bluuebunny/crossref_metadata_2025_split huggingface dataset:
Evaluation and identification of protocols for safe and efficacious institutional administration of intravenous immune globulin in hypogammaglobulinemia associated with chronic lymphocytic leukemia, non-Hodgkin lymphoma, and multiple myeloma.
Authors: Feinsilber Doron , McCoy Cole , Hari Parameswaran , Foy Patrick C. , Narra Ravi , Fenske Timothy S , Shah Nirav Niranjan , Michaelis Laura Christian , Kollu Vidya , Mears Katrina Angela , Osinski Kristin , Froggatt Nancy , Atallah Ehab L. , Dhakal Binod 
Published: September 2018

250 Background: Hematologic malignancies effect both humoral and cell-mediated immunity. We hypothesize that for patients with Chronic Lymphocytic Leukemia (CLL), Non-Hodgkins Lymphoma (NHL), and Multiple Myeloma (MM) outcomes improve with adherence to National Comprehensive Cancer Network (NCCN) guidelines for intravenous immunoglobulin (IVIG).Our objective is to understand resource allocation and implementation of IVIG in outpatient and inpatient settings. We identified a cohort of patients with hypogammaglobulinemia for assessing incidence of sepsis, outcomes, and resource use. We initiated this project by undertaking a large descriptive study of current IVIG use. Methods: A retrospective Institutional Review Board (IRB) approved data capture was conducted covering 2016-2018. Inclusion criteria involved those on an active chemotherapy plan, age > 18 years and diagnosis of CLL, NHL, or MM. IgA deficiency, anaphylaxis to IVIG, planned chemotherapy, inherited immunodeficiency, and thymic deficiency were excluded. We considered patients to be suitable for IVIG if IgG was < 500 mg/dL for CLL and MM and < 400 mg/dL in NHL. Outcomes, number of admissions, sepsis, ICU care, infectious etiology, and monthly IgG levels were examined. Results: A preliminary i2b2 data capture identified a cohort of 563 patients that yielded 12% with bacteremia, 21% with sepsis, and 23% with pneumonia of which 87% were admitted. 28% received IVIG during the 2-year period. Of the 563, 77% were hospitalized and 21% required ICU care. 54% of ICU patients received inpatient IVIG. All influenza and parainfluenza cases were inpatient. Final data analysis will yield greater detail in comparing inpatient to outpatient IVIG use. Conclusions: Large academic institutions appear to have significant variability in use of IVIG in patients with lymphopenia and hematologic malignancies. With this data, we plan to assess for patient-level outcomes based on adherence to NCCN guidelines as a way to enhance Physician Quality Reporting System (PQRS) standards by prioritizing outpatient use of IVIG.
Are we really good to go? Can we do better?
Authors: Magni Katie , Bagley Janet , Durney Jeffrey , Wolfberg Rachel A , Perna Melissa , Crifasi Richard ,   Good to Go Workgroup
Published: September 2018

251 Background: ASCO/ONS (2016) stated that health care continues to see errors regarding chemotherapy administration. ASHP (2015) recommends that institutions establish checkpoints to ensure that chemotherapy orders are correct. These critical safety checks involve stakeholders on the frontline. The institute uses the pharmacy intervention program to combat this critical need. Pharmacy interventions are reviewed monthly and defined as any medication order that pharmacy reviews and recognizes a discrepancy, requiring follow up. An interdisciplinary workgroup of pharmacists and nurses was established to address pharmacy interventions identified. Methods: The workgroup met over two months to revise the existing medication administration criteria and developed a standardized Good to Go worksheet. A mandatory training video was assigned to infusion nurses. The worksheets were piloted over three weeks and reviewed for completion and notes. Pharmacy interventions were collected prior to and during implementation to track compliance and improvement to patient safety. Nurses and pharmacists were identified as team members. Daily debriefing huddles were held during implementation with feedback incorporated and revisions made to the worksheet for the following day(s). This project was approved by the DFCI IRB as a Quality Improvement Project. Results: The pilot unit had a pharmacy intervention rate of 8.8 % for one week prior to implementation. During week one of the pilot the pharmacy interventions decreased to 4.1% and one month after pilot the rate was 4.6% and 4.7%. The most recent pharmacy interventions were communicated to staff. May data showed a further reduction to 2.8%. Nurses reported feeling better organized and more focused, while pharmacists report less phone calls to infusion. Statements from frontline staff and leadership including the positive results of the pilot were added to the training video. Conclusions: With the positive impact on patient safety, the Good to Go project will be implemented throughout the institute in the summer of 2018. Team members will include infusion nurses and pharmacists from all units. A standardized team approach to chemotherapy administration has the potential to minimize medication errors.
Surgical Universal euGlycemic Attainment during Recovery (SUGAR) Initiative.
Authors: Taylor Jolyn Sharpe , Cain Katherine , Earles Terri , Harris Melinda , James Deepthi , Hubbs Cheryl , Dottino Joseph , Stewart Katherine Ikard , McGrew Leon , Siebel Christine , Enbaya Ahmed , Iniesta Maria , Vachhani Shital , Lasala Javier , Thosani Sonali , Best Conor , Sahai Sunil Kumar , Schmeler Kathleen M. , Ramirez Pedro T , Meyer Larissa 
Published: September 2018

