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2002 Congress Abstracts
151
PROMOTING BREAST HEALTH IN RURAL SOUTHEASTERN INDIANA. Adrianne Lane,
EdD, RN, C, Madeleine Martin, RN, BSN, MSN, EdD, Judith Uhler, RN, BSN,
MSN, Marie Linda Workman, RN, BSN, MSN, PhD, University of Cincinnati,
Cincinnati, OH.
Breast cancer is the second leading cause of cancer death in the U.S.
and over 192,000 women are estimated to be diagnosed with breast cancer
in 2001. Although breast cancer screening procedures have been shown to
decrease morbidity and mortality, rural and un/underinsured women are
not receiving these services at the same rate as other U.S. women. Four
nursing faculty were funded for a project designed to increase breast
cancer screening practices and the knowledge of breast cancer risk factors
for women in four medically underserved rural counties. The goal was to
implement a program to: 1) establish linkages among nurses and community
organizations, 2) increase access to mammography screening for community
women, 3) increase number of women knowledgeable about breast cancer screening
and cancer risk factors, and 4) increase resources available (personnel
and material) to provide ongoing programs. Phase 1: A training program,
focusing on breast health, was presented to nurses from each of four counties.
Phase 2: Project and county nurses joined to provide an education and
screening program for area women. This program involved making free mammograms
available through a mobile mammography unit which was brought to each
county. Mammograms and educational programs were provided to 141 women.
Data presented will include prior breast cancer screening practices, reasons
for attending the program, demographics, and other health screening programs
desired by the women. The four goals of the program were met. Several
advanced practice nursing roles were implemented in this program including
collaborator, resource for clinical nurses, and resource in obtaining
funding, as well as the practice functions of promotion of health and
wellness and patient education. This project can serve as a model strategy
in underserved populations. *Funded through the Office of Women’s
Health, Indiana Department of Health and Indiana Commission for Women.
152
EARLY LUNG CANCER DETECTION UTILIZING LOW-DOSE HELICAL CT. Bernadette
McGovern, RN, ANP, MSN, Carol Ann Milazzo, RN, FNP, MSN, Robert Heelan,
MD, Moshe Shike, MD, Helen Miller, CSW, and Carol Satchel, BA, Memorial
Sloan-Kettering Cancer Center, New York, NY.
This year more than 164,000 Americans will be diagnosed with lung cancer.
The overall five-year survival rate for these individuals is 14%. Five-year
survival for early stage lung cancer is 70%, however, only 20%–25%
of individuals are diagnosed at this early stage. Past screening programs,
which involved CXR or combination CXR/sputum cytology, did not demonstrate
decreased mortality as a result of screening. This cancer prevention and
wellness program at this NCI-designated cancer center has been utilizing
low dose helical CT to detect early lung cancer in high risk individuals
for the past year.
All clients schedule a consultation with a nurse practitioner. The NP
determines eligibility and appropriateness for screening, assesses cancer
risk factors, and makes appropriate referrals to smoking cessation as
necessary. A board certified radiologist interprets all low dose CTs that
day and conveys findings to the NP. The NP reviews results with each patient
and arranges all follow up. Patients with suspicious findings are referred
to the pulmonary service for additional evaluation and work up. Those
with low suspicion nodules are followed by the NPs and entered into a
specific database and recalled for follow up studies as needed.
In an effort to further demonstrate the effectiveness of CT screening
in the detection of early stage cancers, and ultimately decrease mortality
associated with lung cancer, we are participating in a cooperative study.
This effort is organized by a non-profit clinical research entity that
consists of 11 area institutions. At this institution, the NP will be
responsible for patient selection, obtaining informed consent, and following
all patients enrolled in the study.
In the course of this presentation we will share our preliminary findings,
review high-risk eligibility criteria, and our screening protocol. The
NPs role as part of a multidisciplinary team in program development, data
collection, and quality assurance will be discussed. The nursing experience
of participating in multicenter research and a variety of ancillary research
opportunities will be explored.
153
CONCERNS ABOUT INSURANCE, PRIVACY/CONFIDENTIALITY, AND RECOMMENDATIONS
REGARDING GENETIC TESTING FOR HEREDITARY BREAST CANCER IN WOMEN. Deborah
J. MacDonald, RN, MS, APNG(c), Jeanne Choi, MS, GC, Sarah McCaffrey, RN,
MS, Jaclyn Yu, summer research student, Li Cheng, RN, MS, PhD, and Jeffrey
Weitzel, MD, City of Hope Comprehensive Cancer Center, Duarte, CA.
Women presenting for genetic cancer risk assessment (GCRA) may have concerns
about insurance discrimination, privacy, and confidentiality related to
genetic testing (GT) for hereditary breast/ovarian cancer. These concerns
may change following the GCRA process, and may differ between affected
and unaffected women. In addition, the estimated probability of a woman
carrying a BRCA1 or BRCA2 cancer-associated gene mutation may influence
her decision regarding whether or not to undergo testing. We are measuring
the impact of GCRA, through the City of Hope Cancer Screening & Prevention
Program Network, on women’s concerns, risk perception, and management
choices. Questionnaires are mailed pre- and post-GCRA to women who had
a personal (affected cohort) and/or family history of breast cancer (unaffected
cohort). Women were asked to report on a four-point Likert scale (1 =
least important; 4 = very important) their level of concern about insurance
discrimination, privacy, confidentiality, and mutation probability in
deciding whether or not to undergo GT. Here, we present preliminary data
for women who did not undergo GT, who responded both to the baseline and
the one-month post-GCRA survey. The mean age of the affected cohort (n
= 12) was 55 (range 42–67). The mean age of the unaffected cohort
(n = 12) was 46 (range 31–64). Overall, prior to GCRA 63% of responders
(n = 24) felt that insurance discrimination was an important reason for
not getting tested. Following GCRA, only 33% of responders (n = 21) felt
the same, (p = 0.05). When assessed for affected (n = 12) versus unaffected
status (n = 11), this change was also significant for the unaffected women,
(p = <0.05). Overall, there were fewer concerns about privacy/confidentiality
after GCRA for both cohorts, (p = 0.046), although there was no significant
difference between the two groups. Regarding mutation probability, 91%
felt that clinician “recommendation” for GT was important
in deciding to have testing pre-GCRA and 85% post-GCRA. Although the sample
size is small, these preliminary findings suggest that the GCRA process
addresses concerns women have regarding discrimination and confidentiality,
and influences the decision to pursue GT. Nurses can assist women by providing
current and accurate information about these concerns.
154
CHALLENGING MEDICAL CENTER EMPLOYEES TO SELF SCREEN. Jan Scott, RN, BSN,
OCN®, and Lisa Hodges, RN, BSN, OCN®, Comprehensive Cancer Center
of Wake Forest University Medical School, Winston-Salem, NC.
Colorectal cancer is the third most common cancer and accounts for approximately
56,000 cancer deaths in the United States each year. Studies have shown
that prevention and early detection can reduce the number of deaths from
colorectal cancer.
Through a grant provided by Colorectal Cancer Education Program ONS/ONS
Foundation Center for Leadership Information and Research, two oncology
nurses formed a multidisciplinary team consisting of nurses, dieticians,
physicians, and physical therapists to plan and provide a colorectal cancer
health fair for employees of the Wake Forest University Baptist Medical
Center (WFUBM). The objective of the project was to provide information
on prevention and screening along with a free fecal occult blood test
(FOBT). The medical center employs over 10,000 individuals with very diverse
financial, educational, and racial backgrounds. The project’s information
was made available to all three working shifts in the medical center.
The goal was to reach everyone from housekeeping to lab technicians to
medical staff on the main medical center campus. This was accomplished
by setting up the fair in a high-traffic area that captured employees
as they entered or left the medical center. The project was posted on
the medical center’s intranet and newsletter as well as on flyers.
Over 600 employees participated in the health fair project. Of those,
217 responded to a follow up survey. The results showed that 69% perceived
the information as being important to them, 77% reported that the information
was presented in an easy-to- understand method, 62% used the FOBT screening
tool. Of those using the tool, 100% reported it was easy to use. Nine
employees reported positive results, five of those stated they followed
up with their physician. At the time of the survey, 39% stated that they
had not used the screening tool, commented that they plan to use it in
the near future. 100% of participants stated that they would like to see
that more programs like this offered to employees in the future.
The health fair was well received and could lead to future multidisciplinary
collaborations that would be offered beyond the main campus.
155
SUN DAYS CAN BE FUN AND LEARNING DAYS. Barbara L. Lineham, RN, MSN, Thomas
Jefferson University Hospital, Philadelphia, PA.
The oncology population and the community need to increase awareness
related to prevention of skin damage and skin cancers. There are a variety
of programs that can be implemented to not only increase awareness, but
also to make learning fun. This may lead to increased focus on the issue
and increase compliance with the teaching. Thomas Jefferson nurses decided
to decorate the oncology unit to reflect the sun and summer. The nurses
station was decorated in a tiki bar motif with tiki glasses and trays
and grass skirting surrounding the area. The nursing tables were decorated
with beach towels, sand buckets, and sun lotion. The unit hung sun balloons
that had smile faces and sun glasses. Educational “suns” were
placed on the walls by each patients room, giving sun protection tips.
These tips were able to be read by all hospital staff coming to the unit,
patients, and families. This increased our ability to educate a large
group of people. The unit was decorated for a full month and educational
information was distributed to all patients. Patients were also instructed
upon discharge regarding sun protection. The unit staff participated in
in-services to assure everyone was up to date and consistent in the information
provided. On two of the “sun days” the staff wore bright clothes
and hats. Sun lotions with differing SPF values were displayed.
Nurses also went to community schools and discussed skin and sun protection
with elementary school students.
This program is productive and well received by the community and hospital.
Skin cancer awareness is a growing concern. By educating our patients
and the community, many people may be spared from skin cancer. “Sun
days” encouraged staff and patient and community learning regarding
this important issue.
156
INITIATING A COMPREHENSIVE COLORECTAL CANCER AWARENESS PROGRAM IN CENTRAL
VIRGINIA. Kathleen C. Bohorfoush, RN, MSN, OCN®, David C. Cattell-Gordon,
LCSW, Diane D. Cole, MPH, and Allison Vonn-Love, RN, BSN, OCN®, University
of Virginia Health System, Charlottesville, VA.
Mortality rates for colorectal cancer (CRCA) in the United States have
declined over the past decade but have held steady in Virginia. Sixty-one
percent of cases in Virginia are stage III or IV at diagnosis. Promotion
of early CRCA detection in Virginia is therefore critical, as it greatly
enhances survival. State legislation in 1999, a Congressional proclamation
in 2000, and the Virginia Cancer Plan 2000 mandated improved CRCA awareness,
knowledge of early detection guidelines, and access to screening, referral,
and timely follow-up. In November 2000 the ONS/ONS Foundation offered
the program “Can We Talk?” to oncology nurses to promote dissemination
of current information on CRCA. With these resources and mandates in place,
a comprehensive CRCA awareness program was initiated in March 2001 at
the University of Virginia Health System (UVAHS) as a collaborative effort
between the Cancer Center and the Digestive Health Center, targeting the
public and healthcare professionals (HCPs) in Central Virginia. The planning
committee included advanced practice nurses, the cancer education coordinator,
the webmaster, the directors of community affairs and marketing, and an
American Cancer Society representative. Prior awareness programs, institutional
goals for community outreach, and the Virginia Cancer Plan were reviewed.
