Barbara J. Cashavelly

Putting Evidence Into Practice®: Evidence-Based Interventions for the Management of Oral Mucositis

Mucositis, an inflammation of the mucous membranes, is a commonly occurring side effect of chemotherapy and radiation. Oral mucositis can cause significant clinical consequences, such as pain, malnutrition, and local and systemic infections. Nurses have a critical role in all aspects of managing mucositis, including assessing it, teaching oral care, administering pharmacologic interventions, and helping patients cope with symptom distress. Mucositis can have a negative impact on the overall treatment experience, especially when severe pain or infections occur. Many interventions for managing mucositis exist; however, some are based in tradition or expert opinion and have not been studied in large, randomized, controlled trials. In addition, a variety of assessment tools are available, which creates confusion and difficulties when comparing interventions across studies. This article reviews empirical evidence related to interventions for oral mucositis. Oral care and rinses, pharmacologic interventions, and other techniques are evaluated. Gaps in the literature and opportunities for research, education, and practice changes are discussed.

Code Status Documentation in the Outpatient Electronic Medical Records of Patients with Metastatic Cancer

BACKGROUNDAdvanced care planning (ACP) is considered an essential component of medical care in the United States, especially in patients with incurable diseases. However, little is known about clinical practices in outpatient oncology settings related to discussing end-of-life care and documenting code status preferences in ambulatory medical records.OBJECTIVETo assess the rate of documentation of code status in the electronic longitudinal medical records (LMR) of patients with metastatic cancer.DESIGNRetrospective review of 2,498 patients with metastatic solid tumors at an academic cancer center. An electronic patient database and the LMR were queried to identify demographic information, cancer type, number of clinic visits, and documentation of code status.PARTICIPANTSThe sample consisted of adult patients with metastatic prostate, breast, ovarian, bladder kidney, colorectal, non-colorectal gastrointestinal (GI), and lung cancers.MEASUREMENTSPrimary outcome was the percentage of documented code status in the LMR.MAIN RESULTSAmong the 2,498 patients, 20.3% had a documented code status. Code status was designated most frequently in patients with non-colorectal GI (193/609, 31.7%) and lung (179/583, 30.7%) cancers and least frequently in patients with genitourinary malignancies [bladder/kidney (4/89, 4.5%), ovarian (4/93, 4.3%), and prostate (7/365, 1.9%) cancers]. Independent predictors of having documented code status included religious affiliation, cancer type, and a greater number of visits to the cancer center. Younger patients and black patients were less likely to be designated as DNR/DNI.CONCLUSIONSDespite the incurable nature of metastatic cancer, only a minority of patients had a code status documented in the electronic medical record.

Feasibility and Validity of a One-Item Fatigue Screen in a Thoracic Oncology Clinic

Introduction: Fatigue is one of the most common symptoms in patients with advanced cancers. Despite its high prevalence, it is often unrecognized and undetected. This study assessed the feasibility and validity of a one-item fatigue scale (OIFS) in an outpatient oncology clinic. Methods: Over a 3-month trial period, all patients in a thoracic oncology clinic were screened for fatigue with a one-item, 0 to 10 scale. Over a second trial period, an additional sample of 100 clinic patients completed validated measures of fatigue, including the Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-F) and Fatigue Symptom Inventory (FSI), in addition to the OIFS. Results: During the initial trial period, more than 95% of patients (574 of 600) had a documented OIFS score on their first clinic visit. Data from the second cohort of patients revealed that the OIFS had good test-retest reliability (r = 0.88) and was highly correlated with the FSI severity scale (0.87) and the FACIT-F (−0.75). Receiver operating characteristic analysis showed the OIFS had good discrimination compared with the FACIT-F (area under the curve = 0.87). Sensitivity and specificity of several OIFS cutoff scores were compared, and scores between 3 and 5 were found to be optimal. Conclusions: The use of a one-item scale to screen for fatigue is feasible in an ambulatory clinic setting. This scale had convergent validity with other measures of fatigue and was able to identify cases of fatigue that met criteria on the FACIT-F. These data support the recommendations in the National Comprehensive Cancer Network guidelines for cancer-related fatigue screening.