252 Background: Surgical site infections (SSI) are infections of the surgical incision or organ space within 30 days of surgery and are associated with increased morbidity, mortality and healthcare expenditures. Diabetic patients undergoing laparotomy are at high risk. Prior studies have shown SSI reduction by avoiding hyperglycemia. The aim of our Quality Improvement (QI) initiative is to reduce the SSI rate among diabetic patients undergoing laparotomy by 40% within 2 years compared to the baseline (2/2015-8/2017) rate of 16%. Methods: We formed a multi-disciplinary QI team including physicians, nurses and advanced care providers from Gynecologic Oncology, Pharmacy, Nutrition, Endocrinology, Internal Medicine and Anesthesiology. The intervention began 2/2018 in our main center and 5 satellite sites including: screening gynecologic cancer patients undergoing laparotomy with hemoglobin A1C, intra-operative glucose monitoring with goal of < 180mg/dL, creation and use of a standardized basal-bolus insulin order set for post-operative care, and endocrine and nutritional consultation. The following variables were assessed: age, race, ethnicity, BMI, cancer type, comorbidities, smoking status, surgical procedure, receipt of antibiotic prophylaxis, hemoglobin A1C, post-operative glucose values, intervention compliance, intra-operative complications, post-operative complications including SSI, hospital readmissions, reoperation and mortality. Results: Since 2/2018, 39 gynecologic cancer patients have undergone laparotomy. Overall compliance with HgA1c screening is 64% (25/39), which has improved from 42% in 2/2018 to 70% in 3/2018 and 83% in 4/2018. Causes of non-compliance included unplanned conversion to laparotomy and need for additional education. Five of 39 (13%) patients were diabetic, including one newly diagnosed through this initiative. The post-intervention diabetic SSI rate is 0% (0/5) with all post-intervention glucose values < 180mg/dL. There have been no safety adverse events resulting in patient harm. Conclusions: Implementing a QI initiative to standardize management of diabetic patients undergoing surgery is both safe and feasible. Effectiveness data will continue to be collected.
Improving safety and adherence of oral chemotherapy.
Authors: Shahin George , Bersabe Adrian Reyes , Layman Clifton Patrick 
Published: September 2018