Funding was provided by the UVAHS and a grant from the Oncology Nursing
Society. In this year’s program public awareness was promoted through
regional print and broadcast media, educational displays, a user-friendly
website, and community lectures by physicians with expertise in cancer,
genetics, and nutrition. Flexible sigmoidoscopy was offered free of charge
to university employees. A nursing education program and journal club
presentation, a letter to regional primary care physicians, and case presentations
at regional interactive teleconferences promoted HCP awareness. Thirty-eight
employees underwent screening; no cancers were detected, however five
employees were referred for colonoscopy because of suspicious findings.
Over 5,000 HCPs and 85,000 citizens were reached with awareness month
activities. Future goals include more thorough evaluation of outcomes
of our outreach efforts, programs for special populations, and addition
of a segment on CRCA in our Cancer Risk Reduction course.
157
BREAST HEALTH AND CANCER SCREENING: A PROGRAM TO EDUCATE AND SCREEN GIRL
SCOUTS AND FEMALE FAMILY MEMBERS AND FRIENDS. Jenenne P. Nelson, PhD,
CNS, RN, Barbara Joyce-Nagata, PhD, RN, and Chamber Jewell, PhD, RN, University
of Colorado at Colorado Springs, Colorado Springs, CO; Anne Zobec, MS,
AOCN®, NP, Cancer Center of Colorado Springs, Colorado Springs, CO;
and Debi Krause-Reinsch, MA, Girl Scouts-Wagon Wheel Council, Colorado
Springs, CO.
Education and screening continue to play a key role in altering breast
cancer morbidity and mortality statistics since the disease remains incurable.
This program was developed collaboratively with Beth-El College of Nursing
of the University of Colorado at Colorado Springs, the Girl Scouts Wagon
Wheel Council, and the Penrose Hospital System. The program provides information
to Girl Scouts and their mothers about breast health and breast self examinations.
The theoretical framework used in this program focused on the interrelationship
between knowledge, empowerment, and family and social relationships, integral
components that support wellness. The program provided knowledge and hands-on
breast self-examinations (BSE) practice. The sample was recruited by inviting
Girl Scouts to attend the program with their mothers and adult females.
Approximately 150 Girl Scouts and their mothers and friends attended the
three-hour program.
Girl Scouts and the adult women practiced BSE techniques and a toured
a mammography suite. The adult females were offered free clinical breast
examination. Multiple evaluation methods were used in this program. First,
participants were asked to evaluate the program upon completion.
Additionally, an 18-month follow-up survey is planned on the effectiveness
of the educational offering as measured by adherence to American Cancer
Society screening age appropriate guidelines. The program significance
rests in the notion that education within a family/social network facilitates
wellness if the individuals are empowered with knowledge. Teaching Girl
Scouts breast health may influence breast cancer detection and screening
techniques not only in the Girl Scouts but also their mothers and adult
females. This model program may help educate young women about early breast
cancer detection as well as offer adult women information about their
breast cancer risks and techniques to identify potential breast problems.
This program was funded by the Colorado Springs Affiliate of the Susan
G. Komen Foundation.
158
PSYCHOLOGICAL, BEHAVIORAL, AND PHYSICAL OUTCOMES FOLLOWING RESULTS OF
BENIGN ENDOSCOPIC SCREENING FOR COLORECTAL CANCER. Janet S. Carpenter,
PhD, RN, Wei Zheng, MD, PhD, Reid Ness, MD, MPH, Walter Smalley, MD, MPH,
William Grady, MD, PhD, and Kaye Washington, MD, Vanderbilt University,
Nashville, TN.
Topic/Problem: Recent research suggests cancer screening may be associated
with significant negative psychological, behavioral, and/or physical outcomes
even when no malignancy is detected. However, research to date has not
evaluated outcomes associated with completion of colonoscopy or sigmoidoscopy
for colorectal cancer screening. Thus, knowledge that is crucial for subsequent
design and implementation of interventions to alleviate adverse outcomes
of endoscopic screening is lacking.
Purposes: Study purposes are to examine the feasibility of collecting
data from patients who have recently completed colonoscopy and/or sigmoidoscopy
as screening for colorectal cancer and identify acute psychological, physical,
and behavioral outcomes of screening.
Framework: This study is based on work by Andrykowski which suggests patients
who experience psychological distress following receipt of a benign cancer
screening test result are less likely to adhere to follow-up screening
recommendations.
Methods: Patients meeting inclusion criteria are contacted by telephone
two weeks following completion of screening and asked for their willingness
to complete a 30 minute telephone interview. Consenting patients are asked
questions about demographics, cancer-related and general psychological
distress (Lerman questionnaire, Centers for Epidemiologic Studies Depression
scale, Profile of Mood States - Short Form, and Positive and Negative
Affect Scale), the presence and severity of physical symptoms (Symptom
Experience Report), and intentions to adhere to follow-up recommendations
(investigator designed behavioral questionnaire). With the exception of
the behavioral questionnaire, all measures have demonstrated reliability
and validity.
Data Analysis: Demographic data will be analyzed using frequencies and
descriptive statistics. Comparisons using t-tests, chi-square, and/or
ANOVA will be used to evaluate differential responses between those receiving
“normal and benign” results (e.g., no pathological findings)
and those receiving an “abnormal but benign” result (e.g.,
benign pathology). We hypothesize that those receiving abnormal benign
results will experience more psychological and physical distress and be
less likely to report intentions to adhere to follow-up screening.
Implications: Results from this in-progress pilot study will demonstrate
the feasibility of data collection and identify acute adverse psychological,
physical, and behavioral outcomes associated with endoscopic screening.
Funded by the Vanderbilt-Ingram Comprehensive Cancer Center as one of
four projects submitted as a package application.
159
A PILOT INTERVENTION STUDY TO INCREASE ADHERENCE WITH SKIN SELF-EXAMINATION
(SSE) IN PATIENTS AT HIGH RISK FOR MELANOMA. Deborah L. Phelan, RN, Susan
Oliveria, ScD, Paul Christos, MPH, MS, Stephen Dusza, MPH, Jamie Ostroff,
PhD, and Allan Halpern, MD, Memorial Sloan-Kettering Cancer Center, New
York, NY.
Patients with multiple nevi are at greater risk for melanoma and must
perform SSE on a monthly basis to detect changes. At this NCI-designated
cancer center, the standard of practice has been to use a patient education
brochure teaching high-risk patients mole mapping, a procedure of recording
moles by drawing them. DermaGraphix, a computerized camera system, currently
offers patients a new way of performing a monthly SSE.
Purpose: To determine if the addition of a photo book containing the patient’s
own set of images would increase patient’s knowledge and compliance
in SSE performance. Every patient was photographed during an initial one-hour
photographic session.
Method: Projected sample size is 100 patients. All participants had baseline
whole-body photography and agreed to random selection into one of two
groups. Group A—nurse instruction with photo book, Group B—instruction
with standard brochure. Nurse instruction included video, relaxation techniques,
and instruction on how, when, and where to perform SSE.
Tool/Instrument: An experimental design was employed. A self-administered
47-item questionnaire was administered at three time points: baseline,
post intervention, and a four-month follow-up. Questionnaires included
demographics, SSE practices, skin cancer knowledge, and personal and family
history of cancer.
Data Analysis: McNemars test for paired comparisons, z-test for proportions,
and descriptive frequencies were utilized to characterize data. An increase
in mean knowledge score resulted post delivery of both interventions compared
with baseline scores. The median grade for both groups (86.3 versus 94.9,
p = 0.001) 86.3%, at baseline increased to 94.9% post intervention (p
= 0.001).
Findings and Implications: The goal was to demonstrate a significant difference
in the level of compliance in performing SSE in those receiving a photo
book as compared to those who did not. Group A demonstrated a higher percentage
in knowledge and confidence. Benefits of the photo book in this population
will be demonstrated. This new technology offers opportunities and rewards
for the oncology nurse working in dermatology. Orem’s Self-Care
Model guided this research initiative focusing on her supportive-educative
system. This presentation will present study results, questionnaires,
photo book, and brochures describing benefits using this photo system
increasing compliance with SSE.
160
MEETING JCAHO STANDARDS IN THE OUTPATIENT SETTING. Teresa Lotito, RN,
OCN®, and Judith O’Donnell, RN, OCN®, St. Joseph Medical
Center, Towson, MD.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
is now recognizing the diverse needs of individuals with chronic diseases
and that the care of such patients can cross multiple systems and involve
numerous caregivers. Many of the new therapies for the treatment of cancer
may continue for 12 months or more. This prolonged treatment phase and
involvement of multiple caregivers can lead to repeated review by the
patient of basic physical and psychosocial information that they feel
should already be a part of their medical record. This practice can lead
to fragmentation of services and confusion and frustration for the patient,
family, and staff. In order to prepare for the JCAHO shift of focus to
the outpatient setting and to improve patient satisfaction, we have developed
a documentation tool that provides a systematic method to track patient
progress through the cancer continuum of care and facilitate communication
among providers. Components of the Plan of Care tool include a brief history,
space for multiple treatment regimes, treatment goals, flowsheets for
medications and lab work, educational needs, psychosocial and spiritual
needs, referrals to supportive services, and notes for significant interventions
(CT scans, biopsies, etc). The tool is designed to cover a six-month period
depending on the frequency of patient visits. The conceptual framework
for this project is information developed by the National Chronic Care
Consortium, 1995; Integrating Care for People with Chronic Conditions.
The consortium recommends that providers work together as a team to address
the multidimensional, interdependent, and ongoing problems of people with
serious and persistent chronic conditions. Consistent documentation on
the Plan of Care tool has resulted in improved identification of specific
needs and goals for each patient, development of a standardized method
of response to each issue, and a method to track changes over time. In
addition, the tool is used to guide weekly patient care rounds allowing
staff to share information, facilitate important referrals to supportive
services, and target discussion to areas of concern.
161
ANNUAL SCREENING URINALYSIS FOR HEMATURIA IN GYNECOLOGICAL PATIENTS OVER
AGE 40: EFFICIENT OR NOT? Joanne Kilduff, RN, BS, Beth Ostrowski, BSN,
RN, Carmen Rodriguez, BSN, RN, and Elizabeth Stier, MD, Memorial Sloan-Kettering
Cancer Center, New York, NY.
Annual gynecological office visits commonly include routine urinalysis
(u/a). We questioned the significance of this routine screening test and
conducted a study at our NCI-designated comprehensive cancer center.
Objective: To assess the efficacy of performing annual screening u/a to
detect microhematuria in the non-symptomatic gynecologic cancer patient
or the high-risk-for-cancer patient.
Design: Women age 40 years and above presenting for annual gynecologic
examination were screened by u/a prior to the pelvic exam. Patients identified
with microhematuria were first assessed with a urine culture, and if negative,
were referred to urology for an evaluation that included cystoscopy and/or
radiographic studies such as CAT scans and renal ultrasounds.
Results: Seven hundred and twenty nine (N = 729) asymptomatic patients,
mean age 59 (range 40–90), were screened by u/a. Fifty five patients
(7.6%) tested positive for microhematuria. Of these patients, seven had
positive urine cultures and were treated successfully with antibiotics;
five patients were currently menstruating, and repeat u/a were negative,
and seven patients were lost to follow-up. Thirty-six had negative urine
cultures and were referred for urologic evaluation. Of these patients,
four had repeat negative u/a and refused further workup. Seven were lost
to follow-up, and one was currently on chemotherapy and deferred follow-up.
