Managing symptoms during cancer treatments: evaluating the implementation of evidence-informed remote support protocols.

BACKGROUND: Management of cancer treatment-related symptoms is an important safety issue given that symptoms can become life-threatening and often occur when patients are at home. With funding from the Canadian Partnership Against Cancer, a pan-Canadian steering committee was established with representation from eight provinces to develop symptom protocols using a rigorous methodology (CAN-IMPLEMENT©). Each protocol is based on a systematic review of the literature to identify relevant clinical practice guidelines. Protocols were validated by cancer nurses from across Canada. The aim of this study is to build an effective and sustainable approach for implementing evidence-informed protocols for nurses to use when providing remote symptom assessment, triage, and guidance in self-management for patients experiencing symptoms while undergoing cancer treatments. METHODS: A prospective mixed-methods study design will be used. Guided by the Knowledge to Action Framework, the study will involve (a) establishing an advisory knowledge user team in each of three targeted settings; (b) assessing factors influencing nurses' use of protocols using interviews/focus groups and a standardized survey instrument; (c) adapting protocols for local use, ensuring fidelity of the content; (d) selecting intervention strategies to overcome known barriers and implementing the protocols; (e) conducting think-aloud usability testing; (f) evaluating protocol use and outcomes by conducting an audit of 100 randomly selected charts at each of the three settings; and (g) assessing satisfaction with remote support using symptom protocols and change in nurses' barriers to use using survey instruments. The primary outcome is sustained use of the protocols, defined as use in 75% of the calls. Descriptive analysis will be conducted for the barriers, use of protocols, and chart audit outcomes. Content analysis will be conducted on interviews/focus groups and usability testing with comparisons across settings. DISCUSSION: Given the importance of patient safety, patient-centered care, and delivery of quality services, learning how to effectively implement evidence-informed symptom protocols in oncology healthcare services is essential for ensuring safe, consistent, and effective care for individuals with cancer. This study is likely to have a significant contribution to the delivery of remote oncology services, as well as influence symptom management by patients at home.

Consensus recommendations for the management of constipation in patients with advanced, progressive illness.

Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.

An interdisciplinary team communication framework and its application to healthcare 'e-teams' systems design.

BACKGROUND: There are few studies that examine the processes that interdisciplinary teams engage in and how we can design health information systems (HIS) to support those team processes. This was an exploratory study with two purposes: (1) To develop a framework for interdisciplinary team communication based on structures, processes and outcomes that were identified as having occurred during weekly team meetings. (2) To use the framework to guide 'e-teams' HIS design to support interdisciplinary team meeting communication. METHODS: An ethnographic approach was used to collect data on two interdisciplinary teams. Qualitative content analysis was used to analyze the data according to structures, processes and outcomes. RESULTS: We present details for team meta-concepts of structures, processes and outcomes and the concepts and sub concepts within each meta-concept. We also provide an exploratory framework for interdisciplinary team communication and describe how the framework can guide HIS design to support 'e-teams'. CONCLUSION: The structures, processes and outcomes that describe interdisciplinary teams are complex and often occur in a non-linear fashion. Electronic data support, process facilitation and team video conferencing are three HIS tools that can enhance team function.

Adopting and introducing new technology to improve patient care: a wedding of clinicians and informatics specialists.

The BC Cancer Agency sees 128,172 patients per year, of which 2,186 are referred to the Patient Symptom Management/Palliative Care (PSMPC) clinics for tertiary symptom management. Other than at the PSMPC clinics, screening for symptom distress is extremely variable because there is no systematic assessment protocol. In a recent audit of patients coming to the Cancer Agency, approximately 64% of patients reported experiencing a moderate to severe level of symptom distress. Of the total patients in the audit (n = 1,147), only 18 were seen by the PSMPC teams and it is unclear whether or not the remaining patients had their symptoms attended to by a health professional at the BCCA.The tool which the BCCA has chosen for screening and assessment is the Edmonton Symptom Assessment System (ESAS), which was developed by Dr. Eduardo Bruera. ESAS is a nine-item, self-reporting, visual analogue instrument used to measure pain and other symptoms using numeric ratings. Cancer Care Ontario (CCO) has developed an electronic means whereby patients' ESAS scores are entered and housed in an electronic health record and then used for triage. BCCA is in partnership with CCO to adapt this system for use in BC.

Development and reliability testing of the Victoria Bowel Performance Scale (BPS).

With changes in bowel function being a common and often distressful issue for palliative care patients, the ability to easily monitor and record changes in bowel status would be helpful in addressing quality of care. Most bowel tools record either constipation or diarrhea, but not both. A new tool, the Victoria Bowel Performance Scale (BPS), was designed as an ordinal nine-point scale from -4 (severe constipation) to +4 (severe diarrhea) and includes three parameters: visual stool characteristics, bowel pattern, and ability to control defecation. This study tested the reliability of BPS using case scenarios in a test-retest format. Sixty-seven raters in Time Period 1 and 54 raters in Time Period 2 ranked the 18 cases. The intraclass correlation coefficients for absolute agreement were 0.822 and 0.853 for Time Periods 1 and 2, respectively. Results showed that the raters were consistent in their scoring over time, with an average Cohen's kappa of 0.70 over all of the raters. The average Pearson correlation coefficient between Time Periods 1 and 2 scores was 0.92. Further prospective testing in day-to-day clinical care is needed to further confirm the reliability and clinical utility of the BPS. A BPS management guideline has been developed to assist with decision making for each BPS score, which also requires validation.