bluuebunny/crossref_metadata_2025_split huggingface dataset:
Patient and physician perceptions: Importance and documentation of patient priorities in treatment planning and decision-making.
Authors: Miller-Sonet Ellen , Rocque Gabrielle Betty 
Published: October 2019

224 Background: The National Academies of Medicine prioritizes patient’s needs, values, and preferences when patient’s and care teams make treatment decisions. However, the collection of this patient information is not part of the formal clinical intake process, nor are pertinent questions included in EHR templates. Methods: Surveys were conducted of cancer patients and cancer physicians to understand perceptions on whether patients’ quality of life priorities (e.g work, hobbies, key events, household responsibilities) are discussed, documented and reflected in treatment plans. Physicians were recruited via a market research panel. Patients were recruited from the Cancer Care data base via an email request to complete an online survey. Results: From February to October, 2018, 310 cancer patients and 109 cancer physicians completed surveys. Cancer patients were mostly female, 91% had been diagnosed in the last year, 61% had breast cancer, and 55% were stage 1 or 2. Among physicians, 88% self-identified as trained in oncology, 33% practice at academic centers, 51% in community practices, 34% from the Northeast, 21% the Southeast, and 25% the Midwest. Most patients (62%) said it was very/extremely important their doctor know their priorities. Most physicians (66%) report they most of the time/always know patients’ personal quality of life priorities before finalizing treatment plans, and 62% say this information has a large/major impact on recommendations. However, only 40% of patients report having this conversation before treatment started. Although 76% of doctors said they discussed what is important to patients most of the time or always, only 60% report it is documented, usually in the social history or notes fields. Only 36% of patients are sure this information is entered into their medical record. Conclusions: Cancer patients want their doctors to know what is important to them, and physicians agree. However, documentation is often relegated to narrative notes fields in the EHR. Considering the key role patients’ priorities should play in treatment planning, there need to be standardized collection tools so this information can be timely collected and shared.
Radiation Oncology Incident Learning System (RO-ILS): Increasing stakeholder participation for safety and quality improvement.
Authors: Nelson Carl , Roy Lori Ann , Wallace H. James 
Published: October 2019

232 Background: RO-ILS was launched in 2014 and is free, web-based and in more than 500 U.S. radiation facilities. After RO-ILS was implemented at University of Vermont Medical Center (UVMMC), reporting of radiation incidents decreased and participation by radiation staff was limited. To improve incident reporting and participation, RO-ILS was relaunched for all radiation staff members at UVMMC with emphasis on improved system access and education on RO-ILS programmatic goals. Methods: Prior to RO-ILS, safety/quality incidents at UVMMC were submitted by radiation therapists, dosimetrists and physics staff on paper forms and reviewed monthly by the Radiation Quality Committee. After implementation of RO-ILS in 2016, RO-ILS incidents were reviewed by the UVMMC RO-ILS administrators with no formalized staff feedback. Due to decreasing staff submissions, RO-ILS relaunched September 2018 with increased training, scheduled submission review to radiation staff and identification of department champions. Results: Between April 2014 and May 2019, 270 radiation incidents were reported. Prior to RO-ILS, a median 8 incidents were reported per quarter but decreased to 6 per quarter after RO-ILS. After RO-ILS relaunch, median reported incidents increased to 42 per quarter. Radiation “Near Miss” events pre RO-ILS, post RO-ILS and with RO-ILS relaunch were reduced from 78% to 34% to 9%, while “Operational/Process Improvement” submissions increased from 17% pre RO-ILS to 49% post RO-ILS to 81% after relaunch. After RO-ILS relaunch, staff participation expanded to physicians, nursing and administrative staff for the first time, and physician participation increased from 0 to 50%. Conclusions: Following implementation of RO-ILS at UVMMC, radiation incident reporting initially decreased and the proportion of “Near Miss” reports decreased. After relaunch of RO-ILS, there was substantial increase in incident reporting involving all staff. As RO-ILS evolves at UVMMC, there is continued decrease in near misses and greater emphasis on “Process Improvement”. Continued education, reporting and feedback from RO-ILS submissions is recommended to maintain this high staff participation level.
Preventing complications: Hepatitis B screening in cancer patients undergoing systemic therapy.
Authors: Prince Rebecca M. , Krzyzanowska Monika K. , Glinsky Victoria , Wong David K , Macedo Alyssa 
Published: October 2019

