W ith decreasing reimbursement and penalties for 30-day readmissions that particularly affect Medicare patients, healthcare systems worry that they will have to absorb unsustainable costs (Hansen, Young, Hinami, Leung, & Williams, 2011). In response, many hospitals are trying to identify low-cost solutions to minimize 30-day readmissions. The complexity of the discharge process coupled with patients’ stress about leaving the hospital as soon as possible causes a higher likelihood of readmission. Nurses, pharmacists, social workers, and other healthcare providers work to give patients all of the information they need before leaving the hospital. However, patients often remain underinformed, problems arise, and they are then readmitted. Readmissions have been linked to poor communication, failure to coordinate and reconcile medications, lack of postdischarge follow-up, and poor planning for care transitions (Berenson, Paulus, & Kalman, 2012; Harrison, Hara, Pope, Young, & Rula, 2011). With the current focus on preventing readmissions, healthcare providers are trying to identify strategies to support patients during the postdischarge period. Patients with cancer are particularly affected by readmissions because they require inpatient care more often than other patients and have complex needs (e.g., medication, symptom management). The complexity and diversity of care requirements create substantial challenges in planning for appropriate postdischarge support (Mistiaen & Poot, 2006). Implementing postdischarge telephone calls for patients with cancer could serve as a low-cost intervention to address their complex needs during the transition from hospital to home. Although telephone follow-up offers a low-cost strategy to reduce readmissions, the intervention involves many factors (e.g., number of calls, timing, call content). For the current article, the authors conducted a comprehensive review of literature to help understand what is known about follow-up telephone calls in patients with cancer discharged from hospital to home.

Cunningham, Regina S. PhD, RN, NEA-BC, FAANEditor(s): Burke, Kathleen PhD, RN-BC, CENP, FAAN Author Information

180 Background: A practice based clinical leadership team (PBCL) was created in the outpatient cancer center to identify, evaluate, and implement initiatives to improve safety, quality, and patient satisfaction. A quality leader facilitates the team which includes nursing, physician leaders, as well as subject matter experts from throughout the cancer service line. METHODS Key focus areas include data review/analysis, facilitating performance improvement teams to enhance patient satisfaction and patient safety; and to reduce variations in care. PBCL members participate in Performance Improvement in Action (PIIA) program that includes just-in-time process improvement training while completing projects in a 90-day period. The PIIA approach embeds quality/lean tools in the organization. The training provides structure, common terminology, and stresses the use of data to make decisions, relying on the voice of the customer and clear articulation of the problem statement before jumping to solutions. The methodology incorporates six sigma/lean tools and plan-do-check-act. RESULTS The PBCL structure has resulted in several specific improvement projects. The patient throughput project team implemented recommendations that increased the percentage of patients who arrived and completed lab tests before their scheduled appointment time by 36%. In addition, a simulation model was created which quantified a 28 minute reduction in total time in the department by increasing the number of patients seen independently by advanced practice providers and removing the room assignment constraint by assigning providers to a "pod of rooms" rather than a specified room(s). An infusion fast track program was implemented for selected medications to expedite patient throughput resulted in an 18 minute (52%) reduction of time in the department. CONCLUSIONS Incorporating clinical leadership in a structured framework for quality improvement increases the buy-in to change while maintaining an objective, data driven approach. The team approach and use of performance metrics provides the opportunity to expedite pilot project testing while raising awareness of key metrics to inform of additional opportunities.

152 Background: Administration of selected multiday chemotherapy regimens typically requires an inpatient stay at an academic quaternary care facility. A growing oncology population exceeding the capacity of oncology allocated beds led to occasional cancellation of patients scheduled for curative-intent treatment, necessitating a reevaluation of our processes. A multidisciplinary group formed to pilot a process by which certain regimens would be transitioned to the outpatient arena and others would be split, requiring only a portion of the regimen to be given inpatient. Methods: The utilization of a variety of quality improvement tools and processes determined the feasibility and safety of transitioning previously inpatient-based regimens to the outpatient setting and identified those regimens that were most appropriate to pilot. An evaluative ranking process identified high-dose cytarabine for treatment of acute myeloid leukemia and infusional cyclophosphamide for multiple myeloma as most appropriate to be home-based regimens. Phase II of the pilot involved developing a process for the administration of select rituximab-based regimens between the inpatient and outpatient setting, with tightly fitted communication to ensure seamless transitions in care. Patients receive rituximab in the ambulatory clinic and are then admitted to a reserved hospital bed for the remainder of the regimen. Results: Since pilot inception and abstract submission, 20 patients have either received their entire regimen as an outpatient or by using our split location process. Preliminary analyses reveal an increased bed capacity for acute patients and outside hospital referrals by preventing scheduled admissions and reducing overall length of stay for rituximab-based regimens. Survey responses from patients and families are overwhelmingly positive. Conclusions: Care delivery models must be continually evaluated to adapt to change in this dynamic health care era. Our pilot suggests beneficial outcomes for patients and health care systems alike. As an institution, we have seen the effects that integrated team communication and tighter care coordination have on patient care and outcomes.