Urology evaluation was completed on 24 patients. Of these, 16 had unremarkable
findings. Four had radiation or Cytoxan induced cystitis. Two had asymptomatic
nephrolithiasis, one had a benign bladder polyp, and one had a persistent
infection with accompanying hydronephrosis.
Conclusion/Nursing Implications: Microhematuria found on routine u/a at
annual gynecological examinations in women over 40 years yields little
clinically significant diagnoses. This data indicates this test is unnecessary
in the asymptomatic patient. Furthermore, it adds to patient cost and
anxiety when referral is suggested. Oncology nurses in this setting now
screen all patients for urinary symptoms and identify when it is appropriate
to collect urine specimens at routine exams. This data leading to a change
in nursing practice is valuable for all oncology nurses and should be
considered in other patient care settings as well.
162
“SHOW ME THE EVIDENCE”: USING AN EVIDENCE-BASED PRACTICE MODEL
TO DEVELOP AN ONCOLOGY ORAL CARE CLINICAL PRACTICE GUIDELINE (CPG). Carrie
Tompkins Stricker, MSN, CRNP, AOCN®, University of Pennsylvania Cancer
Center, Philadelphia, PA; Jacqueline Sullivan, PhD, RN, University of
Pennsylvania Health System, Philadelphia, PA; and Janice Foust, PhD, RN,
University of New Hampshire School of Nursing, Durham, NH.
Integrating contemporary evidence into nursing practice is an ongoing
challenge which our health system’s Nursing Research Committee has
begun to address by designing and promoting an “Evidence Based Practice
(EBP) Framework.” The model’s first two steps involve identifying
a clinical problem and determining it as a priority for practice change.
At our institution, the Products Committee’s re-examination of oral
care products prompted the review of nurses’ oral care practices.
Consultation with the Practice Committee revealed that no institutional
guideline existed, and a subsequent staff survey identified that tradition,
patient preference, and physician orders predominantly guided nurses’
oral care practices, with the exception of existing standards in head
and neck surgery and allogeneic bone marrow transplant. Therefore, the
creation of a health system-wide Oral Care Clinical Practice Guideline
(CPG) was identified as a priority. Oncology recommendations were prioritized
due to a high incidence of oral alterations and product usage within the
hematology/oncology division.
The next phase in the EBP framework involves gathering and evaluating
evidence. Using the model’s suggested resources, existing guidelines
and literature related to oncology oral care were compiled and then evaluated
for strength using model criteria such as evidence of peer review. Pertinent
findings from over one hundred research and scholarly articles, one national
consensus statement, and two published institutional standards were synthesized
and then revised with the guidance of a doctorally-prepared international
nursing expert. General oncology recommendations were presented to the
Products and Practice Committees, and have been integrated into product
purchasing decisions and the Oral Care CPG for the health system.
We will next utilize the “Changing Practice” steps of the
EBP framework to refine, implement, and evaluate a comprehensive clinical
practice guideline specific to hematology/oncology. A nurse-coordinated
focus group will ensure interdisciplinary revision and approval. Nursing
staff will be educated about the new CPG. Through collaboration with the
Nursing Research Committee, a quasi-experimental pre-test/post-test design
will be used to measure statistically and clinically significant changes
in nursing knowledge and patient outcomes related to the implementation
of this evidence-based CPG. This project offers an excellent example of
a systematic, nursing-led approach to evidence based oncology care.
163
PREVENTION OF VESICANT CHEMOTHERAPY EXTRAVASATION. Lee Lay Hoon, RN, ONC,
BHSc (Nursing), National University Hospital, Singapore, and Emily Ang,
RN, INCC, ONC, BN, MN.
Purpose: Extravasation is defined as the infiltration or leakage of
a vesicant chemotherapy into local tissues. It has been well documented
that patients receiving vesicant chemotherapy are at high risk of extravasation.
To minimize the occurrence of vesicant extravasation, a check list has
been developed and all RNs were instructed to follow through the protocol.
Design: A descriptive, cross sectional design was used.
Setting: This study was conducted in the ambulatory chemotherapy cancer
institute of a 900-bed university hospital. A total of 12,000 patients
visit the center yearly for treatment.
Methodology: 1. A briefing on “prevention of vesicant chemotherapy
extravasation” polices and criteria to be audited were conducted
to all RNS. 2. A copy of quality indicator and audit standards were made
available at the nurses’ station for nurses to read and use as a
reference. 3. A cross-audit was conducted within the unit. 4. A random
sample of two to three audits per week, making a total of ten per month,
was carried out. The protocol for “prevention of vesicant chemotherapy
extravasation” for “at risk” patients and process for
audit workflow was followed through for auditing. 5. Data was collated,
analyzed, and reported by the unit based quality improvement representative
at the end of the audit period through a summary report. 6. The results
of the audit were communicated to nursing officers and staff. An action
plan for identified deficiencies was initiated by the nursing officer.
7. A summary report together with quality indicator and audit tool were
submitted to the nursing quality improvement committee chairperson, assistant
director (oncology nursing), and quality improvement coordinator.
Results: The data will be collated and presented on the poster. A copy
of the checklist, audit criteria, and summary report will be presented
on the poster.
164
PICC PROGRAM DEVELOPMENT: BEGIN WITHIN. Josephine Visser, RN, BSN, OCN®,
Lori Potter, RN, OCN®, Vicki Dugger, RN, OCN®, Linda Heckel, RN,
OCN®, and Sheila Ferrall, RN, MS, AOCN®, H. Lee Moffitt Cancer
Center & Research Institute, Tampa, FL.
Securing adequate patient vascular access is a challenge faced by many
oncology nurses. Patients have poor vasculature for a variety of reasons,
often compounded by their disease process and treatment. Peripherally
inserted central catheters (PICCs) have grown in popularity over the past
decade as one means to address vascular access in the oncology patient
population. PICCs offer several advantages over other long-term central
lines including lower costs and fewer complications associated with insertion.
Additionally, PICCs can be inserted by specially educated nurses and placed
at the bedside or in an outpatient setting.
The purpose of this project is to describe the development and implementation
of a PICC program, initially without additional FTEs, at our 162-bed,
NCI comprehensive cancer center.
The need for alternative methods of long-term vascular access prompted
nursing leadership to investigate development and implementation of a
PICC program. A consultant was hired to present an educational program
to a group of nurses representing all areas of the hospital. From that
group, two of the most experienced infusion nurses were identified to
proceed through the credentialing process with the consultant. A team,
which initially included a nursing director, clinical nurse specialist,
and the two credentialed PICC nurses met regularly to develop policies,
select inventory, create order and charge pathways, and implement a competency
program. Perhaps their biggest challenge was determining how to schedule
PICC placements throughout the week that would not interfere with the
PICC nurses’ primary roles in the outpatient infusion center.
Since its inception, the PICC program has grown to four credentialed PICC
nurses. Services are offered five days a week to both inpatients and outpatients.
The PICC nurses continue their primary roles in the infusion center and
integrate PICC placements into the work day. However, a 0.5 dedicated
FTE has recently been approved for the program. Future challenges include
focusing on our quality improvement program and enhanced marketing of
the service.
Implementation of a PICC program such as this does not necessarily require
immediate addition of staff. In today’s healthcare economy, a conservative
approach offering a limited service initially, may yield the most favorable
results.
165
DEVELOPMENT OF A MULTIDISCIPLINARY CLINIC FOR PATIENTS AFTER ALLOGENEIC
BLOOD AND MARROW TRANSPLANTATION. Joyce Neumann, RN, MS, AOCN®, and
Daniel Couriel, MD, University of Texas M.D. Anderson Cancer Center, Houston,
TX.
The incidence of graft versus host disease (GVHD) in the post allogeneic
(allo) blood and marrow transplantation (BMT) patients can approach 70%
depending on the degree of disparity. While the incidence of chronic GVHD
is less when compared to acute GVHD, the complications can be equally
as serious and potentially life threatening. Patient quality of life is
often profoundly impaired and there may be a wide variation in management
practices. At our comprehensive cancer center over 600 transplantations
were performed last year and approximately 60% were allo or matched unrelated
donor for patients with a variety of malignancies. We have approximately
13 BMT physicians and 20 midlevel providers (APNs, PA, and PharmDs). The
patient care in the pre-BMT and post-BMT first 100 days has been standardized.
After the first three months, follow-up varies and data collection and
patient outcomes were not consistently analyzed. In trying to explore
new treatment options for GVHD patients were frequently missed or not
included in potentially beneficial studies.
After identification of interested healthcare practitioners from other
disciplines, the group met and developed guidelines for the clinic. Representation
was obtained from medicine, nursing, pharmacy, physical therapy, social
work, and psychiatry. By having a designated contact person in other departments,
referrals were made in a much more timely manner. The clinic initially
received referral from the BMT physician group, but soon obtained them
from research nurses, APNs, and even other patients. An extensive GVHD
assessment was developed and performed that included a quality-of-life
assessment using the FACT-BMT and the MDASI (M.D. Anderson Assessment
of Symptom Inventory). This poster will include data concerning incidence,
severity and type of GVHD (limited or extensive), symptom management,
and quality-of-life information. A pathway for the treatment of chronic
GVHD has been developed as a tool to decrease variation in practice at
the cancer center and to educate the community healthcare practitioner
concerning the care requirements for these frequently complex patients.
166
EMPOWERING YOUR COLLEAGUES: MANAGEMENT OF NEUTROPENIA MODEL (MONM). Janet
M. Greco, RN, BSN, MA, OCN®, and Catherine Waters, RN, BSN, OCN®,
White Plains Hospital Center, White Plains, NY.
Neutropenia in oncology patients receiving myelosuppressive chemotherapy
can lead to life-threatening infection. It has been estimated that more
than 60% of patients with neutropenia will become infected, and in cancer
patients with fever, 80% have that fever because of infection. Oncology
nurses can empower their colleagues with a management of neutropenia model
(MONM) to help minimize this side effect of chemotherapy to improve patient
outcomes.
At White Plains Hospital Center, a community based hospital in New York,
a senior oncology staff nurse led an interdisciplinary febrile neutropenic
clinical pathway team consisting of oncology nurses, nursing administration,
a nutritionist, infectious disease physicians, and medical oncologists.
After completing a retrospective chart review of admissions with neutropenic
fever and a review of the literature, this committee developed a MONM
that consisted of a febrile neutropenic clinical pathway, standardized
orders, a patient/family education teaching tool, and an oncology nursing
peer education program (ON-PEP).
Utilizing Amgen’s “Neutropenia A to Z” program as a
foundation, this committee developed and delivered a one-day ON-PEP to
all nursing staff at this hospital and their local affiliates. The overall
purpose of this program was to educate nurses on the importance of preventing
a neutropenic infection, early identification of patients at risk, and
effectively communicating their findings with their physician colleagues.
In addition, the ON-PEP provided the theoretical framework for the staff
to effectively implement the MONM.
This process has provided nurses with the assessment and communication
skills to proactively manage their oncology patients who are at high risk
for neutropenia.
This poster presentation will present and describe this program, the febrile
neutropenic clinical pathway, the standardized physicians orders, and
the patient/family education teaching tools developed.
167
CANCER TREATMENT AND SEXUALITY: THE UN(AD)DRESSED SUBJECT. Sacha Simmons,
BSN, RN, and Aiko Kodiara, RN, MS, OCN®, Johns Hopkins Hospital, Baltimore,
MD.