237 Background: Chemotherapy is a risk factor for HBV reactivation in pts with cancer and chronic HBV. Anti-viral prophylaxis can prevent reactivation but requires identification of infected pts. Many guidelines recommend universal HBV screening prior to cytotoxic/immunosuppressive-therapy, but lack of screening is common globally. A serious safety event and high prevalence of pts from HBV endemic regions receiving treatment at our institution led to a quality improvement project to increase HBV screening prior to chemotherapy. We aimed to increase HBV screening in pts starting systemic therapy at Princess Margaret by 100% by February 28, 2019. Methods: Starting April 2017, an interrupted time series study was undertaken. Baseline HBV screening rate was 43%. Diagnostics including interviews, process mapping and root cause analysis were performed. Interventions to address identified root causes were implemented including specifying required HBV tests, tips for ordering HBV tests, provision of electronic Hepatology referral form, a safety alert email, grand rounds presentation of serious safety event, including HBV screening rate in departmental monthly quality emails and Divisional meetings and adding positive HBV results to the laboratory alerting system. The main outcome measure was the proportion of pts starting systemic therapy screened for HBV. Process measures included correct test ordering, number of Hepatology referrals was a balancing measure. Results were analysed with statistical process control charts. Results: From April 2017-Feb 2019, 5604 pts commenced systemic therapy. Interventions were modified iteratively as the project progressed. HBV screening rate improved from 43 to 79% (84% improvement). Incidence of chronic HBV was routinely above the Canadian average ( > 2%). The percent of correctly ordered screening tests fell from 48 to 33% (31% worsening), while the volume of Hepatology referrals remained manageable (1.5 pts/week). Conclusions: Our Quality Improvement project led to a significant improvement in HBV screening prior to systemic therapy. Further interventions are planned to achieve our target improvement of 100%.
Safety culture interventions in cancer care: A systematic review.
Authors: Le Dan , Lim Charles Henry , Fazelzad Rouhi , Krzyzanowska Monika K. 
Published: October 2019

247 Background: Creation of a culture of safety in healthcare organizations is fundamentally important to patient safety. However, there is limited guidance on how to effectively promote a culture of safety in healthcare settings including in oncology. We performed a systematic review to identify interventions or strategies to promote safety culture in cancer care. Methods: Medical Subject Headings and text words for “safety culture” and “cancer care” were combined to conduct structured searches in MEDLINE, EMBASE, CDSR, CINAHL, Cochrane CENTRAL, Epub Ahead of Print & In-Process, PsycINFO, Scopus, and Web of Science databases, for peer-reviewed articles published between 1999 and 2017. Articles were included if they described an intervention or strategy to promote safety culture in an oncology setting, and quantitative outcomes were reported. Study quality was assessed using the ROBINS-I risk of bias tool. Results: We screened 21,572 studies, of which 46 underwent full-text review, and 19 met the inclusion criteria. Studies described interventions in radiation oncology (15 articles), medical oncology (3), and general oncology (1) settings in either North America (15) or Europe (4). The most common experimental designs were interrupted time series (10) or before-and-after comparisons (6), and were of either moderate (89%) or severe (11%) risk of bias. Interventions varied but could be broadly categorized as incident learning systems (8), quality improvement programs (7), provider education programs (2), a provider scheduling system (1), and a patient safety champion intervention (1). While 89% of studies reported improvement in safety culture, there was substantial heterogeneity in evaluated outcomes. Most assessed provider outcomes such as number of reported adverse events (11) or Agency for Healthcare Research and Quality Safety Culture survey results (7). Conclusions: Despite a growing evidence base to identify interventions to promote safety culture in cancer care, definitive recommendations were difficult to make due to heterogeneity in study designs and outcomes. Given the importance of safety culture in cancer care, additional high-quality studies and standardization of outcome measures are needed.
Impact of burn-out syndrome in oncology staff and its improvement through specific interventions.
Authors: Cunquero Tomas Alberto Jacobo , Ortega Inmaculada , Fernández Teresa , Lobo De Mena Miriam , Gil Raga Mireia , Iranzo Vega , Caballero Diaz Cristina , Gomez Ana , Blasco Ana , Camps Carlos 
Published: October 2019