82 Background: Members of the scheduling teams at the Abramson Cancer Center observed prolonged delays between chemotherapy and radiation therapy treatments scheduled by staff from 2 independent departments leading to inconvenience for patients receiving concurrent chemo- and radiation therapy (CRpts). Methods: An analysis of baseline data over 6 weeks revealed that for 157 unique consecutive patients undergoing daily chemotherapy and radiation (a total of 353 encounters), the mean time between scheduled treatments was 122 minutes. For 39% of encounters the wait time was greater than 120 minutes. To improve the adjacency of chemotherapy and radiation appointments and to consistently reduce wait time between treatments to less than 120 minutes, we formed a Chemotherapy/Radiation Scheduling Task Force consisting of patient service representatives, practice managers, and physician and nurse advisors. We determined that CRpts should be scheduled using a “huddle” strategy whereby prospectively identified CRpts are simultaneously scheduled for both treatments in a coordinated manner. Identifying CRpts for coordinated scheduling was facilitated by the creation of a chemo-radiation scheduling inbox to which clinicians and support staff e-mail names of new CRpts in order to alert the scheduling team. Our two lead schedulers meet 2-3 times per week to coordinate patient schedules. A weekly scorecard of the wait times for CRpts patients is distributed via e-mail to the clinicians and support staff. Results: Over the past 6 months, we have used the huddle method for 80% of 986 consecutive CRpt encounters. Our average wait time for huddle-scheduled encounters has been reduced to 62.5 minutes with only 9% of encounters having wait times over 120 minutes. For non-huddle-scheduled encounters, the average wait time is 129 minutes with 57% having wait times over 120 minutes. Conclusions: Utilization of a huddle scheduling method has successfully reduced wait time for CRpts. Use of the huddle method continues to grow with staff training and awareness of the new process.

The Endocrine Tumor Summit convened in December 2008 to address 6 statements prepared by panel members that reflect important questions in the treatment of acromegaly and carcinoid syndrome. Data pertinent to each of the statements were identified through review of pertinent literature by one of the 9-member panel, enabling a critical evaluation of the statements and the evidence supporting or refuting them. Three statements addressed the validity of serum growth hormone (GH) and insulin-like growth factor-I (IGF-I) concentrations as indicators or predictors of disease in acromegaly. Statements regarding the effects of preoperative somatostatin analog use on pituitary surgical outcomes, their effects on hormone and symptom control in carcinoid syndrome, and the efficacy of extended dosing intervals were reviewed. Panel opinions, based on the level of available scientific evidence, were polled. Finally, their views were compared with those of surveyed community-based endocrinologists and neurosurgeons.

Cancer survivors have cancer surveillance and preventive screening needs that require monitoring. Little is known regarding their patterns of care in community primary care practices.Secondary analysis of 750 baseline patient surveys and medical record audits for patients ages 50+ years in 25 community-based primary care practices (N = 109 survivors and 641 noncancer patients).Patient self-reported screening rates for breast cancer (72%), colorectal cancer (81%) and prostate cancer (77%) were higher for cancer survivors compared to noncancer patients (69%, 67%, 53%, respectively). Screening rates documented in the primary care records were lower for all cancers. Cancer survivors were more likely than others to report having been screened for colorectal cancer (P = 0.002) even after excluding colorectal cancer survivors from the analysis (P = 0.034). Male cancer survivors were more likely to report being screened for prostate cancer than those without cancer (P < 0.001), even after excluding prostate cancer survivors (P = 0.020). There were no significant differences in either self-reported or medical record report of breast cancer screening rates among cancer survivors and noncancer patients.Cancer survivors were more likely to self-report receipt of cancer screening than noncancer patients. Medical record reports of cancer screening were lower than self-reports for cancer survivors and noncancer patients. Identifying factors that affect cancer screening among cancer survivors is important and has implications for intervention design.

Anorexia is defined as an involuntary loss of appetite.Approximately 50% of newly diagnosed patients with cancer experience the symptom, which often is accompanied by weight loss and most typically associated with advanced disease.Anorexia significantly affects the clinical course of cancer; it can lead to the development or exacerbation of disease- or treatment-related symptoms, decreased functional status, and diminished quality of life.As part of the Oncology Nursing Society's Putting Evidence Into Practice initiative, a team of oncology nurses examined and evaluated published research literature for the purpose of developing an evidence-based practice resource focused on the management of cancer-related anorexia.Even though anorexia is common among newly diagnosed patients and those with advanced disease, interventions to prevent, treat, and manage the symptom are limited.The evidence revealed that only two pharmacologic interventions, corticosteroids and progestins, can be recommended for use in clinical practice, and dietary counseling was identified as likely to be effective.This article summarizes selected empirical literature on interventions used to prevent and manage anorexia in patients with cancer.Familiarity with the literature will assist oncology nurses in proactively identifying and effectively managing patients experiencing this distressing symptom.