253 Background: Oral chemotherapy (OC) has gained increasing popularity due to perceived advantages in convenience and toxicity profiles compared to conventional chemotherapy. Based on ASCO/ONS guidelines, we established standard operating procedures (SOPs) and a nurse-led oral chemotherapy clinic to guide the safe administration and monitoring of OC in our outpatient hematology/oncology clinic. Methods: A dedicated oral chemotherapy clinic led by a certified chemotherapy nurse was created to ensure standard metrics identified in the ASCO/ONS guidelines were met with each patient visit. Fifty-seven charts were randomly selected for a 3-month post intervention analysis. Results: The OC nurse identified toxicities in 17/57 (30%) of cases prompting notification of the ordering physician. This led to modifications in supportive medications in 9/17 (53%) of cases. Dose modifications occurred in 6/17 (35%). Informed consent documentation was available in only 36/57 (63%) charts. Necessary lab work was missing in 7/57 (12%) cases, prompting completion prior to OC release. An incorrect OC was dispensed by pharmacy in one case. Each visit took approximately 30 minutes from check-in to release of OC. All patients received OC education specific to their regimen. Conclusions: A dedicated visit with an OC nurse provided a vital means to ensure patient education, safe prescribing, proper dispensing, and monitoring of toxicities. Nursing identified the need for supportive care interventions and dose reductions in over 25% of charts which mitigated potential adverse events. Due to average time required for each patient encounter, we found this process to be unsustainable with increasing needs and limited resources. Thus, we revised our SOP to include a checklist of standard ASCO/ONS metrics. We also decreased the follow-up requirement for patients who did not require further intense monitoring after 6 months. Ongoing efforts will be made to ensure the effectiveness of this program. Future interventions will also capture cost effectiveness to establish a fair compensation model for reimbursement and justification of clinical support required to enforce current administration safety standards.
Developing a standardized process for oral chemotherapy management for neuro-oncology.
Authors: McGranahan Tresa , Gershon Megan , Pena Justine , Bains Chamnjot , Van Meter Margaret Elizabeth McCormick , Salas Sarah , Nagpal Seema 
Published: September 2018

258 Background: Oral chemotherapies (OC) have transformed cancer care for millions of patients. While this has improved the patient experience, it presents significant challenges to safety of prescription, administration and side effect monitoring. While there are guidelines for documentation, there is not a best practices system for managing OC. This project identified areas of latent errors and implemented a standardized process for OC management. Methods: After review of the literature, we developed a process map for OC prescriptions at our institution. We then compared processes at three other neuro oncology clinics. We completed a hazard analysis and implemented several changes (see table). We identified binary measures in the medical record for every OC prescription that related to the process changes. Chart review of the 6 months prior to process change was used to create a baseline process mean for each variable. These same variables were monitored every 2 weeks after process change implementation using run charts. Successful process shift was defined as 7 consecutive 2-week averages that were continually on one side of the baseline process mean. Results: 5 months after process change was implemented, we had successfully reduced refills for OC and increased documentation of dose and dose calculation. There is a trend towards improvement in independently verified dose calculation and dedicated chemotherapy teaching visits, however these have not yet reached criteria for process change. Conclusions: This project used published studies, multi-institutional process mapping and hazard analysis to develop and implement a standardize process for OC. This process can be implemented for OC management in other oncology practices. [Table: see text]
Improving patient safety: Utilization of standardized radiation oncology simulation templates.
Authors: Everett Ashlyn S. , Blalock Ginna , Boggs Drexell Hunter 
Published: September 2018

259 Background: Increasing patient volume and treatment complexity in the field of radiation oncology has resulted in increased number of errors possibly affecting patient safety. Effective methods of mitigating these errors include automation, computerization, simplification, and standardization. To improve quality of care and patient safety, our institution established consensus standardized treatment guidelines for each cancer site. However, physician orders for computed tomography (CT) simulation for radiation treatment planning continued to have extreme variability, with error rates of 31%. Therefore, a team was assembled to devise standardized orders to reduce error, improve patient safety, and improve quality of care in the CT simulation order process. Methods: For this study, we investigated 3 commonly treated sites at our institution: breast (14%), prostate (7%), and brain metastases treated with radiosurgery (14%). A standardized template CT simulation order was defined for each disease site using the consensus treatment guidelines. These orders were integrated into the electronic medical record (EMR) on March 5, 2018. To evaluate the efficacy of the intervention, CT simulation order data were queried for the two-month period before and after implementation of standardized template orders. Orders with variation from the treatment guidelines were counted to calculate error rates with and without standardized simulation orders. Results: In the two-months prior to implementation of the standardized order templates, 48 of 151 (31%) CT simulation orders for the three selected sites had variation from the consensus standardized orders. After implementation of the EMR standardized template, 17 of 129 simulation orders (13%) in the three selected sites had variations from the standard during this two-month period. Standardization of CT simulation orders using an EMR template reduced error rates from 31% to 13% (18% absolute reduction; 42% relative reduction). Conclusions: Simplification and standardization of CT simulation orders decreased error rates by 42%, thereby improving clinic efficiency and appropriate patient treatment.
Comparison of PCR/FISH testing and next generation sequencing (NGS) in molecular diagnosis of advanced-stage lung adenocarcinoma.
Authors: Whooley Peter , Guinee Donald , Mandelson Margaret T. , Hubka Michal , Kuppusamy Madhankumar , Chu Frank , Kirtland Steven H. , Rosales Joseph Grant F 
Published: September 2018