Sexual expression in cancer patients can lead to mental and physical well
being and improved quality of life. Aggressive chemotherapy for patients
with hematological malignancies can have a profound impact on their sexuality.
Despite this, the healthcare team rarely discusses the impact of cancer
and its treatment on patient sexual well being. Nurses at our NCI-designated
comprehensive cancer center recognized that this lack of knowledge limited
patient abilities to make informed and safe decisions about their sexual
activities. However, they expressed concerns about their own lack of knowledge
and confidence in the area of sexuality. Because patients are often overwhelmed
with a life-threatening diagnosis, nurses may not perceive sexuality as
a priority. Without a guideline, patients may receive inadequate information
from healthcare providers. The use of a standard guideline increases nurse
confidence and improves quality and consistency of teaching patients about
the effects of treatment on their sexuality. This is a three-phased program:
Investigation, intervention, and re-assessment. In the investigation phase,
questionnaires completed by patients and nurses assess current practices
regarding patient teaching about sexuality. This information will assist
nurses in developing standard teaching guidelines. The intervention phase
consists of three staff education sessions. The first session teaches
how to initiate a discussion about sexuality and perform a sexuality assessment.
The second session teaches nurses to identify specific treatment that
may directly or indirectly affect patient sexuality. The third session
focuses on safety and modifications of sexual activities that are necessary
to prevent complications such as infection or bleeding. In order to maintain
consistency in teaching sexuality, these guidelines will be shared with
other members of the healthcare team. The re-assessment phase will be
conducted one month after the completion of the teaching sessions. The
questionnaire, again completed by patients and nurses, will be used to
evaluate the effectiveness of intervention. The development, implementation,
and evaluation of this program will be presented including the questionnaire
and content of the teaching session.
168
CLINICAL GUIDELINES FOR USE OF ERYTHROPOIETIN IN CANCER PATIENTS: A NURSING
PERSPECTIVE ON BARRIERS AND BENEFITS. Susan D. Ross, MD, FRCPC, MetaWorks
Inc., Medford, MA; Eva Gallagher, RN, Minneapolis VA Medical Center, Minneapolis,
MN; Denise K. Oseguera, RN, MSN, FNP, CS, University of California, Los
Angeles, Los Angeles, CA; Edie Romvari, RN, MSN, CS, FNP, Washington University
Medical Center, St. Louis, MO; Kendell Brinkmann, RN, C, OCN®, Intermountain
Hematology-Oncology Associates, Salt Lake City, UT; and Diana Frame, MEM,
MetaWorks Inc., Medford, MA.
Objective: Our objective is to promote nursing implementation of a guideline
for anemia treatment in cancer patients. Outpatient oncology practice
is heavily dependent upon nurses as both patient advocates and front-line
care providers. Success of guidelines in this setting depends on identifying
and addressing issues unique to nurses.
Method: A panel of four oncology nurses from disparate practice settings
convened to review an evidence-based guideline for the treatment of chemotherapy-related
anemia. The guideline focused on the use of erythropoietin (EPO), was
developed by a multidisciplinary panel, and was based on a systematic
review of the literature through August 2000. Aspects of guideline implementation
of concern to oncology nurses were discussed.
Results: The panel listed barriers to and benefits of implementation of
the guideline in oncology nursing settings. The barriers were: 1) variable
reimbursement rules, especially regarding location of anemia treatment
administration (office versus hospital), and excessive time required by
nurses to pre-certify payment for EPO; 2) patient inconvenience and drain
on productivity to adhere to guideline regarding frequency of injections;
3) variable physician attitudes toward recognizing and treating symptoms
of anemia, and toward “soft” measures of efficacy such as
cognitive function and quality of life; 4) institutional failure to assess
all costs associated with anemia; and 5) regional differences in practice
patterns and infrastructure.
The benefits were: 1) improved patient care—reduction in error,
variation, and inappropriate care with enhanced continuity of care; 2)
support of CQI activities; 3) medicolegal protection; 4) control of transfusion-associated
costs (direct and indirect); 5) support of patient advocacy efforts; 6)
improved work flow; 7) educational value regarding anemia and proper EPO
dosing; 8) improved adherence to chemotherapy schedules; 9) identification
of evidence gaps susceptible to new research; and 10) improved assessment
of etiology of anemia.
Conclusion: The successful implementation of guidelines for anemia treatment
will depend on reinforcing the many ways the guideline can benefit both
patients and nurses and recognizing and removing the barriers. The knowledgeable
support of nurses, in addition to scientific advances such as the development
of a new generation of erythroiesis stimulating proteins to overcome dosing
inconvenience barriers, may facilitate guideline acceptance.
169
USING EVIDENCE TO IMPLEMENT A COLLABORATIVE NEUTROPENIA MANAGEMENT PROTOCOL
FOR IMPROVING CHEMOTHERAPY DELIVERY. Jennifer L. Michelson, RN, BSN, University
of Rochester, Highland Division, Rochester, NY; Kathleen Shedlock, MS,
MPA, RNNP, AOCN®, CS, Amgen, Inc., Thousand Oaks, CA; Suzanne Bergen,
RN, Elizabeth Doherty, RN, MS, ANP, Constance Emens, RN, and Mary Kay
Parrone, RN, OCN®, University of Rochester, Highland Hospital Division,
Rochester, NY.
Achieving a threshold relative dose intensity of greater or equal to 75%
for adriamycin, contributes to disease free survival and overall survival
in non-Hodgkin’s lymphoma (NHL) (Kwak, 1990). In adjuvant breast
cancer, delivery of greater or equal to 85% of total planned dose may
improve overall survival (Bonnadonna, 1995; National Institutes of Health,
Adjuvant Breast Cancer Consensus Conference, 2000).
At a community oncology clinic, baseline chemotherapy dosing and febrile
(FN) data were collected through a physician practice pattern data collection.
Patients treated for adjuvant breast cancer and intermediate and high
grade lymphoma were evaluated. Data demonstrated a FN rate of 0%. Sixty
percent of the adjuvant breast cancer patients sampled received greater
than 85% dose intensity and 66.6% of the NHL patients achieved greater
than 80% planned dose intensity. Analysis of data and review of patient
scenarios indicated that low FN rates were due to dose delays for neutropenia.
A literature review was conducted to identify optimal neutropenia management.
Models identifying patients at risk for the development of febrile neutropenia
were found (Intragumchornchai, 2000; Weiner, 2000; Silber, 1998; Thomas,
2001). Age was found to be a risk factor (Dees, 2000; Morrison, 2000).
Risk models, age considerations, and appropriate G-CSF support were collaboratively
incorporated into a FN management protocol. The protocol recognizes the
nurse role in assessment and emphasizes communication between physicians
and the nurses administering the chemotherapy. A worksheet was developed
to assist nurses in implementing the protocol. Educational programs related
to dose intensity, continuous quality improvement, and neutropenia were
provided to staff. Over time, the new policy is being implemented. The
recent addition of a nurse practitioner will foster collaborative practice
and consistent implementation of the protocol. Increased awareness of
dose intensity, neutropenia, and clinical outcomes have been verbalized
by clinicians. Repeat data collections are planned for fall of 2001 to
evaluate progress in improving dose intensity in this practice setting.
170
PROVIDING EVIDENCE-BASED PRACTICE GUIDELINES AND ORDER SETS TO IMPROVE
CARE OF HOSPITALIZED PATIENTS NEWLY DIAGNOSED WITH LEUKEMIA. Carol White,
RN, MSN, AOCN®, APN, Mary Fox-Geiman, PharmD, BCOP, Kathleen Kotula,
RN, BSN, Sylvia Williams, RN, BSN, Rita Vercruysse, RN, MPH, OCN®,
and John Godwin, MD, Loyola University Medical Center, Maywood, IL.
Although acute leukemias account for less than 4% of all cancers, newly
diagnosed patients are hospitalized for initial treatment (induction)
as well as episodes of neutropenic fever. The stay may be as brief as
a few days or as extensive as four to six weeks. As a medical center involved
in education of medical students, interns, residents, and fellows, it
is important to assist in this training while assuring consistent quality
care to all patients. Since each month a new group of physicians rotate
through the hematology service, a committee was formed to standardize
the care. The committee convened over six years ago and began the process
of developing standardized admission and chemotherapy order sets and clinical
practice guidelines. Over time, these orders and guidelines were adjusted
to reflect changes in clinical practice. In the last year, our Center
for Clinical Effectiveness (CCE) reviewed each service line’s diagnosis
related groups (DRGs) in an effort to reduce variation in clinical practice
and to improve care of patients. Within the cancer service line, a multidisciplinary
committee was formed to reduce variation in clinical practice to improve
care of patients newly diagnosed with leukemia (DRG 473). Areas to change
and improve were evaluated through evidence based clinical practices.
Use of antibiotics, anthracyclines, tests (labs and MUGA scans), growth
factors, and discharge criteria were evaluated and changed via order sets
and guidelines already in place. A “patient and family friendly”
clinical pathway was created to give an overview of what occurs during
the hospitalization. The revised admission orders and leukemic guidelines
were placed on the electronic medical record (EMR). Compliance with practice
changes is monitored monthly by the utilization review (UR) nurse, inpatient
chemotherapy pharmacist, and advanced practice nurse. Quarterly reports
sent to CCE have reflected an increase in compliance and will be included
in the poster presentation. The project has brought together financial,
administrative, medical, nursing, and pharmacy representatives who have
learned from one another. Focus on improving care of the patient while
cognizant of the cost issues involved in today’s healthcare environment
resulted in reduction in resource utilization with improved quality of
care.
171
NURSE DRIVEN NEUTROPENIA MANAGEMENT GUIDELINES: IMPROVING PATIENT OUTCOMES
THROUGH EVIDENCE-BASED PRACTICE. Cathy Maxwell, RN, OCN®, CCRC, and
Lisa Winkler, RN, OCN®, Oncology Hematology Group of South Florida,
Miami, FL; and Mary Lottenberg, RN, BSN, OCN®, Amgen, Inc., Thousand
Oaks, CA.
In early 1998 our community oncology practice participated in a large
physician practice pattern data collection. This retrospective chart review
collected data on breast cancer patients receiving adjuvant chemotherapy.
According to a study by Bonadonna (NEJM, 1995), breast cancer patients
receiving less than 85% of their planned total chemotherapy dose had a
lower percentage of relapse-free and overall survival. We used 85% as
a dose intensity benchmark to determine how well our 10 physician practice
was at delivering chemotherapy as planned. Our data showed that 38% of
the patients studied experienced dose reductions and 42% experienced dose
delays. Overall, 24% of the patients received less than 85% of their planned
dose intensity and 3% were hospitalized due to a febrile neutropenic event.
It was evident that many of the dose reductions and delays were due to
neutropenia and that each physician’s results varied depending on
how neutropenia was managed. The physicians and key nurses in the practice
met to discuss ways to improve the quality of care being delivered to
breast cancer patients. A team of nurses and physicians developed guidelines
for neutropenia management that included intervention with Filgrastim
treatment for breast cancer patients identified as being at risk for dose
reductions and dose delays due to neutropenia. The guidelines were implemented
in October 1998. In September of 2000 we again conducted a chart review
of our breast cancer patients. The results were improved. Twenty percent
of the patients experienced dose reductions and 35% experienced dose delays.
