Highlights of Posters from the Oncology Nursing Society 41st Annual Congress

TON - September 2016, Vol 9, No 5

San Antonio, TX—The 2016 Annual Congress of the Oncology Nursing Society marked the 41st anniversary of the organization. More than 3000 registrants met at the newly renovated Henry B. Gonzalez Convention Center in San Antonio, TX, just steps from the famed San Antonio River Walk.

Attendees had many opportunities to gain new knowledge and reinforce their skills, and to network with old friends and make new ones. Along with 4 days of lectures, oral research papers, keynote addresses, and special interest group sessions, poster sessions featured 230 traditional posters and 75 e-posters. The Oncology Nurse-APN/PA has summarized a few of the many interesting and pertinent topics addressing the areas of infection control, inpatient comfort, and symptom assessment and management, which are applicable to the daily practice of all oncology nursing professionals.

C difficile Surveillance Project Raises Awareness

Concerted testing for Clostridium difficile at Froedtert Hospital, part of Froedtert & the Medical College of Wisconsin, Milwaukee, led to greater awareness of the pattern of infections there, and, ultimately, to measures that should reduce them.

This large academic medical center has a significant population of immune-compromised patients, for whom C difficile infection can be life-threatening. In a project reported at the meeting by Caitlin Seybold, RN, nurses determined the source of C difficile infections on the hematology/oncology unit—where rates of infection were high—and identified patients who had a positive culture when they were admitted.

Before initiation of the project, reports of surveillance cultures were not available to nursing staff or patients, and were not entered into the medical record. “Evidence of a positive surveillance culture upon admission would decrease hospital-acquired C difficile rates,” Ms Seybold pointed out.

For the surveillance project, every patient in the unit was screened on admission and once weekly via a stool sample that was also sent for DNA sequencing. Stool samples were monitored for growth. If a culture was positive, a pharmacist was paged to assess whether interventions (ie, a C difficile treatment bundle) were needed. This bundle includes discontinuing or de-escalating antibiotics when possible, and discontinuing antiperistaltic agents, promobility agents, and acid suppression therapy, if feasible. The pharmacist communicates intervention options to the primary care provider and care team.

To date, 429 patients have been screened, of whom 65 (15%) were found to be colonized with C difficile. Of the colonized patients, 40% acquired the bacteria after being admitted to the hematology/oncology unit, whereas 60% were positive on admission; 23% of these 65 patients developed C difficile colitis, Ms Seybold reported.

“Data collection is ongoing, but so far the data have shown that a positive surveillance culture is a risk factor for the development of C difficile colitis,” Ms Seybold noted. The relative risk was calculated to be 4.67 (P <.0001).

Changes based on these findings have been made to the hematology/oncology units to help prevent infections, including:

  • Cleaning solutions were changed from bleach/Virex to OxyCide, which is less damaging to surfaces, and has a shorter dwell time
  • Daily chlorhexidine bathing was instituted
  • Each patient’s room has a dedicated stethoscope
  • Universal handwashing before and after patient interactions along with universal gloving has been instituted.

The next step is to determine the clonality of the individual strains. “With DNA sequencing, more can be understood regarding the bacterial makeup of the gut microbiome and its changes,” Ms Seybold said. Discussions are also underway about obtaining skin and environmental surface cultures.

Source: Seybold C, et al. Clostridium difficile surveillance project. Poster 217.

Chlorhexidine Bathing Reduces Infections in Transplant Patients

The use of chlorhexidine gluconate (CHG) wipes for daily bathing led to a substantial reduction in hospital-acquired infections in a 12-bed transplant oncology unit at Avera McKennan Hospital & University Health Center, Sioux Falls, SD.

As a result of immunosuppression, oncology and stem-cell transplant patients are especially vulnerable to hospital-acquired infections. CHG is an antimicrobial agent that kills Gram-positive bacteria and some viruses. Daily bathing with CHG wipes has been shown to reduce the risk for a multidrug-resistant infection, such as methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci.

Patients excluded from the intervention were those with an allergy to CHG, or who had severe skin breakdown, rash, or burns; those receiving total body irradiation or the chemotherapy agent thiotepa; and patients with graft versus host disease.

Registered nurses and patient care technicians were trained in using the wipes. Compliance was monitored with documentation chart audits, and education was reinforced with simulation at 3 months. Patients received verbal and written instructions, and scripting was developed for the staff to use when patients declined the CHG baths.