249 Background: Burn-Out Syndrome (BOS) is defined by: emotional and physical exhaustion; cynicism and depersonalization; and no personal nor professional fulfillment. With increasing incidence, it impacts negatively in the patient attention quality and the quality of institutional processes. Few experiences reported about its incidence and impact in Medical Oncology. Lack of resources for its diagnosis and management. Our objective was to determine the incidence of the BOS in our workers, analyze its causes and try to reduce in 20% the percentage of workers suffering or at risk of suffering BOS. Developed as a Quality Training Program (ASCO - ECO Foundation) project. Methods: 23 nurses/nurse-assistants Medical Oncology Department at University General Hospital of Valencia fulfilled anonymized questionnaire with personal details, GHQ-12 evaluation and Maslach index questions, at baseline and after intervention. Causes of BOS analyzed and process map and Ishikawa fish-bone scheme designed. Interventions carried in consequence. Results: 23 subjects, 87% women, 47 year-old median age. 14 nurses, 8 working in the clinic. 90% with more than 5 years of experience in Oncology. At baseline, 75% GHQ-12 good health. Maslech index: 70%, 45% and 55% in risk (medium+high) of BOS related to exhaustion, depersonalization or fulfillment, respectively. In exhaustion, 35% medium risk, 35% high risk of BOS. After priority-matrix development, ergonomy tips and self-improvement tools were identified as the adequate interventions to improve exhaustion risk. After ergonomy tips intervention, 90% GHQ-12 good health, 15% exhaustion medium risk, 50% exhaustion high risk, 65% at risk of BOS related to exhaustion. An improvement of 5% lowering the risk of suffering Burn-Out Syndrome among our workers was achieved Conclusions: BOS risk is complex due to answer subjectivity. We have healthier workers (GHQ-12), but although levels of exhaustion have decreased mildly, those who were already exhausted are worse than before (Maslach Index). Possible causes: renovation work on Clinic, labor instability, local holidays during project. Additional self-improvement tools sessions are now being held.
Developing and operationalizing a safety culture across a hematology/oncology ambulatory network.
Authors: Philip Tony , Gleason Karen , Paul Valadez Jenny , Guerrier Keasha , Abraham Sony 
Published: October 2019

250 Background: The “Safety Belongs to Me” (SBTM) campaign is an initiative that evaluates safety systems utilized by the Medical Oncology ambulatory network. The SBTM project aims to identify, report, and resolve current and future safety risks by implementing weekly interdisciplinary conference calls across the network. In addition it deploys a highly reliable reporting structure for departmental stakeholders (i.e. Administration, Nursing Administration, Materials Operations, Laboratory, and Pharmacy.) Thereby increasing situational awareness, and prevention of complacency as it relates to patient and employee safety risks. Methods: Methodologies utilized include six sigma tools (Kano analysis, etc.) improvement science tools (PDSA, process maps, and driver diagrams), and surveys. These were used to illustrate how principles of process improvement can be utilized to provide an effective framework for systematic innovation in healthcare. Weekly safety calls were started March 2019 after clinical and administrative leadership completed IHI safety culture training. Results: Since implementation of weekly safety calls, an average 13.2 safety issues identified/week with 3.6 issues/week needing follow up for resolution. There has been an increasing trend in safety issues identified and decreasing trend in new safety issues for follow up. Conclusions: The development of a reporting platform augmented a pre-existing process to escalate safety concerns and events within the medical oncology network. This collaborative has facilitated a formalized safety culture that has increased the identification of both potential and existing safety concerns.
Normalizing the use of patient-provider agreement for opioid treatment within a cancer institute.
Authors: Cherenzia Katie , Begnoche Megan , Fenton Mary Anne 
Published: October 2019

