Time to Focus on Inpatient Safety: Revision of the American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards
Authors: Joseph O. Jacobson, Therese Marie Mulvey
Journal: Journal of Clinical Oncology (2012)

In 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) jointly published a comprehensive set of chemotherapy safety standards. The project was the end result of a highly structured multistakeholder process and the sole focus was on outpatient chemotherapy administration in the facilities in which most adult cancer chemotherapy is administered. In 2011, ASCO and ONS convened a workgroup to revise the standards. The revised standards are published in the January 2012 issue of Journal of Oncology Practice (JOP). In addition to clarifying language, the workgroup voted unanimously to extend the standards to encompass the inpatient setting. Inpatient chemotherapy administration, especially in the community setting, is believed to pose a silent but growing threat to patient safety. Most patients with cancer prefer to be managed as outpatients, and ambulatory management of cancer is more costeffective than inpatient management. Indeed, some insurers now require justification to admit a patient to the hospital solely to receive chemotherapy. The trend, then, of shifting adult medical oncology care from the hospital to the outpatient setting reflects patient-centered, cost-effective care. It has occurred gradually during the last decades of modern cancer chemotherapy, accompanied by shifts in care from academic centers to the community, where it is estimated that at least 80% of adult cancer care is provided. The change reflects at least three major advances. First, medical oncologists have become skilled in the management of highly toxic agents. Predictable toxicities of chemotherapeutic agents have been defined and risk factors have been identified, allowing for the prevention or amelioration of most serious adverse effects. Pretreatment assessment of renal function in conjunction with aggressive hydration, for example, has allowed cisplatin to be routinely administered in the outpatient setting. Second, the availability of highly active antiemetics and better-tolerated chemotherapeutic agents has additionally reduced the need for inpatient administration. Third, technologic advances that enable the safe delivery of continuous chemotherapy infusions in the home permit the ambulatory administration of complex regimens that previously required supervision in an inpatient setting. Community oncology practices have also become adept at managing the consequences of cancer and cancer treatment on an ambulatory basis. They have developed comprehensive care systems that rely on highly experienced nursing and pharmacy staff. Certification requirements for nursing and pharmacy staff along with the availability of supportive services that include nutritionists and social workers complement these practices. Patients who experience venous thromboembolic events, for example, are routinely managed with low molecular weight heparin as outpatients. Patients with low-risk chemotherapyinduced fever and neutropenia are managed with close observation and oral antibiotics. Patients who experience treatmentrelated GI toxicity are managed with ambulatory or home fluid resuscitation, and those with hypercalcemia receive potent parenteral bisphosphonates. Each of these patient groups are now routinely spared the risks and inconvenience of hospitalization. The consequence of these advances in the ambulatory care of patients with cancer is the disintegration of trained, cohesive chemotherapy teams in many hospitals; this problem is compounded by flaws in the transfer of data between outpatient and inpatient systems. The advances made in ambulatory practices (electronic chemotherapy order entry, for example) are inconsistently reflected in the inpatient setting. Fundamental changes in hospital staffing have occurred, with fewer dedicated nurses and pharmacists who are skilled in chemotherapy protocols and more hospitalists providing inpatient cancer care. Because of declining inpatient censuses and declining revenue, many hospitals have had to eliminate dedicated inpatient oncology units. This scenario may create a perfect storm in which very ill hospitalized patients are exposed to high-risk procedures (chemotherapy) that are provided by staff with diminishing expertise and without the needed infrastructure. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L S VOLUME 30 NUMBER 10 APRIL 1 2012