I Feel Like I Am 100 Years Old! Managing Arthralgias From Aromatase Inhibitors

Aromatase inhibitors (AIs) are recommended for the treatment of estrogen-sensitive breast cancer in postmenopausal women and provide a superior risk reduction compared to five years of tamoxifen alone. Arthralgias, a common side effect of AIs, may adversely affect quality of life, treatment adherence, and persistence. Early discontinuation of AIs may result in an inadequate clinical response. Over-the-counter analgesics, exercise, and drug holidays are common strategies used to manage arthralgias, however few interventions are evidence-based. Patients experiencing arthralgias may experience distress and, therefore would benefit from ongoing nursing support. When caring for patients with arthralgias, nurses should assess for potential modifiable risk factors, recommend lifestyle changes and/or pharmacologic interventions, and offer ongoing education and follow-up.

Parsing Depression From Fatigue in Patients with Cancer Using the Fatigue Symptom Inventory

CONTEXT A central aim in the management of cancer-related fatigue (CRF) is to identify treatable causes, such as depression. However, CRF and depression symptoms overlap and frequently co-occur, complicating diagnostic assessment. OBJECTIVES As cancer-related symptoms have been associated with more functional impairment among patients who are depressed, this study tested the ratio of fatigue interference to fatigue severity as a method for identifying depression cases. Patients who reported that interference was greater than severity were expected to show higher rates of depression as measured by self-report instrument or structured interview. METHODS A secondary analysis was conducted using data from patients who were attending a hospital thoracic oncology clinic and who completed the Fatigue Symptom Inventory (FSI) and Hospital Anxiety and Depression Scale (Sample 1, n = 86). Analyses were then replicated in a sample of diverse cancer patients who completed the FSI and a structured clinical interview for depression on presentation to a CRF clinic at the same hospital (Sample 2, n = 39). RESULTS Receiver operating curve analyses supported use of the FSI interference/severity ratio in distinguishing depression cases and noncases (area under the curve: Sample 1 = 0.84, 95% confidence interval [CI] 0.74-0.94; Sample 2 = 0.87, 95% CI 0.76-0.99). With sensitivity and specificity weighted equally, the optimal cutoff was ≥ 1.0 in Sample 1 (sensitivity = 62.5%, specificity = 91.4%) and Sample 2 (sensitivity = 90.9%, specificity=85.7%). CONCLUSION A fatigue score pattern in which interference was greater than or equal to severity predicted depression in two patient samples. This ratio may be useful for brief initial screening of depression in the context of fatigue.

Women's experiences with antiestrogen therapy to treat breast cancer.

PURPOSE/OBJECTIVES To understand the experiences of women undergoing antiestrogen therapy (AET) to treat breast cancer. RESEARCH APPROACH Content analysis of tape-recorded focus group interviews. SETTING Breast oncology center of a large medical center in the northeastern United States. PARTICIPANTS Purposive sample of 21 women undergoing AET to treat breast cancer. METHODOLOGIC APPROACH A nonexperimental qualitative, descriptive design using open-ended interviews and content analysis to isolate themes. MAIN RESEARCH VARIABLES Womens experiences with AET. FINDINGS Five themes were isolated and were focused on the overall experience of having breast cancer: symptoms related to AET, shared decision making, being strong for others, discovering new priorities, and recognizing vulnerability. CONCLUSIONS Oral therapies are an increasingly popular treatment option for various types of cancer, particularly in women with estrogen-sensitive breast cancer. Although this type of treatment has been efficacious in terms of disease-free and overall survival, women undergoing AET face many challenges related to treatment. Healthcare providers need to understand womens perceptions of AET and its effects as a first step in the process of developing interventions to improve care. INTERPRETATION More research is needed to distinguish whether the presence of preexisting chronic illness, differences in type of AET, age, and ethnicity impact the overall experience of women on AET. Individual interviews may be necessary to fully explore the experience. Oncology nurses should implement surveillance care to explore the effects of AET on women with breast cancer.

