Pilot Trial of Homebound Hematopoietic Cell Transplantation.

For eligible patients with multiple myeloma (MM) and amyloid light chain (AL) amyloidosis, high-dose chemotherapy and autologous hematopoietic cell transplantation (HCT) is a standard and widely used consolidation therapy. Autologous HCT requires specialized care at a transplantation center and investment from patients and caregivers. We studied the safety and feasibility of delivering transplantation care in a homebound setting to decrease the burden of therapy and increase access to autologous HCT. Patients with MM and AL amyloidosis undergoing autologous HCT were eligible if they resided in designated ZIP codes and had a full-time caregiver, Wi-Fi connection, HCT Comorbidity Index ≤3, and Karnofsky Performance Status score ≥80. High-dose melphalan (on day -2) and hematopoietic cell reinfusion (day 0) were administered in the outpatient clinic. Protocol-specific home care was provided from day +1 through engraftment. Patients were assessed and blood was drawn daily by advanced practice providers. Interventions were delivered by registered nurses. Attending physicians communicated daily through telemedicine. Quality of life, patient and caregiver satisfaction, and fecal microbiota profiling data were collected. Fifteen patients were enrolled and received transplantation care at home starting on day +1 following hematopoietic cell infusion. Patients remained in the program for an average of 12 days and required an average of 2 outpatient visits while receiving home care. Seven of 15 patients were admitted for a median of 4 days (range, 3 to 10 days); admission occurred on day +7 in 5 patients, on day +8 in 1 patient, and on day +12 in 1 patient for neutropenic fever in 2 patients, fever attributed to engraftment syndrome in 2 patients, diarrhea in 2 patients, and dehydration in 1 patient. Only 1 patient had a documented infection (Clostridioides difficile). One patient admitted with neutropenic fever required intensive care unit admission for a gastrointestinal bleed. Forty-seven percent of the patients experienced a grade ≥3 nonhematologic toxicity. There were no deaths on the study. Patients and caregivers reported high satisfaction with care. Microbiota diversity patterns were similar to those of autologous HCT recipients who did not receive post-HCT care at home, although a subset of the cohort maintained microbiota diversity throughout. Homebound HCT in an urban setting is safe and feasible, with less than one-half of patients requiring inpatient admission. Despite increased patient and caregiver responsibility in the homebound setting compared with an inpatient setting, patient and caregiver satisfaction was high. These results support expansion of homebound transplantation care programs.

Access to Care: Using eHealth to Limit Location-Based Barriers for Patients With Cancer.

BACKGROUND: Rural and urban communities may encounter barriers to care, which can lead to delays in timely screening, diagnosis, and treatment. eHealth interventions, such as televisits and remote patient monitoring, are being used increasingly to improve patient access to quality clinical cancer care and to support patient-provider communication. OBJECTIVES: This article describes how eHealth can bridge gaps in patient access to cancer care and provides insight into successful eHealth program implementation. METHODS: Articles that evaluate access to care and eHealth program implementation were summarized. Two case studies illustrate eHealth as a strategy to improve care delivery and access. FINDINGS: Integrating eHealth into clinical practice can help to transform care delivery and improve patient access to quality cancer care by limiting barriers.

Pilot Study of Telehealth Evaluations in Patients Undergoing Hematopoietic Cell Transplantation.

Telehealth involves the use of telecommunication and information technology for the delivery of clinical care and may be a mechanism to alleviate the burden of visits faced by patients undergoing hematopoietic cell transplantation (HCT). Few studies have evaluated the feasibility and acceptability of telehealth visits in the care of HCT patients. We conducted 27 telehealth visits with 25 patients undergoing HCT using a videoconferencing system that allows for real-time, 2-way interactions and administered satisfaction surveys to patients and providers. Of the 25 patients included in the study, 20 (80%) and 5 (20%) were undergoing autologous and allogeneic HCT, respectively. The telehealth visits were distributed as follows: 3 inpatient visits upon admission for HCT; 11 inpatient visits between 2 and 14 days post-HCT; 4 inpatient visits prior to discharge after HCT; 8 outpatient, post-HCT follow-up visits; and 1 handoff to a community oncologist. Out of a total of 54 provider assessments, 7 providers (13%) were unable to complete some part of the physical examination, but no provider reported being unable to manage patients' symptoms through telehealth. Eighty-one percent of patients were either satisfied or very satisfied with the telemedicine session. Overall satisfaction was higher among patients than providers (mean scores 4.12 versus 2.64; scale 1 to 5, with 1 = very poor to 5 = excellent). Technological barriers resulting in delays and suboptimal physical examination were largely responsible for provider dissatisfaction. The use of telehealth to deliver comprehensive follow-up care to HCT patients is feasible across different HCT types but is dependent upon quality of data streaming and videoconferencing technologies.

Building a Program: Implications for Infrastructure, Nursing Education, and Training for CAR T-Cell Therapy.

BACKGROUND: Chimeric antigen receptor (CAR) T-cell therapy program development has regulatory demands and unique operational processes that vary across settings. The infrastructure in which CAR T-cell therapy is implemented has implications for nursing education and competencies. OBJECTIVES: This article presents an overview of operational approaches to CAR T-cell therapy program development and oncology nurse education considerations. These are provided through the lens of two institutions approved to administer CAR T-cell therapy, with differing approaches to CAR T-cell program development, implementation, and staff training. METHODS: Development of freestanding CAR T-cell therapy programs are compared with programs embedded in a specialty area. Issues related to accreditation and financial considerations are explored. Distinct features of inpatient and ambulatory care settings are presented. FINDINGS: CAR T-cell therapy continues to expand as the number of centers offering approved therapies increases. Standardized workflow components and staff education are essential for best patient outcomes regardless of location and type of program that provides the therapy.