Only 5% of the patients received less than 85% of their planned dose intensity
and there were no patients hospitalized for febrile neutropenia. The patients
of all 10 physicians were now being treated in a consistent manner. The
key to the success of our guidelines is the nursing staff’s responsibility
and autonomy in managing patients who become neutropenic. Utilizing guidelines
for neutropenia management saves the nursing staff considerable time and
has improved the overall flow of patient care for the practice.
172
A LEUKEMIA CARE PATHWAY AND PATIENT RECOVERY. Lilibeth S. Williamson,
RN, BSN, Marina Aing, RN, Marlene Gonzales, RN, BSN, Mihaela Fetea, RN,
and Gail Jens, RN, MSN, University of Texas M.D. Anderson Cancer Center,
Houston, TX.
Leukemia is one of the cancers for which we have few effective treatments
leading to a cure. Currently we are seeing an explosion in phase I and
II studies because of efforts to get potentially effective treatments
to patients faster. The drugs in these trials are sometimes very toxic
requiring constant monitoring and support. The most significant complication
in this patient population is infection. At MDACC, we instruct the patients
in the self-care that maximizes function, but as blood counts reach nadir,
compliance diminishes.
We believed that if the patient completed the prescribed care behaviors
and assumed responsibility for checking off the care as it was done, we
would have a higher rate of compliance resulting in fewer infections and
decreased re-admissions. Several staff nurses volunteered to work with
the CNS to improve patient compliance and outcomes. The outcome measures
were length of stay (LOS), visits to the emergency center (EC) within
three days of discharge, and the presence of fungal pneumonia.
A “Leukemia Pathway to Recovery” booklet was developed. It
incorporated oral care, prevention of pulmonary infection, diet, pain
management, safety, and the patient goals. Three supplementary forms were
also given to the patient on admission: “The Patient’s Daily
Worksheet,” “Your Blood Counts,” and “Discharge
Care.” After the patient completed their care activities, they filled
out the daily work sheet; it was collected and replaced everyday. “Your
Blood Counts” and “Discharge Care” provided the patient
with the information about when to call the nurse and what could be expected
when they go home.
Preliminary data from one unit (N = 28) show LOS decreased from 9.19 to
7.48. Return visits to the EC decreased by 50% on the participating unit,
and remained the same on the non-participating unit (N = 58). Information
on occurrence of fungal infections is not available at this time.
Mouth care, breathing treatments, and maintenance of mobility are important
care issues for the patient receiving phase I and II therapies. Increased
patient involvement in daily care will improve patient outcomes.
173
YOGA AS A CLINICAL INTERVENTION FOR ONCOLOGY PATIENTS IN AN AMBULATORY
SETTING. Mary Jane Ott, MN, MA, RNCS, and Claire Willis, MS, LISCW, Dana-Farber
Cancer Institute, Boston, MA.
Background: People living with cancer have specific and unique self-care
needs as a result of diagnostic and treatment procedures including surgery,
chemotherapy, and radiation. Studies have shown that pain, fatigue, insomnia,
and depression are among the common symptoms experienced by oncology patients.
Yoga is an ancient practice of breathing, gentle movement, meditation,
chanting, and relaxation that supports health and healing. Studies have
demonstrated its efficacy as an adjunct treatment in hypertension, cardiovascular
disease, asthma, anxiety, depression, and other illnesses.
Intervention: A series of one hour introductory yoga classes were developed
and offered to patients in a large academic cancer treatment ambulatory
setting. Patients were invited to attend a series of six classes or to
attend individual classes, as they were able to do so. The classes were
designed to teach and promote breath awareness, abdominal breathing, gentle
physical movement, flexibility, meditation, and deep relaxation. An advanced
practice nurse and a social worker, each of whom are certified yoga instructors,
taught the classes.
Evaluation: Self-report evaluations at the end of each of the classes
indicated that the participants found the classes to be most helpful.
They also reported feeling more calm and relaxed and were pleased to find
that they were able to move their bodies more fully. Over time, participants
described feeling more comfortable with their bodies and less stressed
in general. They reported being able to use breathing and gentle movement
outside of class to promote health and well being. Additionally, they
reported sleeping better and having an increased sense of well being.
Discussion: People living with cancer have unique self-care needs during
initial diagnostic work ups and required treatments. As oncology nurses
we are consistently faced with the challenge of finding safe, innovative
ways to support people through stressful therapies and to promote healing
on all levels. Yoga is an appropriate clinical intervention for some oncology
patients that can result in a decrease in symptom burden and an improved
quality of life.
174
A SKIN CARE PROTOCOL FOR THE ADULT BONE MARROW/PERIPHERAL STEM CELL TRANSPLANT
(BM/PSCT) PATIENT. Linda Abbott, RN, MSN, AOCN®, CWOCN, Rhonda Roeder,
RN, BSN, and Jeanette Wigim, RN, BSN, MSN, University of Iowa Hospitals
and Clinics, Iowa City, IA.
The skin is the body’s largest organ and serves several important
protective functions including being a barrier to toxins, chemicals, mechanical
and aqueous assaults, and for sensations such as touch, temperature, and
pressure.
The mild acidity of the skin is an effective antimicrobial barrier. Sebum
also has been identified to have natural fungicidal and bactericidal properties.
Maintaining this natural defensive mechanism against bacterial invasion
is important. If the integrity of the skin is broken, it creates not only
a portal for the entry of infectious organisms but also loss of fluids
and electrolytes. Most soaps are alkaline with a pH of as high as 10–12
which can destroy sebum.
Drying of the skin can also interfere with skin integrity. In order to
decrease transepidermal water loss, which can result in dryness and flaking
of the skin, baths should be followed by an emollient to wet skin.
People undergoing a BM/PSCT are at risk for skin breakdown and subsequent
infection as a result of GVHD, treatment related skin changes, pressure,
irritation, or infectious complications. It is imperative to maintain
skin integrity to afford the best protection from infection for this high
risk population.
Traditional skin cleaning in the BM/PSCT patient has included showering
and washing hands with antimicrobial (chlorhexidine) soap used to eliminate
the normal flora of the skin and thereby reduce the risk of infectious
organisms on the skin. Chlorhexidine, though bacteriocidal, also washes
away the sebum and the acid mantle is disrupted. Chlorhexidine is also
drying and can result in flaking, cracking, and peeling of the skin. With
the advent of bag baths, some immunocompromised patients are currently
bathed with a cleanser other than chlorhexidine with no increase in infection
rates or skin related complications. The purpose of this project is to
look at the incidence of skin drying, flaking, cracking, and infection
when comparing traditional skin cleansing practice to the use of a pH
balanced, non-antimicrobial skin cleanser such as Dove soap or Cetaphil.
The hypotheses is that there will be no increase in infection rates with
the use of a non-antibacterial cleanser and that there will be a decrease
in dryness, flaking, and cracking of the skin. This is a work in progress.
175
MAKING EACH MOMENT COUNT: DEVELOPING A DIVERSIONAL THERAPIES PROGRAM FOR
PATIENTS WITH HEMATOLOGIC MALIGNANCIES. Kristen Haley, RN, BSN, Jennifer
Hunt, BSN, RN, Sacha Simmons, BSN, RN, and Anita Reedy, MSN, RN, Johns
Hopkins Hospital, Baltimore, MD.
Patients with hematological malignancies receive intensive chemotherapy
and are frequently hospitalized for extended periods of time. Side effects
of therapy include nausea, vomiting, pain, and fatigue. Patients are often
fearful and depressed. Depression is partially due to feeling isolated,
helpless, out of control, or unable to improve an adverse situation (Hirsh,
S. & Meckes, D., 2000). Boredom, a less recognized problem, may have
the same causes as depression. Severely immunocompromised patients are
placed in private rooms with the doors closed. This isolates them, limits
their activities, and decreases their opportunity to interact with other
patients. Carpenito (1982) defines diversional activity deficit as “the
state in which the individual experiences, or is at risk for experiencing,
an environment that is devoid of stimulation or interest.” Nurses
recognized that boredom was a problem and believed a lack of diversion
was a contributing factor. A Diversional Therapies Committee was formed
to create a volunteer program and develop appropriate diversional activities.
The committee solicited donations of books, cassettes, CDs, games, and
VCRs for each patient room and, with others, generated unique activities
such as walking and golf putting competitions. They met with rehabilitation
staff to expand their role in these therapies. Social workers, occupational
therapists, and nurses initiated a discussion/support group for patients.
This enabled patients to share experiences and learn coping techniques
such as relaxation and meditation and other activities based on patients’
expressed interests. Barriers faced in implementing this program included
a lack of financial support, inadequate space, and inconsistent volunteers.
A future goal is to evaluate the effects of diversional therapies on patient
depression, nausea, pain, and fatigue. We are confident that this will
justify additional support for this program including funding an activity
coordinator, designated space, and additional materials.
We are improving our volunteer screening process for time commitment and
emphasizing their importance in the diversional therapies program. Our
experience has demonstrated the importance of these activities to the
overall care of our patients. There is a great deal of enthusiasm among
the staff, patients, and other disciplines. We believe other oncology
nurses can learn from our experiences in establishing a diversional therapies
program.
176
PREDICTORS OF WEIGHT GAIN IN PREMENOPAUSAL WOMEN WITH EARLY-STAGE BREAST
CANCER. Carolyn Ingram, DNSc, RN, CON(C), McMaster University, Hamilton,
Ontario, Canada.
Weight gain is common in early breast cancer, and has been linked to risk
of early recurrence, later chronic diseases, and impaired adjustment.
The author hypothesized that newer, adjuvant chemotherapies had changed
this problem over time. Furthermore, premenopausal women have historically
gained the most weight, but have been under-represented in past research.
Brown’s Conceptual Framework for Cancer-Related Weight Change provided
the direction for this study. It supports the belief that weight change
ultimately results from changes in energy balance and that these must
be understood before interventions are planned.
The purposes of this correlational, longitudinal study were to examine
the rate and magnitude of breast cancer-associated weight change, to detect
changes in body composition and selected energy balance factors, and to
determine the relationship between these energy balance factors and weight
change. An inception cohort of 91 premenopausal, stage I and II women
with breast cancer was assembled. Baseline measures were collected before
adjuvant chemotherapy began, and subsequent data were collected at the
start of every other treatment cycle. Predictor variables included dietary
intake (Block 98 Food Questionnaire), physical activity (Stanford Five
Cities Project Questionnaire), resting energy expenditure (derived from
bioimpedance analyses), menopausal symptoms (adapted version of Cooper
& Baird’s Menstrual Status Questionnaire, Cronbach’s alpha
= .70), and nicotine intake (self-reported smoking rates). Weights and
heights were obtained using standardized techniques.
Results indicated that weight gain during adjuvant chemotherapy is not
the problem it once was. Of the sample, 55% maintained stable weights
while 34% gained and 11% lost weight. Subject mean weight gain was 1.4
kg. Weight gainers and losers gained or lost three to four times as much
fat as lean body mass. Physical activity and dietary intake decreased
for both weight gainers and losers. The independent variables predicted
31% of the variance in weight. Future studies should examine relationships
between treatment-related weight change, diet history, and post-treatment
weight change. Subgroups at risk also require further study. These findings
identified associations between breast cancer-associated weight change
and changes in energy balance. They lay the ground work for identifying
patients at risk and designing interventions that are targeted to risk
profiles.
