/IT) strategy across the patient continuum of care is essential to achieve the goal of improving the performance of the healthcare system and enhancing quality of care. Methods: Cancer Care Ontario developed a standardized approach for an IM/IT strategy through clinical engagement, needs assessment, gap analysis, clinical standardization influencing product build, usability testing, change management and post-implementation evaluation. Results: See table below. Conclusions: Ontario’s strategy for IM/IT initiatives includes a repertoire of eTools for system, patient and clinician level end user needs. An ongoing evaluation strategy including real-time patient experience measures will further strengthen the approach. [Table: see text]
Use of an automated notification tool to drive real-time patient symptom intervention.
Authors: Hartman Scott , Bosch Brandon , Denny Diane , Markman Maurie
Published: February 2017

160

Background: Cancer Treatment Centers of America, Inc. (CTCA) is a national network of hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer. The Symptom Inventory Tool (SIT) is an assessment tool that captures the patients’ perceived symptom burden for real-time clinical intervention, from baseline and every 21 days thereafter. The SIT is comprised of questions utilizing the M.D. Anderson Symptom Inventory tool, a validated assessment instrument with questions added and a free text box by CTCA. Methods: An e-mail notification system associated with the SIT was established to allow efficient communication with specialists and support team members who would not traditionally see the patient without such a trigger signifying a need. While the SIT report is housed within the EHR, an automated e-mail profile may be established for each clinician and or team, tailored to the clinical specialty, based on symptom(s) of interest. Patients completing the SIT and scoring a particular symptom(s) at or above a threshold will “trigger” notification of that their score along with information allowing follow-up. Notifications can be set at 15 minute intervals, hourly, daily, etc. Results: 31 users/groups, representing a wide variety of disciplines and multiple care teams, currently utilize the SIT e-mail functionality including: Pain, Distress, Mind Body Medicine, Survivorship, Physical Therapy, and Sleep. The content of the e-mail consists of the patient name, medical record number, and (self-defined) symptom scores of interest. These same patients triggering a notification may be readily tracked for follow-up by the support team throughout their course of treatment or seen only once depending upon patient preference and identified need. Conclusions: The e-mail notification process has promoted communication with specialists and other support team members outside of the core team, cognizant of their different communication needs. Moreover, it allows for effective alignment of resources based on clinician expertise.
The radiation oncology EMR as a quality and outcomes-based informatics platform: A multicenter pilot study.
Authors: Pawlowski Jason Mark , Wotring Tammy , Kennedy Andrew S.
Published: February 2017

168

Background: Radiation oncology specific oncology information systems (OIS) are highly specialized and capture large amounts of rich data related to patient care. There is great potential to expand the utility of these systems from data collection and point-of-care documentation to platforms for radiation oncology informatics. To this end, we have begun an effort to consolidate and standardize the OIS within a large network of radiation oncology clinics. We report initial findings from a multi-center OIS standardization pilot involving five clinics. Methods: Five radiation oncology clinics were converted from a paper-based medical record to an electronic medical record (EMR) on a single instance of the OIS. Clinician-led workgroups developed best-practice EMR workflows to ensure high-quality data were input into the OIS. Database configuration, clinical workflows, and documentation were standardized to enable consortium-wide reporting and dashboarding. Results: Standardization for the five radiation oncology centers was completed in September 2014. Clinical and operational dashboards were generated including dashboards to study radiation toxicity, treatment modality utilization, time studies for each task from referral to treatment, SRS/SBRT utilization, follow-up rates, and referral patterns. Consortium-wide analysis revealed substantive differences in operational and clinical practices. For example: IMRT utilization for prostate cancer patients treated with external beam radiotherapy ranged from 83% to 100% amongst facilities; the time required to contour target volumes on 80% of patients ranged from 2 to 10 days amongst physicians; and follow-up rates ranged from 50% to 83% amongst physicians. Conclusions: Standardization and consolidation of the radiation oncology OIS significantly increased reporting capabilities to include measures based on quality, safety, and patient outcomes. Disparate practices amongst radiation oncology clinics were observed and best practices discovered. OIS consolidation and standardization was essential to develop a consortium-wide understanding of clinical and operational quality.
Faster ways of pursuing quality control using EHR (Electronic Health Record).
Authors: Dwary Ashish Dutta , Master Samip R. , Mills Glenn Morris , Mansour Richard P.
Published: February 2017

