bluuebunny/crossref_metadata_2025_split huggingface dataset:
Post-operative vital signs: How often is too often?
Authors: Filson Kristen , Atherholt Colleen , Simoes Meredith , DiPalma Michael , John Susheela , Reynolds Robin , McGovern Joanne 
Published: September 2018

210 Background: Current protocol for post-operative patients admitted to medical-surgical/telemetry units from post anesthesia care units states vital signs are taken every 15 minutes for 1 hour, every 30 minutes for 2 hours and then, every 4 hours for 24 hours. To date, published evidence-based research regarding the frequency and duration of vital signs to safely monitor post-operative patients is limited. The goal is to determine best practice in post-operative vital sign monitoring to ensure safe patient care. The purpose of this review is to determine what frequency and duration of vital signs is required to identify a deviation greater than 20% of patient baseline to ensure safe post-operative monitoring of patients. Methods: A total of 742 post-operative patients’ charts were evaluated. A time frame in which vital signs deviated greater than 20% from patient baseline was established from the data collected. A chart was created depicting these results; listing the total deviations by individual vital sign and time frame. Results: Results show blood pressure and heart rate are the vital signs that have the greatest deviation from baseline followed by pulse-oximetry. Temperature deviations are widespread, while changes in respiratory rate are seen within the first hour. When looking at specific percentages, it was noted that 65% of the total patients reviewed had a 20% deviation from their baseline vital signs. Blood pressures made up 50% of those deviations, while heart rates made up 45%. A total of 27% of the deviations occurred 4-8 hours after admission, 13% of deviations occurred 8-12 hours after admission, 9% of deviations occurred 1.5 hours after admission, and 7% of deviations occurred 12-16 hours after admission. Conclusions: Based on these results, the best times to take post-operative vitals to ensure deviations are detected are: every 15 minutes for 30 minutes upon admission, 1.5 hours after admission, 4 hours after admission, and then every 4 hours for 20 hours. Findings indicate vital signs can safely be taken less frequently in post-operative patients admitted to medical-surgical/telemetry units.
Implementation of a patient experience–focused review at the time of radiation therapy simulation.
Authors: Robertson John M. , Rutka Elizabeth , Ye Hong 
Published: September 2018

211 Background: Anxiety impairs information retention and may lower patient satisfaction. Because anxiety is highest at the time of radiation therapy (RT) simulation, we added a personal patient experience (PX) review of the treatment process focusing on resolution of any outstanding concerns and measured for a benefit using patient satisfaction scores. Methods: A single PX trained Senior Radiation Therapist met patients at simulation and reviewed multiple factors from registration to any outstanding medical issues, with the goal of addressing and resolving all questions. A CMS-approved patient satisfaction tool was recorded during this time to assess for any benefit of this PX review. The tool asks 17 questions in 5 domains (Registration, Facility, Your Treatment, Personal Issues, and Overall Assessment) and calculates an Overall Facility Rating. Tools received between the date of simulation and the date of follow-up were considered an on-treatment evaluation and were used for assessment. Scores were compared with a Mann-Whitney U test. There were no other formal departmental patient satisfaction efforts during this time. Results: Between 2/16 and 6/18 a total of 1369 patients (median 65 yrs; 64% women; 38% breast cancer; 82% curative) were met at simulation by our Senior Therapist spending a median of 23 minutes per patient (range 0 – 117). We received 732 patient satisfaction surveys (median 67 yrs; 61% women; 40% breast cancer; 90% curative) including 98 on-treatment respondents, 69 of whom had the PX review and reported significantly better scores for 10 of the 17 questions and 4 of the 5 domains (Registration p = 0.04, Facility p = 0.03, Personal Issues p = 0.02, Overall Assessment p = 0.002). The PX review was significantly better for the calculated Overall Facility Rating (p = 0.04). Conclusions: The PX review at simulation was associated with significantly higher patient satisfaction scores in 4 of 5 domains, including areas not specifically addressed during the interview (e.g. cleanliness). Improvements of this amount are typically associated with very large improvements in percentile rankings. This intervention was extremely successful but durability of this benefit into the follow up period was not assessed.
Improving patient-centered oral chemotherapy at an academic cancer center.
Authors: Lim Charles Henry , Petronis Jennifer , Mellor Sabrina , Krzyzanowska Monika K. 
Published: September 2018

