Changing Nursing Practice in Survivorship Care With Clinical Decision Tools.

The paradigm shift to include survivorship care as part of the cancer care continuum underscores the critical need for a change in nursing practice. One way to ensure that change in practice is delivered in a safe and efficient manner is through the use of clinical decision tools (CDTs). Such tools can be used to increase relevant knowledge and skills of nurses and patients. Despite the widespread recognition of their value, CDTs to educate providers on cancer survivors' care are limited and, when available, often are not used. Clinical practice algorithms were developed for disease-specific survivorship clinics in a cancer academic center. This article reviews the conceptual framework of the survivorship algorithms, describes the application of the algorithms in multidisciplinary disease-specific survivorship clinics, and discusses the implementation strategies used to promote clinicians' adoption and implementation of the algorithms. At a Glance • The authors found that algorithms can be successfully used as clinical decision tools(CDTs) to deliver survivorship care. • Algorithms and other CDTs are powerful tools to enhance professional practice. • Additional studies are needed to assess their effect on clinical practice and survivor outcomes.

Usage of erythropoiesis-stimulating agents in cancer patients at an academic cancer center and experience with specific care management tools for anemia.

BACKGROUND: In 2007, the US Food and Drug Administration (FDA) issued regulatory alerts for use of erythropoiesis-stimulating agents (ESAs) in cancer patients with anemia after clinical trials and meta-analysis data found that high ESA doses were associated with adverse outcomes in patients. In response to these findings, specific patient management tools for anemia (consisting in an algorithm and prescribing order set) were developed by a multidisciplinary team at The University of Texas MD Anderson Cancer Center. METHODS: A retrospective study consisted of 7117 patients aged 18 years and older with cancer malignancies who had received an ESA between January 2006 and December 2008 at MD Anderson. Changes in utilization of ESAs and packed red blood cells (PRBCs) were evaluated. RESULTS: The number of ESA doses dispensed each month decreased by 83% from January 2006 to December 2008 (P < .01), and the number of patients who received ESAs decreased by 80% (P < .01). The number of dispensed ESA doses for hemoglobin (Hb) levels ≥ 12 g/dL decreased significantly from 4% to 0% (P < .01), and the number for ≥ 10 g/dL decreased from 44% to 12% (P < .01). The PRBC transfusion rate remained stable in solid tumor patients (P > .05) but increased from 7% to 9% (P < .05) in patients with hematologic malignancies. CONCLUSIONS: The authors summarized their experience with use of ESAs in a tertiary oncology center. The implementation of their patient management tools for anemia might have facilitated the observed change at MD Anderson Cancer Center.

Incidence and prevention of venous thromboembolism in patients undergoing breast cancer surgery and treated according to clinical pathways.

OBJECTIVE: To minimize treatment variations, we have implemented clinical pathways for all breast cancer patients undergoing surgery. We sought to determine the incidence of postoperative venous thromboembolism (VTE) in patients treated on these pathways. SUMMARY BACKGROUND DATA: Cancer patients have an increased risk of VTE because of a hypercoagulable state. The risk of VTE following breast cancer surgery is not well established. METHODS: We retrospectively reviewed prospectively collected data for all patients who underwent breast cancer surgery and were treated on the clinical pathways with mechanical antiembolism devices and early ambulation in the postoperative period between January 2000 and September 2003. RESULTS: During the study period, 3898 patients underwent 4416 surgical procedures. Seven patients with postoperative VTE within 60 days were identified, for a rate of 0.16% per procedure. Six patients presented with only a deep venous thrombosis or a pulmonary embolism; 1 patient had both. The median time from surgery to diagnosis of VTE was 14 days (range, 2-60 days; mean, 22 days). No relationship was identified between stage of breast cancer or type of breast surgery and development of VTE. Two (29%) of the 7 patients with VTE had received neoadjuvant chemotherapy. VTE treatment consisted of subcutaneous low-molecular-weight heparin (n = 5) or intravenous heparin (n = 2) followed by warfarin. There were no deaths. CONCLUSIONS: VTE following breast cancer surgery is rare in patients who are treated on clinical pathways with mechanical antiembolism devices and early ambulation in the postoperative period. We conclude that systemic VTE prophylaxis is not indicated in this group of patients.

Outcomes of treatment pathways in outpatient treatment of low risk febrile neutropenic cancer patients.

BACKGROUND: We treated low-risk febrile neutropenic cancer patients utilizing two standard outpatient antibiotic pathways: oral ampicillin/clavulanate (500 mg) and ciprofloxacin (500 mg) or intravenous ceftazidime (2 g) and clindamycin (600 mg) every 8 h. The objectives were to determine the success of outpatient treatment of low-risk febrile neutropenia, to identify factors predicting outpatient failure, and to determine mortality related to the febrile episode. METHODS: Eligibility criteria included solid tumor diagnosis, stable vital signs, temperature > or =38.0 degrees C, absolute neutrophil count (ANC) of <1000/ml, patient compliance, no significant organ dysfunction, ability to tolerate oral medication and fluids for oral pathway, residence within 30 miles of the institution, 24-h caregiver, and telephone and transportation access. RESULTS: There were 257 febrile episodes in 191 patients meeting the criteria. Patients were treated during March 1998 through February 2000. Median age was 48 (range, 17-77) years, and 60% (n = 153) had an entry ANC of <100/ml; 205 (80%) febrile episodes successfully responded to outpatient treatment, and 52 (20%) were hospitalized. Logistic regression analysis showed the following were related to hospitalization: mucositis >grade 2 (p < 0.002); Zubrod performance status > or =2 (p = 0.029); ANC <100/ml (p = 0.039), and age > or =70 years (p = 0.048). CONCLUSIONS: Outpatient treatment of low-risk febrile neutropenic cancer patients utilizing standard treatment pathways is associated with minimal morbidity and mortality and should be considered an acceptable standard of care with appropriate infrastructure available to provide strict and careful follow-up while on treatment. Certain factors are associated with higher risk of hospitalization and should be further examined in eligible patients with low-risk febrile neutropenia.

The role of nursing in cervical cancer prevention and treatment.

Nurses today assume multiple roles, such as patient advocate, care provider, and research investigator. At the Second International Conference on Cervical Cancer (April 11-14, 2002, Houston, TX), nurses presented original research describing these roles in the context of cervical cancer screening, prevention, and detection in the United States and Sweden; outlined the uses of practice guidelines; and suggested future directions for nursing research. In the 20th century, nurses expanded their patient care responsibilities and promoted cancer control by expanding their skills. Some sought to broaden the spectrum of care by investigating cervical cancer screening disparities, behavioral aspects of screening, and differences between the stated purposes of screening programs and those of the nurse-midwives operating them. In the 21st century, nurses interested in cervical cancer control expect to broaden the scope of their care and their research roles further by continuing to improve training, advocating screening (and increased education about screening), and helping to establish new sources of funding for research.