169

Background: In this era of electronic health records (EHR), quality monitoring can be a fast repetitive process. Having access to the relational database of the EHR permits rapid case identification and quality indicator determination. We hereby describe evaluation of hepatitis B testing prior to rituximab administration, a quality measure as per ASCO guidelines. Methods: We connected SQL Query Manager with EPIC Clarity database. Using the object model for medication orders, location and department, we used SQL language to build a temporary dataset of all patients who have a completed order for a Rituximab infusion at a specific department location within the past 6 months. Using the dataset obtained in step 2, we created a smaller dataset with one row for each patient. We updated each unique patient row by updating columns for the count of completed Rituximab infusions, the first infusion date and the last infusion date. We then updated each row from a query of the order procedure and results object model. The unique patient id and component id are the key fields for this query. The Hepatitis B surface antigen and core antibody results were queried from up to 6 months prior to the initial rituximab dose. We looped through the dataset and compared the first Rituximab start date with the Hepatitis B testing date. If the testing date is before the drug administration date, a Boolean column was updated to indicate a 1 for passing the quality measure and a 0 for not passing. Finally, we reviewed that chart of any patients who fail the electronic quality measure check as some Hepatitis B testing may be represented in scanned results and these scanned results cannot be queried. Results: When the final SQL query runs, it takes less than a minute to see the result set. The query can be run at any interval or date range. Once the SQL procedure is created, there is essentially no labor and very low costs to run procedure at specific time intervals. Conclusions: Quality control is integral for improvement in patient care. Doing quality monitoring can be labor intensive, expensive, repetitive and time consuming. By using the relational database created and maintained by the EHR we can accomplish the quality control in faster way that is time and cost effective.
What is the real rate of surgical-site infection?
Authors: Taylor Jolyn Sharpe , Marten Claire , Potts Kimberly , Cloutier Lynn , Cain Katherine , Fenton Shauna , Tatum Tara , James Deepthi , Hubbs Cheryl , Burzawa Jennifer , Vachhani Shital , Nick Alpa Manchandia , Meyer Larissa , Graviss Linda , Ware Kathy , Park Anne , Aloia Thomas A. , Bodurka Diane C. , Levenback Charles F. , Schmeler Kathleen M.
Published: February 2017

171

Background: Surgical site infections (SSI) are associated with patient morbidity and increased healthcare costs. Although several national organizations monitor SSI including the University Health System Consortium (UHC), National Surgical Quality Improvement Program (NSQIP), National Healthcare Safety Network (NHSN) and Agency for Healthcare Research and Quality (AHRQ), there is no standard reporting methodology. We compared SSI rates from these databases to our own chart review. Methods: We queried the UHC, NSQIP, NHSN and AHRQ databases from 7/2012-6/2014 for SSI following gynecologic surgery at our institution. UHC and AHRQ rely on ICD-9 coding while NSQIP and NHSN employ trained reviewers. Each organization uses different definitions, inclusion and exclusion criteria for SSI. NSQIP reviews 13-17% of cases at our institution while the other agencies include all cases. The rate of SSI was also obtained from chart review for 5/1/2014-6/30/2014 with SSI defined as an infection of the surgical incision or organ space requiring antibiotics. SSI was classified as superficial, deep or organ space (OS). The rates reported by the agencies were compared to the rate obtained by chart review using Fisher’s exact test. Results: The combined UHC/NSQIP/NHSN/AHRQ SSI rate was 5.1% (78/1,540) while the rate found by chart review was 12% (20/166) (p = 0.001). Overall SSI rates for the databases were: UHC 1.6%, NSQIP 8.8%, NHSN 2.9% and AHRQ < 1%. The combined database reported fewer superficial SSI compared to investigator chart review but did not differ significantly when reporting deep and OS: superficial 1.6% v 7.8% (p < 0.001), deep 2.1% v 1.2% (p = 0.57) and OS 2.9% v 3.6% (p = 0.26). The individual databases had wide variation in rate of superficial (UHC 0.7% NSQIP 1.2% NHSN 0.5% AHRQ 0%), deep (UHC 0.7% NSQIP 4.7% NHSN 1.3% AHRQ 0%) and OSI (UHC 0.03% NSQIP 4.4% NHSN 1.4% AHRQ < 1%). Only 19 cases (24.4%) were included in > 1 database. Only one case was included in three databases (1.3%) and no cases were included in all four. Conclusions: There is discordance among national reporting agencies tracking SSI and all agencies reported a different rate of SSI compared to chart review. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.
Discussions of cancer screening: What do physicians say, what do patients hear, and how much shared decision making occurs?
Authors: Talcott James Austin , Aharonoff Gina , Bezuhly Maureen , Herzstein Jessica , Osborne Michael P. , Fowler Floyd Jackson
Published: February 2017