251 Background: Addressing the opioid epidemic can be challenging in a large academic cancer program and necessitates the need for a multidisciplinary approach for implementation of a successful program. The oncologist has a challenging role caring for patients with preexisting pain conditions, acute cancer-related pain, pain at the end of life and cancer survivors who live with cancer as a chronic condition after treatment. Methods: A structured program was developed to address the mounting pressure from many fronts related to the opioid epidemic including insurance companies, pharmacies, and the Department of Health. In April 2018, the Lifespan Cancer Institute implemented a system wide opioid program including patient education, an electronic patient-provider treatment agreement, and an electronic template for provider documentation. The intent of the program is to implement safe processes to safe guard the patient and their family along with the providers. The patient-provider treatment agreement clearly describes the roles and responsibilities of both groups with a goal of reducing risks by improving education. Our responsibility is to provide optimal management while addressing patient concerns and maintaining patient safety. Results: The opioid program has been well received by both caregivers, patients and families. All are engaged in the embedded education process and fully appreciate the need to use opioids safely. The program has been helpful in managing patient expectations and focusing difficult conversations in cases of potential abuse. In April 2018, only 13% of patients prescribed an opioid had a signed patient-provider treatment agreement. As of April 2019, 75% of patients have a signed agreement. Conclusions: The transitioning of care for the patient with chronic pain after completion of active cancer treatment continues to be a focus of future initiatives. Patient satisfaction remains a top priority as the patient-provider agreement becomes a standard of care for all patients receiving opioids. As oncology healthcare providers, our responsibility is to screen and educate patients on the risk of opioid addiction and diversion while providing compassionate palliative care.
An initiative to improve mortality index in gynecologic oncology.
Authors: Taylor Jolyn Sharpe , Miller Jennifer F. , Ballard Edith K. , Blanco Tricia K. , Brown Karen L. , Byrd Corrine C. , Holloway Anita , Smith Arletta , Park Anne , Cain Katherine , Marten Claire , Finch Roshonda , Nguyen Van , Fleming Donna , Levenback Charles F. , Lu Karen H. , Schmeler Kathleen M. 
Published: October 2019

256 Background: The mortality index (MI) is a quality metric that measures the ratio of actual mortality to expected mortality among inpatients. Expected mortality is a probability calculation based on patient risks and comorbidities. A MI of < 1.0 represents that fewer patients die while admitted to the hospital than expected. Methods: We formed a multidisciplinary team that included Gynecologic Oncology (GO), Health Information Management, Clinical Informatics, Revenue Operations, Coding and Institutional Compliance experts. Our aim was to decrease the GO MI by 10% within a year. Quality Improvement Assessment Board approval was obtained. GO clinical providers were educated on proper documentation of patient comorbidities and severity of illness. Audits of the documentation were performed by the multidisciplinary team. GO patients perceived at high-risk of inpatient mortality were identified for additional review. All GO inpatient deaths were reviewed at the monthly GO Morbidity and Mortality conference and opportunities for avoidance of inpatient death were discussed. Plan-Do-Study-Act (PDSA) cycles were repeated with adjustments made to the review and education processes. Baseline (BL) 8/2017-7/2018 and interim post-intervention (PI) 11/2018-2/2019 outcomes were compared using the Mann Whitney U test. Results: The BL median number of inpatient deaths per month was 2 (range 0-7), with a median expected mortality of 2.96 (range 1.46-5.11), and a median MI of 0.84 (range 0-1.37). The PI median number of inpatient deaths per month was 2.5 (range 2-5), with a median expected mortality of 4.24 (range 3.77-5.06), and a median MI of 0.56 (range 0.53-1.27). The number of inpatient deaths per month was similar between groups (2 vs 2.5; p = 0.49) but the expected mortality increased from to 2.96 to 4.24 (p = 0.03). MI decreased by 33% between BL and PI (0.84 vs 0.56). Conclusions: Inpatient mortality is an important quality metric. Accurate measurement of expected mortality is critical and requires proper documentation. This can be improved through education, review and frequent assessment by PDSA cycles. Our preliminary results show improvement in accurate documentation and measurement of expected mortality resulting in a decrease in MI.
Unplanned hospital admission in patients receiving concurrent chemotherapy and radiation.
Authors: Damico Nicholas , Tiemeier Ellen , Krukowski Laura , Colo Lucy , Sydenstricker Christine Marie , Kraska Barbara , Dorth Jennifer Anne 
Published: October 2019