212 Background: Despite established standards for prescribing and monitoring oral anti-cancer medications (OAC) and validated tools supporting OAC patient education, substantial quality gaps remain. Methods: To identify local gaps in care for patients receiving OAC, we used a patient survey in the GI and Endocrine medical oncology clinic. Providers were also interviewed. The survey consisted of 23 questions addressing three domains (treatment plan (T) education, self-management (S) education and health team communication (C) as well as a single question overall satisfaction score. A composite average score encompassing all 23 questions was generated. Questions were derived from ASCO chemotherapy standards and validated patient communication instruments and scored on a 5-point Likert scale. Subsequently, individualized drug-specific written care plans guiding patient education were developed and tested in iterative PDSA cycles. The aim was to improve the composite average patient survey score by 10%. The same patient survey was used to assess the impact of the change ideas. Results: We collected 32 patient surveys, 21 pre- and 11 post-intervention. Baseline surveys indicated lowest scores in the C domain. Providers reported variation in education content and communication techniques used. Care plans with standardized content for 8 OAC agents were tested in simulated and clinic settings in a stepwise fashion, with implementation beginning in Feb 2018. Providers received training on integrating the care plans into clinic workflow. The composite average score for all 23 items improved from 4.18 to 4.29. The single question overall satisfaction score improved from 4.17 to 4.45. Improvement was noted across all 3 domains (T: 4.31 → 4.41, S: 4.26 → 4.36, C: 4.00 → 4.15). For balancing measures, provider teaching time per patient initially rose following implementation before returning to baseline. Conclusions: The intervention led to improvement in the patient experience when starting OAC. Standardized content and a framework guiding provider communication were key elements of the change ideas. To meet the study aim, further PDSA cycles integrating teach back methodology and proactive phone follow up are ongoing.
Consumer demand and implementation of a scalp cooling program at a multi-site organization.
Authors: Featherstone Ashley , Hernandez Karen , Fischer-Cartlidge Erica , Ross Mikel , Haase Curt 
Published: September 2018

214 Background: Alopecia is so feared that patients may opt to forgo treatment or elect for a less effective treatment to prevent it. Consumer demand for scalp cooling has been on the rise recently and has escalated since the Food and Drug Administration cleared the use of scalp cooling machines to minimize chemotherapy-induced alopecia. This organization required a clinical support model to implement this unique intervention and to establish its own benchmarks for safety and quality. Methods: With no precedent for implementation, nursing, administration, facilities, information technology, finance and legal collaboratively established a process for integrating scalp cooling into current practice. Policies, patient education, staff training programs, billing codes and electronic documentation were created; technological solutions for tracking and scheduling patients at multiple sites were established; infection control and biomedical machine management systems were put into place. Results: Initially, eight sites offered scalp cooling for female breast cancer patients receiving alopecia-inducing chemotherapy. After expanded approval for all solid tumor patients, the program grew to all sites (n = 13) providing chemotherapy using one standard process. All sites implemented scalp cooling utilizing existing treatment space and schedules. To date, more than 800 cooling treatments have occurred. Conclusions: Patient priorities must be clinician priorities. A multi-site organization must respond to new research and consumer demand. Successful integration into the patient experience depends on alignment between providers, nursing, and support departments and forward thinking for scalability.
A description of the free text word choices physicians use to describe prognosis in over 50,000 electronic treatment plans.
Authors: Wilfong Lalan S. , Ferencik Mark , Neubauer Marcus A. 
Published: September 2018

219 Background: Fourteen practices within the US Oncology Network are participating in the Center for Medicare and Medicaid Innovation’s (CMMI) Oncology Care Model. To meet the requirement of documenting a care plan that contains the 13 components in the Institute of Medicine Care Management Plan, an electronic treatment plan was developed which incorporates core elements from our EMR, IKnowMed, supplemented by additional physician documentation. Physicians must document in their own words the prognosis section of the care plan. Methods: To better understand the word choices physicians use for prognosis, we evaluated the word choices used in over 50,000 treatment plans. Using an excel based word count macro, all contents of the free text entry “prognosis” field were sorted based on frequency of the same answer and were then ranked from most common use to least common. A word count method was applied to determine and rank the most commonly used words across all answers. The “current status of disease” field in the treatment plan was used to divide the prognosis answers into those that mentioned “Metastatic” and “Not Metastatic” so that prognosis wording trends could be compared using pivot tables and data filters. Results: 70% of prognosis word choices were single words: “excellent, good, fair, poor, or guarded” were the most common. 20% of phrases were multi-word that appeared repeatedly such as “will depend on the response to therapy.” Only 10% of answers were uniquely worded per treatment plan and felt to be personal to the patient’s situation. Additionally, the number of words did not differ between metastatic and non-metastatic disease. Conclusions: To our knowledge, this is the largest cohort of treatment plans where the word choices used by physicians are described to document prognosis to patients. The results indicate that single words or short phrases are commonly used to describe prognosis when the treatment plan is shared with patients. The data set has high potential for further study to better understand the role and impact of written treatment plans (including downstream events) to help physicians refine this documentation for better patient understanding of this important topic.
Development of a person-centered patient portal in oncology using stakeholder co-design.
Authors: Kildea John , Hijal Tarek , Hendren Laurie 
Published: September 2018