180

Background: Like other medical interventions, cancer screening requires shared decision-making (SDM). To better understand the process, we are performing a cluster-randomized trial of educational supports to improve screening guideline compliance for breast, cervical, colorectal, lung and prostate cancer at two urban academic medical centers. We present interim results that focus on recalled SDM discussions. Methods: We are enrolling an age- and sex-stratified sample of 216 patients aged 30 to 89 years, 18 treated by each of 12 primary care physicians at two affiliated hospitals before a periodic physical examination. Screening guideline format (color-coding) and academic detailing are independently assigned to providers. Patients and providers are surveyed immediately after the encounter to document SDM discussions, recommendations and beliefs. Screening guidelines (recommended, not or controversial) were determined by age, sex and risk factors. Results: The first 107 eligible enrolled patients were racially diverse (non-Hispanic Caucasian 65%) and well educated (college grad 84%). Patient-physician disagreement about whether screening had been discussed ranged from 6% (mammogram) to 36% (cervical cancer) and disagreement about whether the screening test had been recommended ranged from 17% (mammography) to 44% (PSA). In only 24 (12%) of 159 jointly recalled screening discussions did both patients and physicians agree that all 3 elements of SDM – reasons for screening, reasons against and that it is optional – were discussed, although patients and physicians separately reported all elements in 58 (36%) and 45 (28%), respectively. Conclusions: Even immediately after the encounter, many patients and physicians recalled whether screening had been discussed and recommendations differently, and most SDM discussions were incomplete. Clinical trial information: NCT02430948.
Prevalence and predictors of second opinions from medical oncologists for early-stage breast cancer: Results from the iCanCare study.
Authors: Kurian Allison W. , Friese Christopher Ryan , Bondarenko Irina , Jagsi Reshma , Katz Steven J.
Published: February 2017

185

Background: A second medical oncology opinion (SMO) may facilitate chemotherapy decision-making. However, little is known about the interplay between SMOs, treatment decision-making and chemotherapy use. Methods: We surveyed women newly diagnosed with early-stage invasive breast cancer and treated in 2013-2014 (response rate 70%), accrued approximately 3 months after surgery through 2 population-based SEER registries (Georgia and Los Angeles), about their experiences with medical oncologists, decision-making, and chemotherapy use. We evaluated demographic, clinical and decisional factors associated with SMO using logistic regression, and evaluated the association between SMO and chemotherapy, adjusting for clinical indication for chemotherapy, results of the 21-gene recurrence score assay, and estimated propensity for SMO given patient and tumor-specific characteristics. Results: Among 1182 insured patients who consulted any medical oncologist, 8.7% had SMO and 2.4% received chemotherapy from the SMO provider. On multivariable analysis, predictors of SMO use were younger age (odds ratio, OR 0.97 per year, 95% confidence interval, CI 0.94-0.99), education (college vs. high school graduate, OR 1.88, CI 1.06-3.33), an intermediate 21-gene recurrence score (OR 2.21, CI 1.18-4.16) and a variant of uncertain significance on BRCA1/2 gene testing (OR 5.61, CI 1.22-25.72). Satisfaction with chemotherapy decision-making was high and did not differ between patients who did vs. did not receive SMO (85.3% quite or totally satisfied vs. 86%, p-value 0.85). On multivariable analysis, chemotherapy use did not differ between SMO recipients vs. non-recipients (p-value 0.25). Conclusions: SMO use was low among early-stage breast cancer patients, and was not followed by more or less receipt of chemotherapy. High decision satisfaction regardless of SMO use suggests little unmet demand. Along with younger age and more education, the factor that predicted SMO use was uncertain results of genomic testing. Studies of precision medicine should track patients’ demand for SMO, which may rise with the dissemination of increasingly complex genomic tests. Funding: P01-CA-163233
Is there a relationship between self-reported healthy days and comorbidity medication adherence among oncology patients?
Authors: Casebeer Adrianne Waldman , Drzayich Jankus Dana , Hopson Sari , Khoury Raya , Parikh Aparna , Stein Alisha , Michael Todd , Stemkowski Stephen , Bunce Mikele
Published: February 2017