177
IMPROVING PAIN MANAGEMENT FOR PATIENTS ON PATIENT-CONTROLLED ANALGESIA
(PCA). Elizabeth Fogarty, RN, Annette Bisanz, RN, MPH, BSN, Mariamma Babu,
RN, Nida Dizon, RN, BSN, Tracey Lewis, RN, and Dianne Stephens, RN, MSN,
BSN, University of Texas M.D. Anderson Cancer Center, Houston, TX.
While reviewing information on patient satisfaction and outcomes in our
inpatient gastrointestinal surgery unit, we found that only 75% of our
patients were satisfied with their PCA pain control. We decided to improve
our patient pain management by decreasing idleness and pulmonary complications
and improve mobility and inhalation. We applied the M.D. Anderson quality-improvement
process called Plan, Do, Check, Act. The first step was gathering the
right people. We traced the steps of the patient through the gastrointestinal
clinic, pre-op clinic, post anesthesia care unit, surgical intensive care
unit, and gastrointestinal intestinal in-patient unit and added representatives
from each of those areas to our team. We also added an anesthesiologist,
nursing instructor, patient educator, and quality-improvement representative
for advice and guidance. The team then held a brainstorming session, developed
a cause-and-effect fishbone diagram, and determined that the problem was
caused by patient and staff education deficits. Our goals were to provide
consistent education about PCA of patients in all areas of the institution,
identify the key elements of patient PCA education, and create interventions
to correct the problem. Thirty patients were surveyed for deficits in
baseline knowledge. We developed a PCA Guideline Sheet (also known as
A.I.R.S.—assessment, intervention, reassessment, and side effects)
and on-line educational materials compatible with the guidelines. We incorporated
the PCA guidelines into our nursing pain—assessment and management
standards and formulated and launched a lesson plan for educating staff.
Then, using the two-step back process (looking two cycles backwards in
the process) we determined that education of patients on PCA pumps needed
to start in the clinic. After patient education materials were used and
the staff was educated, we resurveyed the patients for improvement. Patient
satisfaction with pain control increased from 75% to 90%. Because of the
high success rate, we chose to incorporate these methods and guidelines
into nursing practice within our entire institution.
While the outcome and procedures would prove to be helpful to any patient
care institution, the process of plan, do, check, act could be used to
custom fit any institution’s particular needs.
178
EFFECT OF NUTRITIONAL INTERVENTION AFTER HOSPITAL STAY FOLLOWING ALLOGENEIC
STEM CELL TRANSPLANT. Ofelia Quesada, RN, MSN, CNSN, OCN®, Memorial
Sloan-Kettering Cancer Center, New York, NY.
Between April 1996 and April 1997 at this NCI-funded cancer center,
a retrospective review of 20 allogeneic stem cell transplant patients
without documented GI pathology revealed they had a significant weight
loss after discharge from the hospital. A multidisciplinary team consisting
of clinical nutrition nurse clinicians, bone marrow transplant nurse clinicians,
registered dietitians, pharmacist, the director of the clinical nutrition
team, and a bone marrow transplant attending physician was organized to
determine if early nutritional intervention would improve quality of life
and morbidity. Studies have shown that unintentional weight loss >/-10%
is an independent factor for morbidity and survival after peripheral blood
stem cell transplant. Between March 2000 and March 2001, a cohort of 22
patients without documented GI pathology were enrolled in the study. Age
ranged from 22–55 years (mean 37.64 years). Twenty of 22 patients
received chemotherapy and total body irradiation and two received chemotherapy
alone. All were given nutritional counseling consisting of 24-hour calorie
counts, dietary recommendations such as high calorie dietary supplements,
and counseling by a pharmacist to evaluate drug-nutrient interaction prior
to discharge and at one, three, and six-month clinic visits. Feeding tube
placement was recommended for those who sustained greater than 5% weight
loss. Sixteen patients completed this intervention. Six patients died
before this review was completed. Of the survivors, 10 had sustained weight
loss at one and three months, and six patients maintained their weight
throughout the intervention period. At six months, 62.5% of the patients,
including four of the patients who initially lost weight, regained and/or
maintained weight. This review revealed that although the majority of
patients (62.5%) were able to maintain or regain weight by six months
with close counseling and early intervention, more research is needed
to evaluate which nutritional support measures will decrease or prevent
the incidence of weight loss and improve recovery after transplantation.
179
PAIN MANAGEMENT STRATEGIES FOR ACHIEVING QUALITY PATIENT OUTCOMES AND
JCAHO STANDARDS. Susan M. Zuk, RN, MS, AOCN®, and Melanie Hurst, RN,
BSN, Jennersville Regional Hospital, West Grove, PA.
Caring for patients with pain in a small community hospital lacked a
systematic approach and a method to document outcomes. To meet the goals
defined by the JCAHO Standards and provide optimal pain management became
a strategic priority.
The pain initiative began with the formation of a multidisciplinary team.
A needs assessment quickly determined that only a patient controlled analgesia
procedure existed. The committee drafted a pain management standard of
care which encompassed procedures for assessment, evaluation, education,
and alternative methods to pain control. This policy statement became
the foundation for all strategic efforts.
The committee’s review identified the assessment process and documentation
measures to be inadequate. Working collaboratively with the Nursing Department,
the admission assessment form was modified to incorporate all aspects
included in the standard of care. In addition, the daily flow sheet which
records all vital signs and assessment data was updated to address the
pain response and pain rating (0–10 scale) for each intervention.
Educational tools for acute postoperative pain and cancer pain were incorporated
into the hospital’s education website.
Creative tools were developed to better assess and manage pain. A pain
rating scale equipped with descriptive words, face rating, and 0–10
scale was created in both English and Spanish.
This laminated tool was placed at the patient bedside and mailed to all
physician offices and home care providers. Also, a newly created opioid
equianalgesic conversion pocket guide and educational literature was distributed
to all physicians on staff. The nursing and allied staff received pocket
guides in conjunction with valuable information on guide usage and highlights
of opioid therapy.
Quarterly inservices and physician conferences continue to address critical
aspects of pain management. Quality improvement data addressing assessment
and education criteria demonstrate significant improvement. An innovative
protocol for the prevention of constipation has been recently approved.
Also, future initiatives include establishing a pain management team for
pain consultation in the acute and outpatient settings.
These strategic measures over the past 12 months were successful in meeting
the ascribed standards set by the JCAHO. Hospital wide efforts continue
to propel pain management forward into the 21st century.
180
NONHORMONAL MANAGEMENT OF MENOPAUSAL SYMPTOMS: WHAT IS THE CURRENT EVIDENCE?
Randolph E. Gross, MS, RN, CS, AOCN®, Memorial Sloan-Kettering Cancer
Center, New York, NY.
Nurses who practice within the specialty of women’s health often
are responsible for guiding women through the symptoms associated with
menopause. These symptoms can occur due to natural menopause or through
iatrogenic causes such as chemotherapy or radiation as treatment for cancer.
Additionally, several of the drugs (e.g., tamoxifen, raloxifene) used
widely have side effects that mimic menopausal symptoms, with the most
prevalent being hot flashes. As survival statistics for women with cancer
continue to improve due to early detection and advancements in treatment,
this quality-of-life issue becomes paramount for many of these women.
Furthermore, estrogen replacement is not an option for many of these women
either by choice or due to possible increase in risk for recurrent disease.
Thus, nurses need to have an understanding of the nonhormonal management
of menopausal symptoms. Many of the interventions recommended for such
symptom management presently are based more on anecdotal reports, though
evidence-based practice is emerging. This presentation will discuss the
current evidence on interventions such as diet, exercise, behavioral techniques,
and nonhormonal medications, and will also address current knowledge regarding
the various complementary therapies used by many women today. In order
for nurses to provide the best possible care for the millions of women
who are cancer survivors, knowledge regarding such interventions is necessary.
181
THE IMPORTANCE OF QUALITY-IMPROVEMENT SURVEYS IN ALLEVIATING PAIN IN PATIENTS
RECEIVING RADIATION TREATMENT. Sharon Galperin, RN, Christina Fontaine,
RN, MSN, Carolyn Grandy, BSN, RN, Mitzi Lasta, RN, and Barbara Bottoms,
RN, University of Texas M.D. Anderson Cancer Center, Houston, TX.
A patient-satisfaction survey conducted by our institution showed that
55% of the patients were experiencing pain that interfered with their
normal work. Patients experiencing pain do not always complain as they
associate cancer with pain. Therefore, we needed to ask the patients about
pain and devise a way to decrease pain and improve quality of life. The
purpose of this project was to determine the percentage of radiation-treatment
patients who had pain at a level of four or above on a pain scale of 0–10,
the percentage experiencing good pain relief, and how the nurses could
improve pain management for radiation-treatment patients. The radiation
oncology nurses created a questionnaire that included questions to determine
patient knowledge about their medications, their knowledge about alternative
ways to decrease their level of pain, and whether or not they received
printed pain-management materials. The questionnaire was distributed to
188 adult patients receiving radiation therapy on one day. The results
indicated that not all patients experiencing pain felt they were getting
good relief for their pain. The patients felt they understood how to take
their pain medication but said they were not given verbal instructions
on pain relief. The nursing staff reviewed the results and brainstormed
on how they could change their approach to pain management. The nurses
decided to ask all patients about pain, educate patients on pain management
using printed materials, and inform the physicians when patients experienced
pain at a level of four or greater. All the nurses attended a training
session on pain management. The weekly documentation was reviewed to monitor
documentation of pain management. The survey was repeated six weeks later.
The second survey revealed that 19% fewer patients were experiencing pain
at the level of four or greater. The patient understanding of pain management
increased by 13%. It is vital for nurses to teach patients receiving radiation
treatment about their pain and how it can be decreased or eliminated to
improve quality of life.
182
MANAGING FREQUENT DEFECATION AFTER TREATMENT FOR COLOREC-TAL CANCER. Annette
Bisanz, RN, BSN, MPH, University of Texas M.D. Anderson Cancer Center,
Houston, TX.
Patients who have had treatment for colorectal cancer experience frequent
defecation that can be differentiated from diarrhea based on the more
formed consistency of the stool. A literature review revealed that insoluble
fiber can be used to either speed up or slow gastrointestinal motility.
After piloting a protocol for remedying this symptom and finding it successful
in compliant patients, we established a standard of practice. This standard
of care was made part of a surgical pathway and included patient education
and nursing guidance, and decreased the number of stools per day and enhanced
the quality of the patients’ lives. Patients were taught to take
a small amount of psyllium in very little water so that it acted like
a sponge in the gut, absorbing excess fluid and thereby slowing the transit
time and to titrate the amount of food, fluid, fiber, and medication they
consume. When the number of stools begins to decrease and the stool becomes
more formed, the patients were put on a bowel training program to empty
the content of the colon at an expected time each day. Patients with incontinence
were taught anal sphincter exercises to strengthen the anal sphincter.
Maintaining anal sphincter strength is important while a temporary diverting
ileostomy is in place so that at the time of reversal, the anal sphincter
is in good condition. The outcomes experienced have been favorable in
compliant patients. Patients can reduce their defecation from 30 stools
per day to three per day on this bowel program. Accomplishing the desired
outcomes requires ongoing nursing assessment and problem solving with
the patient to achieve adequate results. The outcomes are remarkable,
allowing patients to go back to work, socialize, and regain a quality
of life not possible when they are confined to the home because of frequent
defecation.
183
INTERACTIVE GUIDE TO MANAGING CANCER PAIN. Ann E. McFarren, RN, BSN, Susan
Brink, DrPH, and Jane Lincoln, MSW, HealthMark Multimedia, Washington,
DC.
