Sekwon Jang

Improving Documentation of Pain Management at MedStar Washington Cancer Institute.

PURPOSE Appropriate cancer pain documentation is one of the quality measures in the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI). MedStar Washington Cancer Institute has participated in QOPI since 2008, and documenting a plan of care for moderate to severe pain (which was defined as a pain score of ≥ 4 on a scale of 0 to 10, with 10 being the worst) was identified as an area for improvement. METHODS We undertook a structured approach to improve documentation of the plan of care for moderate/severe pain with support from ASCOs Quality Training Program. Our team used standard plan-do-study-act (PDSA) methodology to achieve our goal of 90% documentation. We used a statistical process control chart (p chart) to determine whether our process was under control and to monitor the improvement in the documentation of pain management. RESULTS The baseline rate of a documented plan of care for pain was 70%. In January 2014, we implemented action plans including an electronic health record trigger for a pain score of ≥ 4, education for fellows and midlevel providers, and establishment of a faculty consensus on documenting management of pain unrelated to cancer. After these interventions, the pain documentation rate improved to 90%. CONCLUSION After one cycle of PDSA, we achieved our goal of a 90% pain documentation rate. To sustain our project, we continued to monitor the pain documentation rate quarterly in 2014 and continue the process of education and orientation to new staff, rotating residents, and fellows.

Antitumor and Anti–Hepatitis C Viral Response After Administration of the Anti–Programmed Death 1 Antibody Pembrolizumab

INTRODUCTION Antibodies that block programmed death 1 (PD-1) receptor and its ligand, PD-L1, have showndurable responses in multiple cancer types. PD-1 has been shown to be upregulated in hepatitis C virus (HCV) –specific CD8 cells. This suggests that anti–PD-1 therapy may be a therapeutic target in patients with HCV infection. However, patients with chronic hepatitis are usually excluded from clinical trials. Herein, we report a case in which PD-1 antibody was administered to treat metastatic Merkel cell carcinoma (MCC) in a patient with untreated chronic HCV infection. Treatment resulted in a rapid antitumor response as well as a rapid decline in HCV RNA without apparent hepatocellular injury, which suggested that not only can anti–PD-1 therapy induce antitumor immune responses, but that it may also restore antiviral T-cell function and overcome viral immune escape.

Early discussion of advance directives for patients with newly diagnosed cancer.

91 Background: Although advance care planning and the completion of advance directives (ADs) are important methods to prevent unwanted aggressive care once patients have lost their decision-making capacity, only a minority of patients have ADs at the time of cancer diagnosis. METHODS We established a new multidisciplinary outpatient clinic to provide comprehensive care to patients with newly diagnosed cancer at the Inova Dwight and Martha Schar Cancer Institute in Northern Virginia. Improvement in advance care planning was chosen as one of the first quality improvement initiatives for 2015. We started the first PDSA cycle after creating the team, establishing the problem and goal statement, and reviewing the process map. We had three measures including: 1. Inquiring whether the patient has advance directives or not at the time of scheduling their first appointment, 2. Provide written information about advance directives at the patients first visit, 3. Obtain advance directives by the third office visit. The goal for each measure was 90%, 90%, and 50% by the end of 2015. RESULTS Between May-June 2015, 65 patients were evaluable. Baseline rates were 26%, 2%, and 12%, respectively for measures 1, 2, and 3. In July 2015, we convened a staff meeting to review each staffs role in the process of advance care planning. The new patient schedulers had training and created a telephone script to effectively communicate advance directives information with patients. The front desk staff included written information about advance care planning in the new patient information folders. Clinical staff were asked to address any questions or concerns that patients have and to encourage patients to complete the ADs by next visit. After this intervention, the rates increased to 100%, 44%, and 33%, respectively for measures 1, 2, and 3 in August and September, 2015 (n = 45). CONCLUSIONS Early discussion about the ADs for newly diagnosed cancer patients at our outpatient clinic showed improvement in the rate of completed ADs by a third office visit.

Effect of intervention on a quality measure of pain management at Medstar Washington Cancer Institute.

144 Background: Medstar Washington Cancer Institute (MWCI) has participated in Quality Oncology Practice Initiative (QOPI) since 2008. Adherence to pain assessment and intensity documentation was high, but lower in plan of care for moderate/severe pain documentation (69%, compared to QOPI aggregate of 79%) during the fall 2011 round. One potential explanation for the discrepancy was lack of communication between the nursing staff assessing the pain and the physician treating pain. We hypothesized that the use of pain card can improve the communication between nurses and doctors, as well as prompt physicians to document the plan of care for moderate/severe pain. METHODS MWCI created a team of physicians, nurses, quality resources, and administrative staff in December 2011. We abstracted up to 10 patients charts per oncologist for those patientswho reported moderate to severe pain (pain score of more than 3 of 10 on numeric rating scale) each quarter during 2012.We used data for quarter 1 and 2 as a baseline. We implemented the use of pain card by nurses to report pain for these patients to the physician in quarter 3 and 4. Chi square test was used to compare documentation rate in the first two quarters and last two quarters. RESULTS The total number of charts evaluated, pain documentation as well as confidence intervals for each quarter are shown in the table. Our results show significant improvement in pain documentation by physician in last two quarters compared to first two quarters ( p = 0.0007). CONCLUSIONS Our study demonstrates pain card improved communication between nurse and physician resulting improved documentation of pain by physician. [Table: see text].