189

Background: Previous studies established the link between comorbidities and Health Related Quality of Life (HRQoL) for cancer patients. Adherence to comorbid medications has been found to be predictive of HRQoL in other disease states, but this has not been established for patients with cancer. This study sought to investigate the association between healthy days (HDs) and comorbidity medication adherence (CMA) for cancer patients. Methods: A survey was mailed to 5,098 patients with metastatic breast, lung or colorectal cancer who received treatment in 2014 and had at least one comorbid condition. Survey responses were merged with Humana claims data for analysis. The CDC’s Healthy Days measure was used to identify self-reported overall, physical and mental unhealthy days in the past 30 days and the number of days that poor physical or mental health limited usual activities. The Morisky Medication Adherence 8-point scale was used to differentiate high CMA ( > 6) and low CMA ( < 6). P-values are from chi-square and t-tests. Results: The survey response rate was 32% (N = 1,629). Respondents were mostly female (66%), and Medicare beneficiaries (90%) with mean age of 69.7 years. Patients with lung cancer experienced more overall unhealthy days than those with either breast or colorectal cancer (mean: 16.2 vs 12.6 and 13.5, p < 0.0001). The number of overall unhealthy days was higher among patients with low CMA compared to high CMA (mean: 15.4 vs 13.5, p = < 0.0001). Patients with low CMA had more mentally unhealthy days than those with high CMA (mean: 6.0 vs 8.2, p = 0.0128). There was no difference in physically unhealthy days by CMA. Patients with low CMA had 3.7 more unhealthy days that kept them from doing their usual activities (12.0 vs 8.3, p< 0.0001). Conclusions: Surveyed oncology patients with high comorbidity medication adherence reported fewer unhealthy days, in particular mentally unhealthy days, in the past 30 days. The complex interplay between comorbidity medication adherence and HDs for cancer patients warrants further investigation. These results suggest that increasing patients’ level of comorbidity medication adherence may be an avenue for improving the number of healthy days they experience.
Do perceived barriers to lung cancer screening differ between attending physicians and residents?
Authors: Greenwood-Hickman Mikael Anne , Jones Laura , Marsh Katie , Rivera M. Patricia , Molina Paul , Reuland Dan , Bowling J. Michael , Birchard Katherine , Maygarden Susan , Henderson Louise
Published: February 2017

192

Background: In February 2015, legislation went into effect requiring Medicare to cover lung cancer (LC) screening with low dose computed tomography (LDCT) for high risk patients. Despite this, much debate and uncertainty exist among physicians about LC screening best practices. We aim to compare perceived barriers to LC screening between resident and attending physicians in Family and Internal Medicine, two departments selected for their high likelihood of seeing patients eligible for LC screening. Methods: Between February and July of 2015, a 23 question Qualtrics survey was conducted among physicians and residents at a large academic hospital to assess knowledge and beliefs of LC screening. In the Family and Internal Medicine departments, we surveyed 100 residents (30% response rate) and 86 attendings (49% response rate). Responses from the two departments were combined and stratified by attending or resident status. Results: Most respondents were White and non-Hispanic. Attendings were older (mean age 47, range 32-64) and mostly male (54%), while residents were younger (mean age 30, range 28-35) and mostly female (63%). The majority of attendings (62%) and residents (78%) agreed that limited time during patient visits requires presenting problems take priority over LC screening. Other barriers cited by both groups included cost to patients (74% attendings and 83% residents), potential for complications (53% and 70%), and too many false positives (67% and 73%). Over half of both groups agreed that inconsistent recommendations make it difficult to decide whether or not to screen for LC. In addition, the majority of both groups indicated that they were undecided about the benefit of LC screening for patients (43% attendings and 55% residents). No statistically significant differences were found. Conclusions: Regardless of resident or attending status, respondents identified inconsistent recommendations, time restrictions during visits, cost to patients, potential complications, and a high false positive rate as barriers to LC screening. Both groups reported being undecided about the utility of LC screening. These findings suggest a need for alternative strategies for future LC screening implementation.
Quality improvement strategies in medical oncology: A qualitative analysis from a scoping review.
Authors: Franco Bryan B. , Dharmakulaseelan Laavanya , Singh Simron , Haynes Adam E. , Wong Brian M. , Cheung Matthew C.
Published: February 2017