The Cancer Pain: Your Guide to Relief™ CD-ROM will provide information
and interactive tools to focus cancer patients’ learning, decision
making, and treatment planning. This interactive program will increase
the knowledge and self-efficacy of patients and caregivers and help them
to participate with their healthcare team in the pain management process.
The program was developed based on a patient education practice model
for design of multimedia interventions to support treatment decision-making
during previous research and development efforts. The model assumes that
patients spend varying levels of time and energy in each of three activities—information
gathering, clarifying values and personal preferences, and problem-solving
in order to manage daily activities despite pain or to avoid pain. The
Cancer Pain: Your Guide to Relief™ prototype was developed based
on the results from the group interviews and patient, caregiver, and consultant
feedback on “concept screens.” The overall design combines
personal goal setting with information about barriers to meeting those
goals because of lack of pain control. The prototype product was tested
with cancer patients and caregivers. Pre to post, testers showed an increase
in knowledge (p < .001), a change in beliefs about the inevitability
of pain with cancer (p = .004), and self-efficacy scores showed a definite
improvement overall (p = .001). The presentation will include a demonstration
of the product’s interactivity.
184
“POWER OVER PAIN”: A COLLABORATIVE COMMUNITY EDUCATION CAMPAIGN.
Susan Boulet, RN, MSN, OCN®, North Florida Regional Medical Center,
Gainesville, FL; Ellyn Radson, RN, BSN, University of Florida College
of Pharmacy, Gainesville, FL; Karen Allman, RN, BSN, OCN®, Malcolm
Randall VA Medical Center, Gainesville, FL; and Winnie Nielson, RN, BA,
Hospice of North Central Florida, Gainesville, FL.
Pain, a prevalent and universal human experience, is the most frequent
reason that people seek health care. Relief of pain has been a human concern
throughout history, while at the same time, the responsibility for pain
management has been vaguely defined. Pain, as a healthcare priority, has
received increasing attention in recent years, but without a concomitant
improvement in the clinical management of pain. Not only does pain impact
the health of an individual, it impacts the health of a community. Accordingly,
community education may be one avenue to defining accountability for effective
pain management. The North Florida Chapter of the American Society of
Pain Management Nurses (ASPMN) has initiated a collaborative community
pain education project entitled “Power Over Pain.” This project
will culminate in a pain awareness week in January 2002 during which community
seminars, media education, and 5K fun run will spotlight pain management.
The goals of this community education campaign are: a) to inform the community
about a person’s right to appropriate pain management, b) to provide
information about the impact of untreated and under treated pain, and
c) to educate people about effective ways to communicate pain to healthcare
providers. After obtaining an unrestricted grant from Abbott Laboratories,
a planning committee of eight registered nurses representing the major
healthcare institutions in a north-central Florida community was established.
These nurses, all of whom have an interest in pain management, are active
members of one or more of the following organizations: ASPMN, Oncology
Nursing Society, American Cancer Society, Hospice Nurses Association,
and American Society of Post Anesthesia Nurses. Having established an
alliance with the American Pain Foundation (APF), the “Power Over
Pain” community education campaign has become a pilot program in
the APF “Stop Pain Now” initiative. This poster presentation
details the steps taken to develop this campaign: 1) concept development,
2) budget projection and funding, 3) timeline assignment, 4) recruitment
of professional and community support, 5) educational content development,
6) promotion and advertising, 7) partnering with a national pain organization,
and 8) quantifying community response to the educational campaign.
185
“THIS IS NOT YOUR ORDINARY WALK IN THE PARK” AND OTHER WAYS
TO FIGHT FATIGUE AND RESTORE ATTENTION. Paula Hutchison, RN, BSN, OCN®,
Dayton Oncology & Hematology, PA, Dayton, OH; Pamela Gray, RN, OCN®,
Medical Oncology Hematology Associates, Inc., Troy, OH; Sandy Hoskins,
RN, OCN®, Hematology and Oncology of Dayton, Inc., Dayton, OH; Cathy
Jackowski, RN, OCN®, and Joyce Marrs, RN, BSN, OCN®, Medical Oncology
Hematology Associates, Inc., Dayton, OH; and Susan Newton, RN, MS, AOCN®,
Ortho Biotech Oncology, Dayton, OH.
The Miami Valley Fatigue Coalition is a group of oncology nurses from
the Dayton, Ohio area who are passionate about helping patients to combat
fatigue. Our goal for the year 2001 was to offer a community based activity
to increase awareness of cancer survivors, caregivers, and families on
ways to fight fatigue and restore attention.
On Saturday, April 7, 2001, as a culmination of national cancer-related
fatigue awareness week, a “restorative walk” was sponsored
by the Miami Valley Fatigue Coalition and the West Central Ohio Chapter
of the Oncology Nursing Society, with the support of Ortho Biotech.
To make it convenient for cancer survivors and to promote attendance,
the event was offered at two local nature centers. More than 100 people
attended the event. We discussed the benefits of the natural environment
to restore attention, and the importance of exercise in increasing energy.
Evidence-based research has shown that activities involving the natural
environment can help restore attention in patients undergoing chemotherapy.
In addition, more and more data is being reported regarding the benefits
of light exercise for cancer patients who are experiencing cancer-related
fatigue.
The highlight of the event was a guided walking tour through the beautiful
gardens and peaceful woods. Door prizes, goodie bags, and an Easter egg
scavenger hunt with “fighting fatigue hints” were distributed
to all.
Several newspapers featured articles about the event and provided information
about fatigue and conducted interviews with patients as well as nurses
from the coalition. Many local businesses provided door prizes and were
informed of the cause. Girl Scout and church youth groups facilitated
the activities. Coalition nurses disseminated information regarding cancer-related
fatigue and what can be done to reduce it. Those who attended the event
gained valuable insight concerning cancer-related fatigue. The feedback
from participants was overwhelmingly positive. Participants learned firsthand
that one must expend energy to create energy. The coalition is concerned
about the lack of attention paid to this most common symptom of cancer.
Therefore, plans are in place to make this an annual event.
186
PREDICTING THE RISK OF NEUTROPENIC COMPLICATIONS IN PATIENTS TREATED WITH
ADJUVANT CHEMOTHERAPY FOR EARLY-STAGE BREAST CANCER. Carrie Cappozzo,
MS, FNP, RN-C, for the ANC Study Group, Cancer Center of Albany Medical
Center, Albany, NY.
Neutropenia is associated with increased morbidity and decreased quality
of life in patients treated with chemotherapy for cancer. As the primary
dose-limiting toxicity of chemotherapy, neutropenia frequently results
in chemotherapy delays and dose reductions that can compromise treatment
effectiveness and long-term survival. Prophylactic G-CSF reduces the incidence
and severity of neutropenic complications including low relative dose
intensity (RDI) and febrile neutropenia (FN). A tool to predict the risk
of neutropenic complications with chemotherapy would facilitate the proactive
management of neutropenia by identifying patients who most likely would
benefit from prophylactic G-CSF. The first step in developing such a tool
is to identify predictive risk factors associated with neutropenic complications.
Accordingly, we retrospectively performed multivariate logistic regression
analysis on data from the records of 20,799 patients given multiple cycles
of adjuvant chemotherapy for early-stage breast cancer. Developed from
a nationwide survey of 1,243 community oncology practices, this large
database contains detailed information on patient demographic and clinical
characteristics; planned chemotherapy dose and schedule, subsequent treatment
delays, dose reductions, and RDI; and the incidence of FN. Study endpoints
were low RDI and FN. Covariates that independently predicted low RDI were
increasing age, positive estrogen receptors (ER), decreasing body surface
area (BSA), low pretreatment blood counts (WBC or ANC), and chemotherapy
regimen. The adjusted odds ratios for low RDI were 1.44 for age 65 or
older, 1.59 for low pretreatment blood counts, and 2.46 and 2.07 for the
CAF and CMF regimens, respectively. The covariates that independently
predicted FN were increasing age, negative ER, decreasing BSA, low pretreatment
blood counts, and chemotherapy regimen.
The adjusted odds ratios for FN were 1.23 for age 65 or older, 1.70 for
low pretreatment blood counts, and 1.87 and 1.92 for the AC-T and A-CMF
regimens, respectively. This study confirms the ability to develop predictive
models for neutropenic complications with adjuvant chemotherapy for breast
cancer. Ultimately, the factors identified here and others may be incorporated
into predictive models for determining which patients should be given
prophylactic G-CSF. Such models would enable nurses to intervene early
to help prevent serious complications related to neutropenia.
187
PHYSIOLOGICAL AND PSYCHOSOCIAL ASSESSMENT MEASURES IN POST-BREAST-CANCER
LYMPHEDEMA. Jane M. Armer, RN, PhD, Davina Porock, PhD, BSN, Deidre Wipke-Tevis,
PhD, RN, Donna Williams, PhD, Debbie Daunt Kelly, BSN, BA, University
of Missouri-Columbia, Columbia, MO; and Eris Zagar, MS(N), Ellis Fischel
Cancer Center, Columbia, MO.
Post-breast cancer lymphedema is a chronic, distressful symptom that is
poorly understood, acknowledged, and addressed by health providers. Accurate
incidence and prevalence are elusive because it is under-reported, secondary
to imprecise physiological measures generally used in clinical practice
and common disregard for the serious impact on quality of life.
The research goals were the (1) description of lymphedema prevalence through
increased precision in physiological measurement; (2) description of lymphedema
management through self-care and health system measures; and (3) identification
of effects of lymphedema on quality of life, health locus of control,
and overall adjustment to chronic illness. A descriptive-correlational
cross-sectional study design was used to document the prevalence of lymphedema
among 103 women treated for breast cancer at a Midwestern United States
cancer center. Effects and management of lymphedema were explored among
women with lymphedema using qualitative and quantitative measures. Certain
psychological measures (quality of life, health locus of control, and
overall adjustment to chronic illness) were compared among women with
and without lymphedema to increase our understanding of the impact of
lymphedema on women’s well-being. Additional in-depth qualitative
interviews were carried out with women with post-breast cancer lymphedema
(N = 20) to assess onset, self-management, and impact on functional ability,
family relationships, and quality of life. Further work is now completed
comparing circumferences, water displacement, and infra-red laser perometry
assessments of limb fluid volume in healthy women and breast cancer survivors
(N = 80). These measures will be applied in an on-going prospective study
of post-breast cancer lymphedema.
A significant portion of the preparation for this study included the development
of an assessment tool specific to lymphedema risk factors, identification,
onset, and management. The self-care behaviors women used to relieve symptoms
were addressed through semi-structured and open-ended questions. The goal
was the development of a tool which is useful for scoring risk and guiding
recommendations for self-care. Preliminary results, including tool and
physiological measurement reliability, will be reported.
Research funded by the National Institute for Nursing Research #1 R15
NR05247-01 and MU Research Council and MU Research Board.
188
PEGFILGRASTIM: AN INVESTIGATIONAL SUSTAINED-DURATION G-CSF WITH ONCE-PER-CYCLE
DOSING AND SAFETY AND EFFICACY EQUIVALENT TO THOSE OF FILGRASTIM. Cindi
Bedell, RN, MSN, OCN®, and Frankie A. Holmes, MD, US Oncology, Dallas,
TX; Michael Green, MD, Royal Medical Hospital, Melbourne, Australia; Jeffrey
Crawford, MD, Duke University, Durham, NC; and Bertrand D. Liang, MD,
Amgen Inc., Thousand Oaks, CA.