Women living with and beyond breast cancer have special health care needs. Persistent physical and psychological symptoms such as fatigue, pain, sleep disturbances, and fear of recurrence as well as quality-of-life outcomes have been described in women during and after breast cancer. Much less information exists on the experience of women completing treatment. This study describes the information and support needs of women following breast cancer treatment. A semistructured interview guide designed by the research team was used to gather data. Major findings indicate that women continue to experience a variety of physical and psychological symptoms and have concrete information and support needs following therapy, including the need for information on persistent treatment effects, emotional distress, and lifestyle changes. Findings illustrate that there is need to provide comprehensive information and support to help women transition from breast cancer therapy. Additional research is needed to optimize approaches to providing posttreatment care.

Background: While cancer screening is generally increasing in the U.S., colorectal cancer (CRC) screening remains low. Most CRC screening interventions focus either on patients or individual clinicians without examining the office context in which CRC screening is implemented. This study examines whether primary care practices that involve staff in general forms of health education have higher CRC screening rates than practices that do not. Methods: Cross-sectional data from 22 New Jersey and Pennsylvania family medicine practices were analyzed. Data include chart audits for 795 men and women eligible for CRC screening (age 50–70) and practice information surveys for each practice. Generalized estimating equations were used to determine CRC screening correlates. Results: Overall, 31.3% (n = 249) of patients received CRC screening. Practices that reported using nursing or health educator staff to provide behavioral counseling to patients on topics such as diet, exercise or tobacco use were significantly more likely to also have higher CRC screening rates (z = 7.30, p < 0.0001). Their patients had 2.96 times increased odds of CRC screening than those in other practices (95% C.I., 2.21–3.96). Reminder system use was also associated with higher CRC screening (z = 4.96, p < 0.0001). In practices that used reminder systems, patients had 2.57 times increased odds of CRC screening than others (95% C.I., 1.77–3.74). Conclusions: These findings suggest that interventions to achieve better CRC screening rates do not need to focus solely on CRC. Higher CRC rates may be achieved by capitalizing on the enhancing contributions of non-physician practice members providing more general health behavior change patient education.

6547 Background: Although medication errors comprise 10–25% of all medical errors, little is known concerning the occurrence or types of medication errors occurring while treating patients on a clinical trial. Therefore, we retrospectively reviewed the medication errors reported in patients enrolled on clinical trials at our center. Methods: As part of a multidisciplinary continuous quality improvement project, from January 2003 through December 2006, we collected voluntary reports of medication errors in adult and pediatric patients on clinical trials involving both oral and intravenous chemotherapy. All reports were classified prospectively regarding clinical trial involvement, severity category (A to I) per the National Coordination Council on Medical Error Reporting and Prevention, type, cause, and where in the medication use process the error occurred. Results: There were 163 reports involving patients treated on clinical trials. The most common errors were those corrected prior to reaching the patient in 68% of events (Category A&B), while 31% reached the patient but did not result in harm (Category C&D), with 1% resulting in temporary patient harm (Category E&F). The most common type of errors were prescribing (66%), improper dose (42%), and omission errors (9%). Not following an institutional procedure or the protocol was the primary cause for these errors (39%), followed by the written order (30%), and poor communication involving both the healthcare team and the patient (26%). The processes where the errors initiated were in prescribing 47%, administration 10%, dispensing 6%, and monitoring 5%. Conclusion: Medication errors do occur in clinical trials, however the majority of these are corrected prior to reaching the patient or do not result in harm. Not following an institutional procedure or the protocol was the most common cause of error. This is most likely due to the protocol procedures differing from existing standards of care. Protocol-specific education through the Centralized Education and Training Service, a shared resource within our cancer center, addresses this issue enhancing the quality and safety of clinical trials through the education and training of healthcare professionals. No significant financial relationships to disclose.

Venous thromboembolism (VTE) is a common complication of malignant disease, affecting approximately 1 in 200 cancer patients. Oncology nurses are instrumental in identifying patients with cancer at high risk of venous thromboembolism. Risk factors include: stage of disease, chemotherapy, the patient’s degree of immobility, a history of recent surgery, and the presence of a central venous catheter. The treatment of venous thromboembolism in patients with cancer usually involves a sequential combination of unfractionated heparin or low-molecular-weight heparin (LMWH), followed by oral warfarin or LMWH. LMWHs are an alternative to warfarin for secondary prophylaxis and long-term treatment. LMWH is given by subcutaneous injection, does not require hospitalization for administration or routine laboratory monitoring. Recent clinical trial results have shown that LMWH use is associated with improved survival in cancer patients with relatively good prognoses. Patients receiving any anticoagulant therapy should be monitored for signs of pulmonary embolism or bleeding and intravenous sites (if present) should be monitored for oozing. Appropriate patient selection, a carefully constructed treatment plan, extensive patient education, and regular patient contact are integral elements for the nursing care of patients with cancer-associated thrombosis treated in the outpatient setting.