258 Background: Concurrent chemotherapy and radiation therapy (CCRT) has become a curative treatment for many malignancies. Many patients are ultimately cured, but at the cost of significant acute toxicity. When severe, this can require unplanned hospitalization. More research is needed to better identify patients at risk for hospitalization and how to prevent it. Methods: As part of quality improvement at the Seidman Cancer Center, patients in the University Hospitals (UH) system who underwent CCRT were identified. A review was done to determine which patients experienced an unplanned admission in the UH system during their radiation course or within 30 days and the admission diagnosis. We recognized malnutrition and dehydration as causes for hospitalization that were preventable. Several interventions were then performed to reduce these admissions. The first was standardized nutrition screening that prompts earlier dietician referrals for patients at risk of malnutrition. We also instituted hydration assessments for patients beginning in the 3rd week of radiation. Patients found to be dehydrated were scheduled to receive intravenous (IV) fluids as an outpatient for the remainder of their treatment course. Admission rates for patients undergoing CCRT have been tracked as part of this initiative and are reported here. Results: From 7/2017 to 12/2018 we identified 303 patients who completed CCRT. 78 (26%) had an unplanned hospital admission during their treatment course or within 30 days of completing radiation. This included patients with primary head and neck, CNS, GI, lung, GYN, and GU malignancies for which admission rates were 36%, 32%, 23%, 29%, 19% and 8% respectively. 18 (23%) of these patients were admitted after completing the radiation course but within 30 days. The initial admission rate prior to intervention was 34%. This has since declined to 19% (table). Conclusions: Unplanned admission rates are high in patients who undergo CCRT across disease sites. Patients remain at risk following completion of radiation therapy for up to 30 days. Some admissions may be prevented by early dietician referrals and IV hydration. [Table: see text]
Decreasing time to initiation of inpatient chemotherapy at LAC+USC medical center utilizing an admission checklist.
Authors: Patel Ronak , Chiu Victor , Spicer Darcy V. 
Published: October 2019

262 Background: Delays in the initiation of chemotherapy for scheduled inpatient admissions cause excess lengths of stay and shift infusion start times to the evenings when hospital staffing is decreased. We sought to characterize delays in our admission process and assess the feasibility of using an admission checklist to shorten start times in a large academic safety-net hospital. Baseline data for scheduled chemotherapy admissions in July and August of 2017 (n = 25) showed a mean time to chemotherapy initiation of 14.6 hours and mean excess LOS was 0.7 midnights. Significant delays were identified in the time between ordering and resulting of pre-chemotherapy labs (average 2.6 hours), and the time required to obtain imaging to confirm peripheral-inserted central catheter (PICC) position (1.6 hours). Methods: We created a checklist of a standardized admission workflow for physicians, which included moving all pre-chemotherapy labs, pharmacy verification of chemotherapy regimen, and PICC imaging to the outpatient setting. We organized multiple staff in-services to introduce the admission workflow prior to implementation on May 1, 2018. We then performed a retrospective chart review of all scheduled inpatient chemotherapy admissions from May to August of 2018. Results: In the first 2 months after intervention, the mean time to chemotherapy initiation was 8.5 hrs, representing a 42% reduction. In the subsequent 2 months, the mean time to chemotherapy initiation was 11.6 hours, representing a 21% reduction from baseline. Mean excess LOS was 0.4 midnights and 0.5 midnights for those time periods, respectively. For the entire post-intervention group, 7 out of 26 patients obtained pre-chemotherapy labs in the outpatient setting. Conclusions: We observed an initial mean reduction of 6.1 hours in the time to start chemotherapy, as well as a reduction in mean excess length of stay with the introduction of a new admission workflow and admission checklist. We observed incomplete adoption of the checklist, and an increase in time to chemotherapy initiation after the first two months of implementation, suggesting that physician non-adherence represents a significant barrier to maintaining these reductions.