203

Background: In 2001, the Institute of Medicine (IOM) outlined imperatives to improve quality of care. Quality improvement (QI) has since become essential to cancer care but barriers still exist to the publication of and participation in QI initiatives, including limited recognition for QI and uncertainty with methodologies. We sought to identify strategies used in QI in scholarly medical oncology literature to provide practical guidance for QI. Methods: We conducted a scoping review using Arksey and O’Malley’s framework. A search of EMBASE and MEDLINE databases found 48,186 unique English citations published between January 2001 and August 2014. We utilized an iterative process to refine the inclusion criteria and two reviewers independently reviewed abstracts, resulting in the inclusion of 270 articles. The reviewers then extracted text segments relevant to QI strategies. A qualitative content analysis approach was used to accurately analyze and summarize this process-oriented data. Results: Fifty-four unique QI strategies identified were used alone or in combination to improve structures or processes of care. Five content categories of strategies that targeted structures of care emerged: 1) more methodical approaches (eg, lean thinking, supply-demand analyses), 2) participatory action research and similar strategies, 3) infrastructure to promote health care provider collaboration, 4) application or improvement of information technology (IT), and 5) progression towards a systematic assessment of all patients’ needs. We identified three categories of QI strategies for processes of care: 1) improving patient-clinician relationships or communications, 2) care navigation, and 3) telehealth. Conclusions: Our review identifiedQI strategies in published literature. Strategies were consistent with and expanded on the IOM’s redesign imperatives such as effective use of IT, development of better teams, and care coordination. Identification of strategies provides professionals with tools to engage in QI and may encourage support and recognition for QI. Future studies should examine the impact of different QI strategies on outcomes of care in oncology.
Initiative to streamline clinical trials (ISCT): Guidance for academic investigators/sponsors.
Authors: Grant Jasmine , Brodeur-Robb Katherine , Urton Alison May , Bosch Jacqueline , Seymour Lesley , Arts Karen E.
Published: February 2017

219

Background: The 2011 Canadian Cancer Research Alliance (CCRA) report on the State of Cancer Clinical Trials in Canada outlined in detail the threats to the conduct of academic oncology clinical trials caused by increasing complexity and workload resulting from a perceived onerous regulatory environment. The report recommended engaging Health Canada and key stakeholders to foster agreement in appropriate interpretations of the Canadian Food and Drug Regulations Part C Division 5 and ICH Good Clinical Practice (GCP) guidelines. Methods: The ISCT Working Group (ISCT WG) was formed in 2012 to address the CCRA recommendations for academic clinical trials and include experts from multiple therapeutic areas. The primary objective of the ISCT is to develop specific, practical interpretations of current regulations, laws and guidelines to facilitate Canadian clinical trials. Feedback was obtained from interested parties and ISCT members by means of surveys, face-to-face meetings and conference calls. Results: The major areas of concern identified include Health Canada Clinical Trial Applications, Investigational Product supply, monitoring, oversight of equipment and facilities, delegation of duties, validation of electronic systems, source documents and records retention, trial costs, the consistency of interpretation by different divisions of Health Canada, and access to related resources. A subcommittee was established for each area identified above and a series of recommendations to streamline processes with a focus to reduce regulatory burden for academic clinical trials. The ISCT WG used other relevant documents including the OECD framework and FDA Guidance on Risk Based Monitoring to inform its work. Conclusions: The final recommendations of the ISCT have been provided to all stakeholders, presented at international conferences and published on the N2 website. Canadian academic sites have used guidelines during Health Canada inspections with success. Future goals include an ISCT Workshop for academic site leaders to facilitate implementation of the ISCT guidelines, continue to address areas of concern, and track the success of the recommendations in ameliorating the conduct of academic trials.
Establishing an oncology quality dashboard for improvement.
Authors: Denny Diane , Gross Danielle
Published: February 2017