262 Background: As the number of clinically actionable genetic markers for lung adenocarcinoma has increased, the need for accurate and timely identification of these markers has become paramount. In January 2018, our practice began systemically using NGS on all lung adenocarcinoma biopsy specimens. We compared NGS testing to our previous standard (PCR- and FISH-based assays) with regards to breadth of markers tested and time to diagnosis. Methods: We compared detection of mutations in EGFR, ALK, and ROS1 and time from resection or biopsy to test results in recently diagnosed patients from January-March 2018 with stage III/IV adenocarcinoma of the lung to similar patients diagnosed January-December 2016. Results: 63 patients were eligible for analysis: 17 patients in 2018 and 46 patients in 2016. Mean time to diagnosis was 13 days for EGFR, 16 days for ALK and 18 days for ROS1 in 2016, based on previous methods (PCR/FISH) compared to 27 days for EGFR, 26 days for ALK and 26 days for ROS1 in 2018 with NGS testing. Four of the 46 samples (8.6%) were found to have insufficient tissue using PCR/FISH, whereas 1 out of 17 (5.8%) samples were found to be insufficient with NGS testing. NGS testing returned up to 35 molecular markers, including those which might be targets for clinical trial therapy. Conclusions: The use of NGS testing increased the number of actionable molecular markers tested and appears to have resulted in an increase in the time taken to diagnose EGFR, ALK, and ROS1. The clinical significance of this time difference (i.e. time to treatment initiation) as well as ultimate cost of NGS compared to PCR/FISH remain to be determined. FIGURE 1: Time to diagnosis of molecular tests in lung adenocarcinoma stage III/IV using PCR/FISH from January through December 2016 and NGS from January through March 2018.[Table: see text]
Quality improvement interventions to reduce chemotherapy dose-modification ordering errors at a large academic medical center.
Authors: Soriano Margaret , Chang Anne , Galway Aralee , Listro Laura , Liu Evaline , McGuire Jessica , Mulvey Therese Marie , O'Donoghue Sheila , Parikh Aparna Raj , Rosato Erika , Ryan David P. , White Lawren , Woolwine Melissa Anne , Isakoff Steven J. 
Published: September 2018

264 Background: Despite clear advantages of Electronic Health Records (EHR) systems for safe cancer chemotherapy administration, persistent opportunities exist to further reduce chemotherapy order errors. Unintended dose escalation orders of previously dose reduced chemotherapy were the most commonly reported “near-miss” medication safety events at our institution. This can lead to potential patient harm, delays in care, decreased patient satisfaction, reduced infusion room efficiency, and increased care team workload and decreased satisfaction. We sought to reduce chemotherapy order errors using interventions developed with process improvement techniques. Methods: Unintended dose escalation errors per month (the primary outcome measure) were identified through the hospital safety reporting system and by monitoring the EHR (EPIC) chemotherapy administration reports to identify dose escalations. All cases were confirmed with primary chart review. The pre-intervention baseline assessment period was 6/2017-11/2017, and the post intervention period was 12/2017-5/2018. Two interventions were selected: 1) Revision of the nursing chemotherapy checklist posted on all infusion room workstations for use prior to releasing chemotherapy orders; and 2) educating ordering providers and nurses about new EHR functionality to display prior and future chemotherapy orders. Statistical Process Control chart analysis was conducted with upper (UCL) and lower (LCL) control limits of 3 standard deviations. The primary aim was to reduce the number of chemotherapy errors by 50% in the post-intervention period. Results: The pre-intervention period averaged 3.83 chemotherapy ordering errors per month (UCL = 9.71, LCL = 0). The post-intervention period significantly reduced the average errors per month to 1.33 (UCL = 4.97, LCL = 0). The copy/forward feature in multi-day cycles was the most common source of unintended dose escalations. Conclusions: Implementation of the 2 interventions resulted in a 65% reduction of unintended dose modification errors. Based on successful results and positive staff feedback, we plan to roll out these interventions at additional satellite facilities.
An interprofessional pathway for patients initiating treatment with palbociclib: Optimization of toxicity monitoring.
Authors: Thawer Alia , Singh Susan , Boudreau Angela , Mackinnon Lori , Ng Lisa , Lawrence Shikha , Charbonneau Flay , Stinson Jordan , Slater Deana , Trudeau Maureen E. , Gandhi Sonal 
Published: September 2018