221 Background: Patient portals are software products that provide care recipients (patients) with access to some or all of their personal health information (PHI) within a healthcare institution’s electronic medical record (EMR). Most patient portals are just that–windows into an EMR. However, in today’s connected world, a patient portal can offer much more than just access to PHI. By exploiting modern technology and by recognizing that care recipients are people with complex needs that extend beyond just the delivery of care, patient portals can be person-centered. Such person-centered needs include: the ability to plan ahead and know one’s position in a waiting list, to feel in control of one’s own care, to understand one’s treatment options, and to share in all decision-making about one’s care. Methods: We used stakeholder co-design, involving care recipients, care providers (clinicians) and technical experts at all levels, to design and develop a person-centered patient portal from within the healthcare system. Results: Our mobile-friendly patient portal, known as Opal (opalmedapps.com), contains the following: One-stop multi-speciality and multi-institutional operation; Appointment schedule with personalized appointment preparation guidelines; Appointment check-in and waiting room management tools; Monitoring of step-by-step radiotherapy treatment planning; Access to PHI contextualized with explanatory information; Access to personalized educational materials; Patient-reported outcomes questionnaires with response visualizations; An automated rules-based system to minimize clinician workload; Triggered notifications to alert patients and clinicians to actionable events. Conclusions: Opal is currently in beta release involving a small number of oncology patients at our centre who are providing feedback about its use and usefulness. Their initial feedback is very positive and enthusiastic. A full pilot study is starting by July 2018.
A process for improving patient survey scores in the oncology care model (OCM).
Authors: Perry Manuel , Rudy-Tomczak Katie , Hines Scott 
Published: September 2018

222 Background: The Oncology Care Model is an alternative payment model created by The Center for Medicare and Medicaid Services. Our goal was to improve patient education and to improve the patient experience. We hired nurse practitioners to achieve this. Methods: Crystal Run Healthcare is a multi-specialty group practice with nine oncologists. A total of 4 nurse practitioners have been hired since implementation of the OCM Program in July 1, 2016. All oncology patients and their family who are scheduled to initiate a new treatment program or a change in an existing treatment are scheduled to meet with a nurse practitioner for 60-75 minutes in order to review details of their treatment including a 13-point treatment summary recommended by the Institute of Medicine. Results: CMS administered anonymous patient surveys at baseline and in rolling 6 month episodes reported every 3 months. Data is represented from January-September 2016 (baseline)and is compared to July 2016-March 2017. Since implementation of our nurse practitioner access program, patient survey scores improved dramatically. Average overall rating improved from the 11th-20th percentile to 71st-80th percentile. The most dramatic improvement occurred in shared decision making which improved from 11th-20th percentile to the 91st-99th percentile. Conclusions: The addition of nurse practitioners who are tasked with educating patients regarding their treatment offers an opportunity for patients to have a comprehensive visit to review treatment details. The most striking improvement was seen in shared decision making which likely reflects the benefits of a prolonged discussion between the nurse practitioner, the patient and their family.[Table: see text]
Increasing the percentage of advance directives in patient medical records.
Authors: Waynick Christopher A. , Conwill Jan , Gian Victor 
Published: September 2018