223

Background: Cancer Treatment Centers of America (CTCA), a national network of five hospitals, formed a Quality Improvement Committee to bring together both clinical and administrative leadership (physician, nursing, pharmacy and quality) across the enterprise vested in the oversight of quality and patient safety. Tasked with facilitating and driving measurement and improvement the group established a Quality dashboard housing metrics of importance given current performance, evidence-based practice, and evolving external standards. The dashboard includes a mix of outcome, process, and structure measures with targets, both externally driven and CTCA established. Methods: The dashboard houses data sourced from a multitude of systems and is segmented into clinically relevant categories such as Infection Prevention, Nursing, Medication Management, and Medical Oncology to name a few. These categories are further broken down into specific measures, reported by quarter, and color-coded (red/yellow/green) to display progress. Targets are established based upon external benchmarks, where data is available. Each metric is also graphically displayed, trending the 6 most recent quarters of data as another visual reference. Finally, a glossary was created to standardize key measure details across the enterprise for accurate data collection including documentation of source, numerator, denominator, references, inclusions, exclusions and rationale. Data is updated monthly to reflect most current performance and promote timely intervention. Results: Since development of the Quality dashboard, CTCA has experienced various red to yellow to green progressions as well as upped its targets indicating significant advancement in performance. Standard data collection and visual identifiers within one repository has enabled CTCA to accurately focus time and resources where needed in order to continually improve care. Conclusions: The establishment of the enterprise-wide quality dashboard has led to great collaboration within CTCA’s network of hospitals. The display of the data allows both a focus upon individual and network strengths and opportunities for improvement as well as a mechanism for communicating shared goals.
Optimizing discharge teaching process to increase the efficiency and effectiveness of the follow-up call.
Authors: Kaufman Laurie , Aranzamendez Gina , Hayes Beverly A , Pathak Kavita , Rohe Duke , Haywood Valerie
Published: February 2017

226

Background: Patients undergoing complex oncologic operations are at high risk for perioperative complications associated with adverse effects on quality of life, costs and overall outcomes. Complications within 30 days of discharge are most commonly identified during first 48-72 hours post-discharge. Telephone follow-up can provide a safety net and is part of a larger discharge teaching process. Initial review of the current follow up processes underscored many variations. An interdisciplinary team was tasked to optimize discharge processes across the continuum of care which leads to a more efficient follow-up call encounter. Methods: Working with in and outpatient frontline staff from focus group teams, pre and post implementation work flow processes were captured. Inefficiencies were used for a redesign session to develop a standard discharge teaching guide and patient checklist. A database was used for data collection of measures for issues and complications encountered by patients. Storyboards were used to communicate the project progression to those working within the processes being redesigned. Results: A 42% reduction in inefficiencies of overall discharge teaching process was obtained with the largest decrease during the post discharge phase. The number of patients contacted during follow-up calls increased by 12%: discussions were longer and documentation took less time (excluding outliers). 46% of the issues were handled by the Clinical Nurse Leaders: all other medium/high issues were handed off to primary team. The time spent for follow-up calls increased, therefore, increasing direct labor cost. The rate of complications and severity decreased during the implementation phase. Effects on the readmission rates remains to be seen and patient satisfaction scores are showing a positive trend. Conclusions: Involving content experts to assess the discharge teaching process identified a worklist of inefficiencies. Using these to optimize the process, a discharge teaching guide and patient checklist were developed. Inefficiencies were reduced and process made more effective with an increased percent of patients contacted during the follow-up call.
Reducing hospital aquired pneumonia (HAP) with Massey Screen.
Authors: Slavin Kerri , Dunbar Robyn , Clements Cheryl , Bonawitz Margaret , McGovern Joanne
Published: February 2017