In the 12 months prior to the implementation of daily CHG baths, 11 hospital-acquired infections were documented, for an infection rate of 2.99 per 1000 patient-days. At 12 months’ postimplementation, 7 infections had been documented, for a rate of 1.93 per 1000 patient-days, according to Kayla Koob, BSN, RN, OCN, who presented the poster. This represented a 35.5% decrease in hospital-acquired infections after implementation of the CHG bathing, she noted.

Among patients who did not use the wipes (ie, declined them or met exclusion criteria), there were 13 infections, for a rate of 3.6 per 1000 patient-days.

“Based on the positive project results, daily bathing with CHG wipes will continue with this patient population,” Ms Koob concluded.

Source: Koob K, et al. Does chlorhexidine bathing reduce the rate of infections for transplant-oncology patients? Poster 229.

Evidence-Based Strategies Can Reduce Hospital Unit Noise Levels

“Diligence to reduce noise levels can improve patient satisfaction and environmental safety,” according to Preston Lee Andrew, RN, CN III, who presented an evidence-based strategy that proved successful on his 31-bed unit at Duke Cancer Institute, Durham, NC.

Since 1960, the average daytime noise level in hospitals has increased from 57 to 72 decibels—45 decibels awakens patients from sleep.

Although the national benchmark for patient satisfaction with noise (based on the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]) is 78%, his unit-based HCAHPS scores averaged below 50% in 2014. This disappointing finding led Mr Andrew and colleagues to prioritize the HCAHPS survey item Quietness of Hospital Environment. They set a unit goal of meeting and exceeding the 78% HCAHPS benchmark, and developed a number of initiatives to do so:

  • Staff meetings were held to educate providers on noise levels and review implementation strategies for noise reduction; signage was put on the unit
  • Bedside reporting was implemented
  • At the nurses’ station, Yacker Tracker decibel readers were placed and set at 70 decibels; a stoplight indicates when levels are exceeded, which can enhance awareness about excessive noise
  • Mindfulness of conversations at the nurses’ stations and outside of patient rooms was emphasized
  • Overhead paging was eliminated.

Prior to the intervention, the level of noise on a 10-point scale was >9; this dropped to 5.14 after the intervention. HCAHPS scores for Quietness of Hospital Environment also significantly improved (P <.05). The most significant improvement, 80% satisfaction, occurred in month 3, meeting the target goal. Most scores, however, were inconsistent month to month, and some “drift in practice” has occurred, “yet all scores were higher than the preimplementation scores,” Mr Andrew reported.

The nursing staff had the following observations: the unit was quieter immediately postintervention, night shift noise levels are higher than day shift levels, change of shift is the loudest time during any shift, and Yacker Tracker has been useful in reminding staff to be mindful of noise, but may be too sensitive around some equipment (eg, printers).

The intervention did not appear to impact noise from visitors, patients’ rest or sleep, or staff fatigue at the end of a shift, but the staff did perceive “improved abilities to perform work activities with less distractions,” he said.

Source: Andrew PL, Meise A, Brooksbank N. Implementing evidence-based strategies to reduce unit noise levels in order to increase patient healing, improve staff communication, & patient satisfaction. Poster E14.

Making Good Use of the Telephone

Oncology nurses manage chemotherapy-related adverse events and the patient anxiety associated with the fear of them. Nurses’ proficiency in doing so was demonstrated in 2 telephone-based projects described at the poster session.

Dennise Geiger, RN, and colleagues in the outpatient infusion center of Regional Cancer Care Associates of Central Jersey, East Brunswick, NJ, created a standardized algorithm to aid the telephone triage nurse in handling symptom-related calls. It is part of the dedicated telephone triage system that practice maintains, which designates a personal contact for patients concerned about chemotherapy-related adverse effects.

“We get 50 to 90 phone calls a day,” said Ms Geiger, who manages these calls 4 days a week for the busy practice. “One day, I actually had 110.”

As the dedicated triage nurse, Ms Geiger understands symptom management quite well, but other nurses are less familiar. The standardized, evidence-based algorithm chart, based on American Society of Clinical Oncology guidelines, is useful for these nurses; it includes a flow chart of questions that should be asked based on the particular symptoms, and self-management strategies they can describe to patients. It also instructs the nurse about what to do when patients require more support.

The system facilitates consistent management of care, and gives nurses confidence, Ms Geiger said. “It’s especially useful to nurses who don’t always rotate through triage,” she commented. “Nurses feel more comfortable, and this translates into how they speak to the patient and how secure the patient feels.”

By providing immediate access to experienced nurses, the system has reduced unnecessary emergency department visits and hospitalizations. It has also increased nurses’ satisfaction to 100% (up from 60% in 2014), and enhanced their patient care skills.

