Smart Start: Rituximab, Lenalidomide, and Ibrutinib in Patients With Newly Diagnosed Large B-Cell Lymphoma.

PURPOSE: Chemoimmunotherapy for patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) is largely unchanged for decades. Both preclinical models and clinical data suggest the combination of lenalidomide and ibrutinib may have synergy in DLBCL, particularly in the non-germinal center B-cell-like subset. METHODS: We enrolled 60 patients with newly diagnosed non-germinal center B-cell-like DLBCL in this investigator-initiated, single-arm phase II trial of rituximab, lenalidomide, and ibrutinib (RLI) with the sequential addition of chemotherapy (ClinicalTrials.gov identifier: NCT02636322). Patients were treated with rituximab 375 mg/m2 intravenous once on day 1, lenalidomide 25 mg once per day on days 1-10, and ibrutinib 560 mg once daily continuously of each 21-day cycle (RLI). After two cycles, standard chemotherapy was added to RLI for six additional cycles. The primary end points were overall response rate (ORR) after two cycles of RLI alone and complete response rate after completion of RLI with chemotherapy. In evaluable samples, circulating tumor DNA and DLBCL90 assays were performed. RESULTS: The median age was 63.5 years (range, 29-83 years) with 28% age 70 years or older. The revised international prognostic index identified 42% as high risk, and 62% were double expressor of MYC and BCL2 protein. The ORR after two cycles of RLI was 86.2%, and the complete response rate at the end of RLI-chemotherapy was 94.5%. With a median follow-up of 31 months, the progression-free survival and overall survival were at 91.3% and 96.6% at 2 years, respectively. CONCLUSION: Smart Start is the first study, to our knowledge, to treat newly diagnosed DLBCL with a targeted therapy combination before chemotherapy. RLI produced a high ORR, and RLI with chemotherapy resulted in durable responses. This establishes the potential for developing biologically driven and noncytotoxic first-line therapies for DLBCL.

Fellow Designations of Interest to Nurse Leaders.

Achieving fellow designation is commonly a career goal for nurse leaders. The path to achievement can be confusing, and once a goal is set, choosing the right designation is important. This column outlines the background of fellow designation, clarifies differences between fellow designation and other career advancement options, and presents ideas for consideration by nurse leaders as they pursue career advancement through fellow designation.

Reducing hospital readmissions of postoperative patients with the martin postoperative discharge screening tool.

Hospital readmission for postoperative complications, a safety and quality issue for nurse leaders, occurs with 20% of postoperative Medicare patients and costs $15 billion annually. Nurse leaders should evaluate readmission rates for postoperative complications and evaluate ways to reduce the incidence. The Martin Postoperative Discharge Screening Tool was developed to address this vulnerable population and guide clinical staff to develop interventions to improve the readiness of identified patients for discharge. Preliminary results of the project are presented in this article.

Global nurse leader perspectives on health systems and workforce challenges.

AIM: As part of the 2011 annual American Organization of Nurse Executives conference held in San Diego, California, a session was presented that focused on nursing workforce and health systems challenges from a global perspective. This article includes content addressed during the session representing nurse leader perspectives from the UK, Singapore and the USA. BACKGROUND: Recent events in global economic markets have highlighted the interdependence of countries. There is now a global focus on health-care costs and quality as government leaders struggle to reduce budgets and remain solvent. EVALUATION: Finding solutions to these complex problems requires that nurse leaders adopt more of a world view and network with one another as they look for best practices and creative strategies. KEY ISSUES: Nursing leadership challenges such as staffing, competency development, ageing populations, reduced health-care funding and maintaining quality are now common global problems. CONCLUSION: There is a need for innovation in nursing practice to accommodate the enormous challenges facing nursing's future. IMPLICATIONS FOR NURSING MANAGEMENT: Opportunities on an international scale for nurse leaders to have dialogue and network, such as the conference presentation discussed in this article, will become increasingly more important to facilitate the development of innovative leadership strategies.

Using portfolios to introduce the clinical nurse leader to the job market.

Development of a portfolio is an effective strategy used by clinical nurse leaders (CNLs) to inform prospective employers of their specialized skills in quality improvement, patient safety, error prevention, and teamwork. The portfolio provides evidence of competence relative to the role of clinician, outcomes manager, client advocate, educator, information manager, systems analyst/risk anticipator, team manager, healthcare professional, and lifelong learner. This article describes the CNL portfolio developed by experts from the University of Tennessee Health Science Center and Methodist LeBonheur Healthcare. Examples of portfolio documents generated throughout the master's entry CNL curriculum are provided, along with student experiences using the portfolio in the employment interview process.

Transforming nursing workflow, part 2: the impact of technology on nurse activities.

OBJECTIVE: To assess the impact of new technology on nurse workflow, nurses at 2 hospitals were observed before and after implementation of an electronic medication charting system. In part 1 (September 2010 issue), we discussed the chaotic nature of nurse activities and its implications on transforming workflow. BACKGROUND: Numerous studies have documented the impact of technology on performance and satisfaction, but technology's impact on the frequency, duration, and pattern of activities is less understood. These patterns are important to the development of new care models. METHODS: Observers shadowed nurses at 2 hospitals before and after the implementation of an electronic medication charting system. A total of 196 hours of observation was recorded at one site, and 185 hours at the other site. RESULTS: Analysis of variance revealed a number of significant differences in the time spent on a variety of activities, but the duration and frequency of nurse activities were not drastically altered by the additional technology. CONCLUSIONS: Computer use increased; however, the impact was evenly distributed among other activities. More importantly, time with patients and verbal communication remained unchanged as nurses seemed to incorporate the new requirements into their normal routine.

Transforming nursing workflow, part 1: the chaotic nature of nurse activities.

OBJECTIVE: To quantitatively measure workflow and computer use, the activities of 27 medical-surgical RNs were recorded through direct observation. BACKGROUND: Previous studies have shown how nurses spend their time but have not documented the pattern, duration, or frequency of activities. The absence of this information is problematic for leaders charged with improving performance and staff development. METHODS: Observers recorded nurse activities and location in real time using predefined lists. More than 98 hours of observations were recorded. RESULTS: Assessment, charting, and communicating were the most frequent activities, consuming 18.1%, 9.9%, and 11.8% of nurse time, respectively. The duration of 40% of the activities was less than 10 seconds. Timelines revealed that nurses constantly switch activities and locations in a seemingly random pattern. CONCLUSION: The results indicate that there is little "flow" in nurse workflow. The chaotic pace implies that nurses rarely complete an activity before switching to another. The opportunity to use critical thinking and engage in planning care is severely limited under these circumstances. The implications for cognition and role transformation are discussed. Part 2 of this research explores the impact of new technology on nurse activities and workflow.

Designing a patient care model with relevance to the cultural setting.

Healthcare leaders are challenged to develop new approaches to care that better serve populations and use valuable resources in more effective and efficient ways. The authors discuss a model of care under development at Sidra Medical and Research Center, Qatar, with emphasis on how to translate the best available evidence in a way that is applicable and meaningful for the cultural setting. Strategies that nurse leaders can call upon to engage their team members' cultural intelligence during the planning and design of new processes of care are also discussed.