Using Patient Portals to Increase Engagement in Patients with Cancer.

OBJECTIVES: To review patient portals which serve as a tool for patient engagement by increasing access to electronic health care information and expanding ways to communicate with health care providers. DATA SOURCES: Reviews of the literature and first-hand experience. CONCLUSION: Meaningful Use requirements propelled the design and development of patient portals in recent years. Patient engagement in oncology can improve quality of life and outcomes. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses facilitate patient adoption of patient portals and support usage. Patient education helps manage communication expectations and understanding of online medical information.

Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses.

BACKGROUND: The prevalence of medication errors associated with chemotherapy administration is not precisely known. Little evidence exists concerning the extent or nature of errors; however, some evidence demonstrates that errors are related to prescribing. This article demonstrates how the review of chemotherapy orders by a designated nurse known as a verification nurse (VN) at a National Cancer Institute-designated comprehensive cancer center helps to identify prescribing errors that may prevent chemotherapy administration mistakes and improve patient safety in outpatient infusion units. OBJECTIVES: This article will describe the role of the VN and details of the verification process. METHODS: To identify benefits of the VN role, a retrospective review and analysis of chemotherapy near-miss events from 2009-2014 was performed. FINDINGS: A total of 4,282 events related to chemotherapy were entered into the Reporting to Improve Safety and Quality system. A majority of the events were categorized as near-miss events, or those that, because of chance, did not result in patient injury, and were identified at the point of prescribing.

Considerations for the Doctor of Nursing Practice Degree.

Today's progressively complex healthcare landscape increasingly demands leaders who are adept at managing change in uncertain environments. Representing this country's largest group of healthcare workers, RNs influence how research translates to practice and ensure quality patient outcomes. Doctoral programs provide prospective nursing students with opportunities to pursue degrees focused on research or practice. The doctor of nursing practice (DNP) degree emphasizes leadership in clinical settings.
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The future of oncology care with personal health records.

Personal health records (PHRs) and patients' access to their own clinical information through a patient portal are changing the patient-physician relationship. Historically, health care providers have been gatekeepers of patients' medical records. Now, these portals provide patients access to clinical information, electronic messaging with the clinical team, and appointment and billing information. This type of access supports patient empowerment by engaging patients in their own care. Patients desire online access to information. The health care industry, like any other, must respond to the needs of its consumers. Oncology practices face unique challenges to meeting this need because of the complex nature of medical records of patients with cancer. Health care providers worry about the consequences of patients receiving "bad news" online, thereby increasing patient anxiety. This anxiety may, in turn, increase providers' workload by creating additional calls or visits to the office. These valid concerns require careful consideration when implementing a PHR or patient portal into a practice. Providers will benefit from a clear understanding of actual compared with potential risks and benefits. Much of the concerns about the negative effect on providers' workload and the potential increase in patients' anxiety have not been borne out. On the other hand, the implementation strategy, governance structure, and end-user education are crucial components to ensuring success. Successful implementation of a PHR or patient portal affords the opportunity to improve patient satisfaction and increase efficiency in provider workflow. The possibility exists to improve patient outcomes by engaging the patient in decision making and follow through.

Nurse and physician perspectives on patients with cancer having online access to their laboratory results.

PURPOSE/OBJECTIVES: To compare the perspectives of oncology nurses and physicians regarding online access to laboratory results for patients with cancer pre- and postimplementation, and to evaluate the impact on workload. DESIGN: Pre- and postimplementation surveys distributed to nurses and physicians. In addition, a nursing workload study was conducted to measure the number of phone calls received from patients regarding laboratory results. SETTING: The outpatient department of a comprehensive cancer center in a large, urban setting in the northeastern United States with more than 500,000 patient visits each year. SAMPLE: 460 outpatient nurses and 349 attending physicians were surveyed; 10 of those nurses were invited to participate in the nursing workload study, as well. METHODS: A survey was sent to nurses and physicians one month prior to implementation and then repeated six months postimplementation. A nursing workload study was conducted for 16 weeks beginning one month prior to implementation and completed three months postimplementation. MAIN RESEARCH VARIABLES: Nurse and physician perspectives; nursing workload. FINDINGS: Nurses demonstrated greater support than physicians with regard to patient access, their level of comfort with the patient access, and patients' ability to interpret results. Statistical significance was identified in all three questions (p<0.05). Perspectives on workload did not differ by role; nurses and physicians anticipated an increase in workload prior to implementation, but reported that workload decreased or stayed the same postimplementation (p<0.005). The nursing workload study supported that finding because no change was observed in the average number of phone calls per day during the implementation period. CONCLUSIONS: Oncology nurses and physicians have different perspectives on providing patients with cancer with online access to laboratory results. Concerns about increasing workload were not substantiated in the current study. IMPLICATIONS FOR NURSING: Providing patients with online access to their laboratory results is a growing trend. Understanding the perspectives of oncology nurses can inform future directions for increasing health-record transparency for patients with cancer. Future research may explore the impact on the nurse-patient relationship.