New patient anxiety related to initiating chemotherapy often stems from the fear of adverse effects. In a project led by Penny Moore, MSN, RN, OCN, NEA-BC, and presented at the meeting by Kori Fenner, RN, of The Ohio State University James Cancer Hospital, Columbus, a 48-hour postchemotherapy phone call proved reassuring to patients.

“We want to catch problems before they cause admissions,” said Ms Fenner. A script was created for nurses to use when calling patients 48 hours after treatment. The nurse caller is ideally the nurse who managed the patient’s infusion, and the call is usually placed midday. Significant symptoms are referred to the nurse practitioner or physician.

A monthly review of data, which is conducted to determine trends, revealed that the most complaints by far were for fatigue (22%), and that 7% of patients had an issue that required consultation with a provider.

After 4 months, the Press Ganey scores “are trending up,” Ms Fenner said. Scores were 95.4% for management of adverse events, and 98.2% for nurses’ concern about questions and worries. “Patients appreciate their nurse’s concern for how they are doing. It gives them a sense of comfort that we are there if they need us.”

Their next steps are to convert the callback process into a flow sheet in the electronic medical record for ease of tracking data, expand this process to all infusion locations, build time into the productivity model to support adequate staffing, and track incoming symptom management calls to determine if proactive callbacks result in fewer triage calls.

Sources: Patel A, Geiger D, Woerner S, et al. Managing chemotherapy-related side effects through telephone triage. Poster 82.
Moore P, Mullen M, Fenner K, et al. I’m calling to check on you: implementing chemotherapy call backs for new chemotherapy patients. Poster 55.

Which Nonpharmacologic Interventions for Fatigue Really Work?

Cancer-related fatigue is a common symptom among cancer survivors that affects them physically, socially, spiritually, and financially. Many survivors report using nontraditional treatments, some of which were evaluated in a systemic review by Noël Arring, DNP, RN, OCN, Manager for Nursing Research, Mayo Clinic, Scottsdale, AZ.

Dr Arring reviewed the literature from January 2005 to May 2015, focusing on cancer survivors and searching by these terms: fatigue, cancer fatigue, neoplasm, exercise, and complementary therapies. She found 162 articles, 25 of which met the inclusion criteria. The studies evaluated physical activity (n = 8); herbal medicines (n = 3); health education (n = 3); and procedure-based therapies (n = 11), including acupuncture, yoga, biofield therapy, and multimodal mind–body approaches.

Based on her review, Dr Arring reported the following conclusions:

  • Physical activity: 1 of 6 home-based walking studies showed significant decreases in cancer-related fatigue, 2 facility-based interventions showed significant improvements, and 1 that combined home- and facility-based interventions showed improvements. Water-based physical activity and combined individual- and group-based interventions had high adherence rates.
  • Herbal medicine: All products studied (ie, ginseng, intravenous PG2—an extract of the Astragalus root, Bojungikki-tang) were safe and effective; all the studies showed significantly decreased cancer-related fatigue “but results should be approached with caution.” Most studies had sample sizes <100, which limits the generalizability of the findings, and, to date, the positive studies have not been replicated.
  • Health education: 2 interventions were group and individual face-to-face education, and 1 was a tailored Internet-based intervention. Two of the 3 were effective. The Internet-based intervention had a significant effect on fatigue; however, the majority of patients eligible for this study declined to participate, “which raises questions about lack of interest or ability of cancer survivors to use web-based health education interventions.” The group-based intervention also had a significant impact, and enrolled 80% of eligible patients, showing high acceptance.
  • Procedure-based therapies: Of the 11 studies, 7 deemed their interventions to be effective, but 6 of the 7 evaluated only breast cancer survivors, which may limit their generalizability; 2 yoga studies showed no significant effect on cancer-related fatigue immediately after the intervention, but favorable effects at 3 months; the biofield intervention significantly improved fatigue versus the control group, but not compared with the mock intervention. Four acupuncture studies were positive, but 3 had very small sample sizes.

Dr Arring concluded that safety and low attrition rates were key strengths of the studies of nonpharmacologic interventions. Significant, positive outcomes were reported in 15 studies, including 4 for physical activity, 3 for herbal medicines, 2 for health education, and 7 for procedures.

“These are promising interventions for cancer-related fatigue for posttreatment cancer survivors,” and they should continue to be developed and tested, ideally in larger populations, but they should not be used for fatigue management “as stand-alone treatments,” she said.

Source: Arring N, et al. Non-pharmacological interventions for cancer-related fatigue in post-treatment cancer survivors. Poster 178.

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