268 Background: CDK 4/6 Inhibitors such as palbociclib in combination with hormonal therapy are considered the new standard of care for eligible advanced breast cancer patients with ER positive, HER2 negative disease. These agents have toxicities warranting standardized monitoring algorithms. Methods: An interprofessional pathway was created for palbociclib that identified key patient milestones and responsibilities of different care providers. Blood work (BW) parameters for dose interruption/reduction were specified, with a minimum absolute neutrophil count (ANC) of 1 as the threshold for continuing therapy. A retrospective chart audit was conducted to assess adherence to the biweekly BW and toxicity assessment pathway. Toxicity results were compared to the PALOMA-2 trial. Results: Consecutive patients were assessed between June 2016 and August 2017. Median follow up was 193 days. Twenty five patients before and 24 patients post algorithm implementation were included. Median age was 59, and 80% had >2 lines of prior systemic treatment. Dose reductions were observed in 57% of patients, 84% for neutropenia (Table 1). This is higher than documented in PALOMA-2. Instances where BW and clinic assessment were indicated and completed went from 43% to 69% and 32% to 67% respectively. Conclusions: Our study included heavily pre-treated patients and used an ANC treatment continuation threshold of 1 as opposed to 0.5; this might explain the increased incidence of neutropenia and dose modifications. This algorithm, with defined provider roles and patient milestones, appears feasible and effective in standardizing follow up and optimizing patient care.[Table: see text]
Creating an optimal care coordination model for patients with lung cancer on Medicaid.
Authors: Marbaugh Amy , Asfeldt Thomas , Kramar Amanda , Lucas Lorna 
Published: September 2018

273 Background: The Association of Community Cancer Centers (ACCC) created an Optimal Care Coordination Model (OCCM), which provides a comprehensive self-assessment tool designed to orient cancer programs to achieving patient-centered, multidisciplinary care. The OCCM is designed to help cancer programs, regardless of resources, location, or population, improve care for lung cancer patients, especially those on Medicaid. Methods: An environmental scan was conducted in early 2016 with a focus on coordination of care after lung cancer diagnosis to improve experiences and outcomes for Medicaid beneficiaries. Five ACCC Cancer Program Members each hosted 2-day site visits in mid-2016. Interview sessions were conducted to explore effective practices and current care models for patients with lung cancer insured by Medicaid. Key problems in care coordination were identified, as well as local solutions that had been put in place to overcome these barriers. The NCI Community Cancer Centers Program’s (NCCCP) Multidisciplinary Care (MDC) Assessment Tool was the foundational template to create the OCCM. The MDC Tool included 7 assessment areas that were identified as impactful to establishing multidisciplinary care and includes a Level 1-5 evaluation matrix. Results: The beta version of the OCCM was created in early 2017. The number of Assessment Areas was expanded to better capture current care coordination philosophies; (1) Patient Access to Care; (2) Prospective Multidisciplinary Case Planning; (3) Financial, Transportation, and Housing; (4) Management of Comorbid Conditions; (5) Care Coordination; (6) Treatment Team Integration; (7) Electronic Health Records (EHR) and Patient Access to Information; (8) Survivorship Care; (9) Supportive Care; (10) Tobacco Cessation; (11) Clinical Trials; (12) Physician Engagement; (13) Quality Measurement and Improvement. Conclusions: Seven ACCC Cancer Program Members are currently validating the model by each implementing at least one program-specific quality improvement project focused on an Assessment Area over a 12-month time period. All programs are collecting extensive data to determine the extent their program improved within an assessment area. Final results will be available for dissemination in 2019.