226 Background: Advance care planning is often initiated too late, which leads to added stress and high resource utilization at the end of life which is contrary to many patients’ wishes. Ideally, discussing patient’s wishes should start early. An advance directive (AD) documents patient preferences for end-of-life care. Methods: In order to improve this process, the team used the DMAIC process: Define, Measure, Analyze, Improve, and Control. In the define phase, 79 new cancer diagnosis patients’ medical records were reviewed and completed. This revealed that 25.58% of these patients claim to have an AD, but only 5% have an AD documented in their record within 30 days of their first visit. Upon further discussion with staff, there was no standard process. The focus performance metric for the project was to have the AD in the chart within 30 days of their first visit. Goal was set at 20%. Analyzing the process was as follows: Process map, Fishbone diagram to determine potential improvements. Priority pay-off matrix. The most effective process change would be to add a notice in the new patient packet for the patient to bring their AD with them to their first visit. Results: The first iteration of the improve phase included the notice created in the analyze phase. After completion, 60% of patients had an AD in their chart within 30 days of their first visit. For the second iteration, the team worked with psychology staff to create a letter to the patient explaining the advantages of having an AD in the chart. Results were 100% of the performance improvement metric. Controlling this process change is simple, but continuing a 100% target is difficult. Some patients who do not have an AD in their chart feel uncomfortable with it or do not understand what it is. Future improvements include patient education processes and provider discussions with the patients to ensure an 80% target is maintained. Conclusions: The team learned developing and communicating a formal process is imperative to achieving the target. Also important is to communicate clearly with the patients, enabling them to understand what (and why) their provider needs from them.
Standardized approach to incident management across a radiation oncology network.
Authors: Frey Seth D , McAleer Mary Frances , Walker Gary , Natter Rachel Bissonnett , Edwards Timothy , Koong Albert , Herman Joseph M. , Minsky Bruce D. , Khan Mohamed K , Dragun Anthony E. , Olson Michael R , Gabel Molly , Bierman Robin , Turner Lehendrick , Llorente Manolo , de Carvalho Icaro Thiago , Selek Ugur , Hahn Stephen M. , Kuban Deborah A. 
Published: September 2018

235 Background: Quality and safety reporting is one of the most important aspects of creating a culture of safety. As part of a multidisciplinary Cancer Network, the Radiation Oncology Division at the lead institution devised an electronic incident reporting system that was implemented at the Network partners to define, standardize, quantify, and trend incidents in the radiation oncology treatment and care process. The purpose of this study is to assess robustness of the system, initial trends seen, and potential to improve quality and safety of the Network practice. Methods: Beginning in January 2017, the incident reporting system at the lead institution was configured to provide inclusion of 13 partnering radiation oncology facilities. Over one year, the organizations were on-boarded and trained on the use of the application. Descriptive analyses of the data from the use of this new reporting system were used in this study. Results: From January 1, 2017 to April 30 2018, a total of 832 incident reports were submitted by 13 different facilities. The average number of days from event submission to resolution was reduced to 10.25 days, compared with up to 60 days before implementation of the new central reporting system. The change in reporting rate was variable across the partner sites following implementation of the new system. The most frequent event types reported included ineffective communication (13%), planning-related problems (5%), incomplete or missing simulation orders (5%), and scheduling error or conflict (4%). Conclusions: Implementation of a centralized reporting system across a network of partner sites has greatly improved the overall reporting process, with reduced event resolution time and increased capability of tracking and trending incidents. By standardizing incident reporting across institutions, there are multiple opportunities to augment a strong culture of safety.
Use of a chemotherapy toxicity prediction tool to decrease the risks for hospitalization in the elderly.
Authors: Mintchev Mintcho Elinov , Bersabe Adrian Reyes 
Published: September 2018

256 Background: Oncologists commonly use performance status scores such as ECOG and Karnofsky when making treatment decisions. However, there is limited data on the utility of these measures in selecting therapy and predicting treatment-related complications in the elderly. In July 2016, medical oncologists at our institution made it standard practice to use the Cancer and Aging Research Group toxicity prediction score (CARG) to identify elderly patients who are “fit” for conventional therapy versus those who are “frail” and may experience increased complications. Methods: We retrospectively reviewed referrals to our outpatient medical oncology clinic for patients 75 years of age and older. Referrals leading to systemic therapy (i.e. chemotherapy, targeted therapy, and immunotherapy) or changes to conventional therapy based on CARG were included in our study. We evaluated CARG utilization during the 6 months before and the 6 months after its institution. We also assessed how changes to therapy due to CARG impacted admissions and emergency department (ED) visits. Results: Thirty-eight patients with mean age of 81.2 years, 52.6% male, met inclusion criteria. Their diagnoses included GI (36.8%), lung (21.1%), hematologic (18.4%), breast (10.5%), GU (2.6%), and other (10.5%) malignancies. During 2016, CARG was assessed in 14 patients, 9 of whom received systemic therapy. CARG was assessed in 12.5% and 41.2% of patients receiving systemic therapy in the 6-month periods before and after its incorporation, respectively. Patients whose therapy was decreased in intensity or withheld based on CARG had fewer mean admissions (0.7 versus 2.25), days of admission (4.3 versus 8), and ED visits (1.1 versus 2.5) compared to those who received conventional therapy. However, the study lacked power to establish statistical significance. Conclusions: A CARG assessment occurred in less than 50% of elderly cancer patients who received systemic therapy and further inquiry may help formulate interventions to increase its adoption. Therapy modifications based on CARG may lead to fewer hospitalizations, admission days, and ED visits, but more consistent use of the score and further investigation are necessary.