Chemotherapy-induced neutropenia (CIN) is a serious consequence of cancer
treatment that can substantially increase a patient’s risk of infection
and compromise treatment efficacy. Prophylactic G-CSF (Fligrastim [Neupogen])
administered after chemotherapy reduces neutropenia and related complications.
It must be given by daily injection, however, possibly compromising adherence
by necessitating extra office visits or administration by patients or
caregivers who must master home administration without nursing support.
Pegfilgrastim, a sustained-duration formulation of Filgrastim created
by adding polyethylene glycol to the Filgrastim molecule, is given only
once per chemotherapy cycle. Owing to a novel clearance mechanism, pegfilgrastim
stays in the body through the absolute neutrophil count (ANC) nadir, leaving
only as the ANC rises. Pegfilgrastim is not removed by the kidneys like
Filgrastim, but is instead cleared from the circulation through binding
to neutrophils and neutrophil precursors. When the ANC is low there are
fewer neutrophils, so the blood levels of pegfilgrastim remain high. This
unique self-regulating mechanism protects patients from neutropenia in
a patient-specific manner according to their ANC kinetics after chemotherapy.
Clinical trials in patients with solid tumors and hematologic malignancies
including lung cancer, breast cancer, and non-Hodgkin’s lymphoma
have shown that pegfilgrastim given prophylactically once-per-cycle is
at least as safe and effective as a course of daily Filgrastim. A single
injection of pegfilgrastim per chemotherapy cycle was as effective as
Filgrastim in reducing days of severe neutropenia and the incidence of
febrile neutropenia (FN) in all cycles. In the largest phase III trial
in breast cancer patients treated with AT (doxorubicin/docetaxel), pegfilgrastim
compared to Filgrastim was associated with significantly less FN over
all cycles (9% versus 18%, P = 0.029). A median of 10 daily injections
of Filgrastim was administered per cycle compared to a single dose of
pegfilgrastim. Pegfilgrastim is well tolerated with side effects similar
to those with Filgrastim; bone pain did not differ between pegfilgrastim
and Filgrastim in randomized blinded clinical trials. Pegfilgrastim is
a novel colony-stimulating factor that can simplify how prophylactic growth
factors are given after chemotherapy. Minimizing the number of injections
given on successive days has positive implications for both patients and
nurses.
189
OUTPATIENTS’ TITRATION AND EVALUATION OF ORAL TRANSMUCOSAL FENTANYL
CITRATE (OTFC®; ACTIQ®) FOR BREAKTHROUGH PAIN (BTP). Susan Rice,
RN, OCN®, Kentucky Cancer Clinic, Hazard, KY; Sally Adelus, RN, Bay
Area Pain Center, Los Gatos, CA; and Lorie Bruno, Cephalon, Inc., West
Chester, PA.
Background: Breakthrough pain (BTP) is an unpredictable, transitory
flare of pain superimposed on a background of chronic pain managed by
around-the-clock opioids. ACTIQ (oral transmucosal fentanyl citrate; OTFC®)
is a novel product designed to provide rapid analgesia for BTP in opioid-tolerant
cancer patients. ACTIQ is available in six dosage strengths (200–1600
mcg), thus offering patients personalized control of BTP. The successful
dose of ACTIQ is determined using an individualized titration process.
Patients are instructed to titrate upward until one ACTIQ dose provides
adequate BTP relief with minimal side effects (“successful titration”).
Purpose: We conducted an 88-site, open-label study with cancer outpatients
to characterize the titration process used in clinical practice and assess
patient satisfaction with ACTIQ for management of BTP. Patients entered
their titration experience information in a diary. Safety was evaluated
collecting adverse events (AEs).
Results: Over 19 months, 393 patients were enrolled. Summary statistics
from initial data review were as follows. At baseline, 72% of patients
were experiencing three or more BTP episodes/day; 44% were taking an oxycodone
or hydrocodone combination product for BTP. At their physicians’
discretion, patients started ACTIQ titration at 200 mcg (65%), 400 mcg
(28%), 600 mcg (3%), or ³800 mcg (3%). Successful titration was reported
by 60% of patients. Of these patients, 88% rated ACTIQ as better or much
better overall and 91% rated ACTIQ as better or much better in speed of
onset than their prior BTP therapy. Sixty-two percent reported they were
better or much better able to perform daily physical activities and 93%
planned to continue using ACTIQ to manage BTP. The most common reasons
for discontinuation were AEs (11%), insufficient efficacy (10%), or other
(19%). The most common AEs (at least possibly related to ACTIQ) were nausea
(10%), somnolence (7%), taste perversion (7%), dry mouth (6%), and dizziness
(6%).
Conclusions: ACTIQ is an effective and well-tolerated treatment option
for cancer-related BTP. Based on these preliminary statistics, when successfully
titrated, approximately nine out of every 10 of these cancer outpatients
considered ACTIQ to be better and faster acting than their previous therapy
and planned to continue using ACTIQ for BTP.
190
DELIVERING FULL PLANNED DOSE ON TIME (PDOT) CHEMOTHERAPY (CT) WHILE LOWERING
THE INCIDENCE OF FEBRILE NEUTROPENIA (FN) HOSPITALIZATIONS IN HIGH RISK
BREAST CANCER PATIENTS (BCP). Jerry Hinton, RN, OCN®, CCRC, Mid Ohio
Oncology Hematology, Columbus, OH; B. Bilodeau, RN, MSN, AOCN®, B.
Ford, RN, MSN, AOCN®, and D. Sarnacki, RN, MSN, AOCN®, Amgen Inc.;
C. Wood, RN, BSN, OCN®, CCRC, Sharp Health Care; and M. Gerbracht,
RN, MSN, AOCN®, Amgen Inc.
Recent studies suggest that about 20% of early-stage BCP receive £85%
of intended dose intensity (DI) when treated with CT. Neutropenia was
found to be the primary reason for delays and reductions. Bonadonna et
al. have suggested that women who receive less than 85% total planned
CT dose have a poorer prognosis. Budman et al. have shown that BCP who
received less than standard or moderate dose therapy have inferior outcomes.
Dr. Jeffrey Silber published a risk model (JCO, 1998) that showed first
cycle nadir absolute neutrophil counts (ANC) can predict the probability
of subsequent neutropenic events. To prospectively evaluate the efficacy
of such a risk model in delivering PDOT and reducing FN hospitalizations,
stage I–III BCP receiving adjuvant AC, CMF, or CAF were enrolled
in a non-randomized study. Patients with a first cycle nadir ANC £500mm3
were assigned to the high risk (HR) group; patients with an ANC >500/mm3
were assigned to the low risk group. HR patients received G-CSF (Filgrastim)
for all subsequent cycles starting 24 hours after CT and continuing to
a post nadir ANC³10,000/mm3. LR patients did not receive G-CSF unless
an FN episode or a delay due to neutropenia occurred. The relative dose
intensity (RDI) for the study subjects was compared to the RDI for a large
historical control group consisting of BCP who received the same CT regimens.
Overall 20.1% of historical control patients versus 4.7% of all study
subjects received £85% PDOT while 7.1% versus 2.7% respectively
were hospitalized for FN. This trial of 528 patients demonstrates the
feasibility of identifying a subgroup of BCP at high risk for neutropenia
who would most benefit from targeted use of Filgrastim support to deliver
PDOT while reducing these HR patients and assure they achieve greater
than 85% planned DI. They also play a crucial educational role in helping
patients understand the rationale for maintaining planned dose intensity
in early stage breast cancer treatment.
191
PHYSIOLOGICAL BIOMARKERS OF CANCER TREATMENT-RELATED FATIGUE. Judith K.
Payne, PhD, RN, AOCN®, College of Nursing, Wayne State University,
Detroit, MI; Ian Rabinowitz, MD, University of New Mexico Cancer Research
& Treatment Center, Albuquerque, NM; and Barbara F. Piper, DNSc, RN,
AOCN®, FAAN, University of Nebraska Medical Center, Omaha, NE.
Fatigue is the most frequently reported symptom of cancer and cancer therapy.
Despite this fact, there is relatively minimal information regarding its
intensity, exacerbating factors, and its underlying mechanisms. The purposes
of this study were to evaluate changes over time in serum melatonin, serotonin,
cortisol, hemoglobin, and bilirubin levels in patients with early stage
breast cancer receiving chemotherapy; explore correlations between these
posited fatigue biomarkers and subjective fatigue; and determine how changes
may be related to insomnia, depression, and health-related quality of
life.
Using a conceptual framework viewing fatigue as a multi-dimensional experience,
this study used a prospective descriptive repeated measures design. A
sample of 20 subjects (n = 10 and n = 10 matched healthy controls) diagnosed
with early stage breast cancer and receiving chemotherapy for the first
time were recruited from a large academic southwestern medical center.
Instruments included a demographic questionnaire, medical record reviews
and self-reported medical history, the Piper Fatigue Scale, Fatigue Intensity
Scale, Morin Sleep Diary, CES-D, SF36, and sleep wrist actigraphs. Physiological
serum measures were drawn pre and post treatment at baseline and three
months. Following completion of data collection, final data analysis will
include descriptive statistics and repeated measures ANOVA. Preliminary
data indicate that subjects experienced fatigue as a common and distressing
side effect of chemotherapy treatment, with changes detected in physiological
serum markers as well as sleep patterns. Understanding mechanisms of fatigue
and the nature of relationships between physiological fatigue biomarkers
and subjective fatigue will enable fatigue research-based interventions
to be tested in future studies.
192
CHARACTERIZATION OF BIOTHERAPY-INDUCED PERIPHERAL NEUROPATHY. Constance
Visovsky, RN, PhD(c), ACNP, Case Western Reserve University, Cleveland,
OH.
Problem/Purpose: Patients treated with neurotoxic drugs experience peripheral
neuropathy resulting in alterations in hearing, vision, touch, balance,
and blood pressure. This study is unique in its prospective design, correlating
physical change with clinical and physiologic measures. Limited data exist
quantifying physiologic peripheral nerve changes in individuals receiving
biotherapy. Studies of factors predictive of susceptibility to neuropathy
are lacking.
This exploratory, predictive study will characterize peripheral nerve
function over time in individuals undergoing biotherapy. The aims are
to determine: 1) changes in peripheral nerve function following treatment
with biotherapy, 2) the extent to which individual characteristics predict
peripheral nerve changes beyond the effect of drugs, and 3) the relationship
between extent of neuropathy and symptom distress. Criterion validity
of clinical measures assessing effects of neuropathy will be determined.
Framework: A physiologic framework of neuronal degeneration is used.
Methods: Independent variable: Cumulative dose of biotherapy over time.
Moderating variables: Aage and gender. Outcome variables: Sensation, gait/balance,
vibration, muscle strength, vision, hearing, orthostatic blood pressure,
and symptom distress. A convenience sample of 65 subjects are being recruited
from patients diagnosed with cancer receiving biologic agents at three
cancer centers in Cleveland, Ohio. The sample size was determined by power
analysis (alpha .05 power .87, effect size .25). Measures are taken at
baseline, one, and three months after treatment, and two months post-treatment.
Data Analysis: Data will be analyzed using plots and regression slopes
to determine change over time. Hierarchical regression will determine
predictors (age, gender) controlling for cumulative drug dose. Multiple
regression will examine the relationship between peripheral nerve changes
and symptom distress. Pearson’s correlation coefficients will determine
criterion validity of clinical measures for hea |