Processes of code status transitions in hospitalized patients with advanced cancer: Code Status in Advanced Cancer

Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown.

Use of Antidepressant Medications Moderates the Relationship Between Depressive Symptoms and Hospital Length of Stay in Patients with Advanced Cancer

Patients with cancer often experience depression, which can influence treatment outcomes and quality of life. This article evaluates associations among depressive symptoms, use of antidepressants, and hospital length of stay in patients with advanced cancer.

Resiliency among nursing staff in an inpatient medical oncology unit.

24 Background: Inpatient medical oncology nursing staff members often care for seriously ill patients with complex needs, and are at particular risk for burn out. This qualitative study explored the experiences of registered nurses (RN) and nurse practitioners (NP) on an inpatient medical oncology unit. We identified factors influencing resiliency in caring for oncology inpatients on a daily basis. METHODS We conducted in-depth qualitative interviews with 24 RNs and 13 NPs working on an inpatient medical oncology unit at an academic medical center. A semi-structured interview guide was used to elicit perspectives on facilitators and barriers to resilience in caring for oncology patients. Content analysis was conducted to identify themes between RNs and NPs. RESULTS Both RNs and NPs described being emotionally affected by daily experiences with patient suffering and death. However, they commonly identified that relationships with patients at the end of life (EOL) were sources of profound inspiration; and they felt privileged to engage with patients during this significant phase of their lives. Factors that negatively impacted resilience included a) barriers to communicating with team members and patients about EOL issues, b) successions of acutely ill patients on the unit, and c) work-life balance issues in the context of intensive shift schedules. Following emotionally difficult days, staff found motivation to return to work the next day through: a) mutual understanding and support from unit coworkers, b) sense of connection to seriously ill patients and their families, and c) general perception of oncology nursing as part of ones identity. CONCLUSIONS Nursing staff were intrinsically motivated to connect with seriously ill patients and to provide meaningful EOL care. Connections with coworkers and patients/families and personal identification with the role of oncology nursing helped staff to return to work after emotionally difficult experiences on the unit. Results identify potential targets for intervention to increase resiliency, including increasing workplace cohesion, communication and support within the unique inpatient milieu.

Chemotherapy order review, activation, preparation, and administration redesign at a large academic cancer center.

221 Background: Chemotherapy medication errors are potentially catastrophic due to the small window of therapeutic index, high toxicity, and the compromised clinical status of most recipients. Although compliant with major guidelines for chemotherapy administration, MGH Cancer Center still experienced chemotherapy medication errors tracked in the safety reporting system. Analysis of the safety report data prompted the chemotherapy order review, activation, preparation and administration redesign project with two aims: 1) establish the standard for safety checks for chemotherapy order review, mixing, product verification and administration across all areas of adult chemotherapy infusion by April 2013 and 2) reduce to zero the number of chemotherapy related medication errors by January 2014. METHODS A multidisciplinary team including nursing, pharmacy, and physicians was convened and a problem statement, aim statement, project scope, boundaries and measures of success were delineated. Process maps of each chemotherapy administration area (four in total) were created in an iterative fashion via meetings with front line staff and administration. Cause and effect diagrams were created by small groups of staff members from each area and improvement projects were brainstormed and implemented by nursing directors. Error data from safety reports was compiled quarterly and shared with all workers. RESULTS A single gold standard for MGH Cancer Center chemotherapy order review, activation, preparation and administration was created for all areas that administer chemotherapy to adults. This redesign project has led to several spin off improvement projects including a medication error awareness project led by nursing and a new competency assessment for oncology nurses. The total number of medication related safety reports has decreased by 67%. The time since our last major chemotherapy administration error is 239 days and we are on track to meet our second project aim. CONCLUSIONS This project employed quality improvement tools and practices to redesign and standardize chemotherapy administration and decrease safety reports related to chemotherapy errors by 67%.