Proper management of patients using doxorubicin: Request for a transthoracic echocardiogram prior to initiating therapy.
Authors: Andriatte Guilherme , Sabino Larissa Zuppardi Lacerda , Waisbeck Tania , Inaoka Riguel Jun , Centrone Ana Fernanda , Araujo Sergio Eduardo Alonso , Santos Vanessa , Scacchetti Tatiana , Rolla Fabiana , Tomazo Deborah , Ardanaz Priscila , Silva Iracema Morais , Santos Valéria Armentano , Vogel Cristina , Conte Elisa , Barreto Michele , Ferracini Fabio , Machado Maria Aparecida 
Published: October 2023

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Background: Certain antineoplastic agents exhibit specific organ toxicity, such as anthracyclines which main adverse effect is cardiotoxicity. Guidelines recommend cardiac assessment prior to initiating treatment. The initial transthoracic echocardiogram (TTE), performed up to 30 days before the first dose, is essential for recognizing the clinical status of the patient and planning the treatment. Consequently, we assessed compliance with the TTE request and implemented interventions to enhance patient safety. Methods: This project aims to achieve continuous improvement through the PDSA tool. We identified low adherence to the TTE request before initiating doxorubicin by retrospectively analyzing medical records from August 2021 to July 2022. We then evaluated the effectiveness of interventions implemented from August 2022 in the Oncology and Hematology units of a large institution in Brazil, which includes private facilities and public partnerships. Results: Between August 2021 and July 2022, a total of 306 patients initiated treatment with Doxorubicin. Among them, 149 (49%) were inadequately managed without undergoing a TTE within 30 days before starting therapy. Of these, 44 (43%) were from the private site, while 105 (51%) were from the public site. The main reasons for this non-compliance were the lack of standardized protocols and knowledge among members of the care team, as well as the patients' lack of understanding and recognition regarding the importance of the test. To address these issues, initial actions were prioritized based on their impact on patient safety. Educational strategies were implemented, including meetings and the creation of alerts with decision support in electronic medical records, from August to November 2022. During this period, 166 medical records were analyzed, revealing 63 cases (38%) of non-conformities. Among these, 16 patients were from the private site, and 47 patients were from the public site. The initial analysis, guided by the implemented actions, indicated a potential shift in the process, highlighting the need for continuous efforts and ongoing effectiveness assessment. Subsequently, between December 2022 and May 2023, an additional 178 medical records were evaluated. This assessment identified 68 cases (38%) of non-compliance, with 16 patients (25%) from the private site and 52 patients (46%) from the public site. Conclusions: Based on the presented results, there is an improvement in adherence to conducting the TTE among patients treated at the private site, while the indicator shows a smaller change in the population treated at the public site. This difference underscores the necessity for a deeper understanding of the challenges and the implementation of tailored actions to address them. Cardiotoxicity is the main anthracycline adverse effect, so interventions must prioritize safe, effective, equitable treatment.