232

Background: Hospital Acquired Pneumonia (HAP) is a leading cause of prolonged hospitalization in patients. The oncology population is especially susceptible to critical illness related to an immunocompromised state. The purpose of this study was to implement the Massey Bedside Swallowing Screen upon admission to the oncology telemetry unit to detect any deficits that could potentially lead to HAP, in conjunction with strict oral care for identified high risk patients. Methods: The importance of the Massey Bedside Swallowing Screen upon admission and the knowledge that early detection leads to better patient outcomes was educated to the nursing staff. Every patient admitted to the oncology telemetry unit was screened with the Massey Bedside Swallowing Screen. Patients identified as high-risk were placed on nothing-by-mouth (NPO) precaution. A Speech and Swallow Evaluation was ordered to further evaluate the patient. Acutely ill oncology patients unable to perform their own oral care were placed on a strict oral care regimen performed by the nursing staff. The charge nurse audited compliance with this protocol. Results: The pre-intervention phase of the study evaluated January – April 2015 included 1,605 patient days. The data revealed 4 HAPs acquired on the oncology telemetry unit, demonstrating 2.45 incidence/1000 patient days. Post-intervention [May – August 2015] indicated 2 HAPs acquired on the oncology telemetry unit, signifying 1.35 incidence/1000 patient days. With the implementation of the Massey Bedside Swallowing Screen for each patient upon admission, and strict oral care regimen for high-risk patients, the overall incidence of HAP on the unit decreased by 50%. Conclusions: Oncology patients assessed with the Massey Bedside Swallowing Screen upon admission to the oncology telemetry unit were noted to have improved outcomes and lower rates of HAP. Every oncology patient admitted to an acute care unit should have an admission screen in place to evaluate risk for aspiration. Early detection of patients at high-risk for HAP and implementation of interventions to improve oral care in high-risk patients lead to improved patient outcomes through lower incidence of HAP in the acute care setting.
Reducing pain, agitation and delirium to optimize outcomes in mechanically ventilated critically ill oncology patients.
Authors: Kennedy Michele , Bullick Dana , Barniak Sharon , McGovern Joanne , Patel Trisha , Hoag Jeffrey
Published: February 2017

233

Background: Greater than 60% of cancer patients experience chronic pain which is heightened in critical illness. Optimal pain assessment is challenging in the critically ill leading to under treatment due to sedation during mechanical ventilation (MV). The Society of Critical Care Medicine (SCCM) favors treating pain with intermittent boluses rather than continuous infusions; however,appropriate analgesic doses and means of titration are elusive leading to over sedation, prolonged ventilation, and delirium. Utilization of protocols promotes better nursing assessment of sedation-delirium scores which reduce the use of sedatives. The purpose of this study was to assess the need for a nurse driven pain-sedation protocol in ventilated oncology patients. Methods: This retrospective study included 51 mechanically ventilated oncology patients admitted between12/2013 and 6/2015. The analgesics, sedatives, dosing and duration of MV were collected. Sedative titration was evaluated relative to analgesics used by nursing staff. Results: Fentanyl was administered in 94% of patients, an average rate of 142mcg/hr (3413mcg/day) significantly higher than rates of 43mcg/hr). Midazolam was administered at an average rate of 1.25mg/hr in 57%, while 54% received propofol (15.5mcg/hr), demonstrating concurrent use of sedatives and analgesics. In 49%, sedatives were increased without prior adjustment of analgesics indicating that pain was unaddressed and undertreated. In the setting of over-sedation nursing neurological assessment was difficult and associated with prolonged duration of MV (9.7 days). Conclusions: Guidelines recommend “analgesia-first sedation” to promote use of analgesic agents over sedatives to treat pain and agitation and reduce undertreating pain. This becomes crucial in the oncology population. This study demonstrates inconsistencies with guidelines and further supports the need for a structured pain-sedation protocol to decrease over-sedation, adequately treat pain and potentially decrease delirium and prolonged MV. Subsequently, a protocol has been developed which will be implemented after education has been provided to the multidisciplinary team.
Burden of bloodstream infections among ambulatory pediatric hematology/oncology patients with a central line.
Authors: Barysauskas Constance , Bundy David G. , Gaur Aditya H. , Hord Jeffrey D. , Miller Marlene R. , Werner Eric J. , Winkle Cindi , Billett Amy
Published: February 2017

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Background: Pediatric hematology/oncology (PHO) patients are at high risk of bloodstream infections (BSI). The burden of BSI in PHO patients in the ambulatory setting has not been well documented. Methods: The Children’s Hospital Association leads the Childhood Cancer and Blood Disorders Network, a multicenter United States quality improvement collaborative, working to reduce the incidence of inpatient and ambulatory Central Line-Associated BSI (CLABSI) among PHO patients. Positive blood culture events (+BCE) were adjudicated as CLABSI, single positive blood cultures (SPBC) with potential commensals, or secondary BSI (attributed to source other than the central line) following standardized National Healthcare Safety Network definitions. Our study investigated the prevalence of +BCE among all centers with 90% complete monthly reporting of both +BCE and central line days (CLD) for at least one year (n=25) between January 2012 and September 2014. Ambulatory and inpatient BSI rates and 95% confidence intervals (CI) were calculated as the number of +BCE per 1,000 CLD per month. Results: A total of 1,747 +BCE and 4,883,413 CLD were reported among our target ambulatory population, whereas 1,095 +BCE and 353,259 CLD were reported among our corresponding inpatient population [Table]. While the CLABSI and SPBC rates were significantly lower in the ambulatory setting compared to inpatient (p<0.001), the total number of ambulatory CLABSI and SPBC events was 2.0 and 1.6 times higher than inpatient events, respectively. Conclusions: Our findings from a large multicenter collaborative demonstrate the burden of BSI among ambulatory PHO patients and identify benchmarks for future quality improvement work.Further investigation is necessary to develop effective infection reduction strategies for ambulatory PHO patients with central lines. [Table: see text]
Measuring cancer care quality: An update on development and validation of the CAHPS survey for cancer care prototype.
Authors: Yost Kathleen J. , Evensen Christian , Keller San , Garfinkel Steven
Published: February 2017

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Background: At the 2013 ASCO Quality Symposium, we presented the formative development work and results of the 1st field test of the Cancer CAHPS survey. At that time, we noted next steps in the development and validation of the survey. In this poster/presentation, we will provide updates on these activities. Methods: The Spanish translation was completed in 2013. We conducted interviews with 9 cancer patients in 2014 to identify composite labels that resonated with consumers. We collaborated with diverse cancer care providers (health maintenance organizations, medical foundations, small oncology practices, and comprehensive cancer centers) to identify an approach to sampling patients that could be standardized across settings. With the input of stakeholders, we added additional Shared Decision Making (SDM) and Access to Care questions. Data on the revised survey were collected in a 2nd field test from May 2015 – November 2015. We will analyze these data to assess the feasibility of the sampling approach and confirm the psychometric properties of the survey. We embedded several secondary experiments in the 2nd field test including assessing the effect of language (Spanish vs. English) and mode of administration (mail only vs. web-mail mixed mode) on survey responses. Results: The Spanish-language survey is currently being fielded. Consumers identified “user friendly” composite labels, abbreviated here as Communicates well, SDM, Explains treatment, Supports self-management, Access, Delays, and Claims. We developed a comprehensive sampling approach that relies on billing data to identify cancer patient eligible to receive the survey. Preliminary findings indicate that the standardized sampling approach is feasible. The survey was administered to 3,581 patients across 4 cancer centers (i.e. reporting units) in the 2nd field test. Results of the psychometric analyses and embedded experiments will be completed in December 2015 and available for dissemination in January 2016. Conclusions: The cumulative findings from the 1st and 2nd field tests and other development activities conducted to date will be used to support an application for the CAHPS trademark.
Psychosocial oncology quality indicators prioritization exercise.
Authors: Cadotte Tory , Ismail Zahra , Moody Lesley , Rugg Maria
Published: February 2017

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Background: One of Cancer Care Ontario’s (CCO) roles is to monitor and report on cancer system performance to support quality improvement. CCO’s Psychosocial Oncology (PSO) program developed a measurement plan with potential indicators to evaluate patient access to and the effectiveness of PSO services across the province. The objective of this study was to conduct a modified Delphi process to build consensus and prioritize PSO indicators based on their relevance to provincial goals, ability to measure regional and provincial performance and result in tangible actions. Methods: Through consultations and literature reviews, 16 measurement concepts were identified as quality indicators for the PSO Program. Members of the PSO Provincial Committee (n = 32) evaluated each indicator based on set criteria: relevance, outcome-focused, directional, and actionable. Two rounds of input was gathered through a structured worksheet with a minimum response rate of 60%. Round one was based on a simple ‘Yes or No’ response to the indicators’ ability to meet the defined criteria. Participants were encouraged to comment on each indicator and suggest new indicators. Indicators not meeting at least half of the evaluation criteria, on average, were removed from the list. Net new indicators suggested by at least 10% of respondents were included in round two. In round two, members rated each indicator on a scale of 1-5, indicating to what degree the indicator met the evaluation criteria. Results: After round one, the original list was narrowed from sixteen to nine indicators. Four new indicators were also added. After round two, three indicators were identified as meeting the evaluation criteria: 1) wait times to specialized PSO services, 2) access to registered dietitian services by the head and neck cancer population, and 3) documented follow-up with patients with anxiety and/or depression. Prioritized indicators were reviewed with the PSO Committee and CCO senior leadership to confirm direction. Conclusions: The prioritization exercise provided consensus across divergent perspectives and identified top priorities. Work is underway to further develop/refine these indicators for provincial reporting.