SummaryPractice and infusion nurses at North Shore Medical Center Cancer Center identify all patients treated at the center who are subsequently admitted to the hospital with a possible chemotherapy-related toxicity. For each of these patients, nurses complete a standard data collection form reviewed by a team of clinicians who determine whether the patient has suffered from a chemotherapy-related toxicity. Data from these patients are then entered into a toxicity registry used by the clinician team to analyze trends, establish toxicity benchmarks, and modify clinical practices so as to prevent future cases of toxicity. The registry and accompanying analysis has led to the development of quality improvement initiatives targeted at certain types of chemotherapy-related toxicity. These initiatives, in turn, have served to reduce the risk of such toxicities, including eliminating admissions of nondiabetic multiple myeloma patients due to hyperglycemia and reducing the risk of treatment-related diarrhea in colorectal cancer patients.Moderate: The evidence consists of pre- and post-implementation comparisons of the number of hospital admissions due to chemotherapy-related hyperglycemia in nondiabetic patients with multiple myeloma and the percentage of colorectal cancer patients experiencing treatment-related diarrhea.
Developing OrganizationsMass General North Shore Medical Center Cancer Center
Date First Implemented2001
Problem AddressedA significant portion of cancer patients receive chemotherapy treatment that can be highly toxic and cause severe side effects that may lead to the need for inpatient care. The incidence of toxicity is rarely tracked in community care settings where the vast majority of cancer patients receive care, thus limiting the ability of these settings to understand the problem and develop quality initiatives that could improve the safety of chemotherapy administration.
- Many chemotherapy patients: More than 1.5 million new cancer cases will be diagnosed in 2010.1 Although no hard data are available, a significant portion of cancer patients receive chemotherapy as part of their treatment.2
- High toxicity, leading to need for inpatient care: Chemotherapy can be toxic to patients, with such toxicity manifesting in numerous ways, including nausea and vomiting, diarrhea, constipation, hair loss, peripheral neuropathy, mouth and throat sores, infections, and anemia.3 Often patients who experience these chemotherapy-related symptoms require inpatient care; for example, of all of North Shore Medical Center Cancer Center's patients who are admitted to the hospital, approximately one-third are due to chemotherapy-related toxicity.2
- Inadequate data to inform quality improvement: Clinical trials often measure treatment-related toxicity, but relatively few patients receive care in these settings. Rather, most chemotherapy administration occurs in community-based settings that do not track trends in toxicity, thus preventing the implementation of quality improvement activities to reduce such toxicity. A patient registry that tracks chemotherapy toxicity can help clinicians to monitor trends and modify practices to minimize toxicity,2 but relatively few organizations have such registries.
Description of the Innovative ActivityPractice and infusion nurses at North Shore Medical Center Cancer Center identify all patients treated at the center who are subsequently admitted to the hospital with a possible chemotherapy-related toxicity. For each of these patients, nurses complete a standard data collection form reviewed by a team of clinicians who determine whether the patient has suffered from a chemotherapy-related toxicity. Data from these patients are then entered into a toxicity registry used by the clinician team to analyze trends, establish toxicity benchmarks, and modify clinical practices so as to reduce the risk of future cases of toxicity. Key elements of the program include the following:
- Nurse-led data collection: Oncology and chemotherapy infusion nurses identify patients who received chemotherapy at North Shore Medical Center Cancer Center in the past 30 days and subsequently required hospital admission. Data are collected through three methods, with duplicate forms being discarded, as outlined below:
- Hospital admission log: Each day, the lead oncology practice nurse reviews the daily hospital admission log for the cancer center's affiliated hospital (North Shore Medical Center) to identify all center patients admitted to the hospital who received chemotherapy in the last 30 days. For each patient identified, the nurse completes a standardized data collection form using information gathered from the patient chart, including demographics, characteristics of the cancer diagnosis, comorbidities, treatment details, and reason for admission.
- Patient or family notification: Some cancer center patients or their family members will call the center to report the admission. In these circumstances, a practice nurse records this information using the standardized data collection form.
- Subsequent chemotherapy visits: Whenever a patient returns for a subsequent cycle of chemotherapy, the infusion nurse asks the patient about chemotherapy side effects and hospital admissions within the past 30 days. The nurses complete the standardized data collection form for each patient reporting toxicity-related side effects and/or hospital admission.
- Confirmation of chemotherapy-related toxicity admissions: All medical oncologists, a nurse practitioner, a practice nurse, an infusion nurse, and a pharmacist meet monthly during lunch time to review the completed data collection forms for that month; the team typically reviews between 5 and 20 cases at each meeting. Team members discuss each case and consult the patient's medical charts from the cancer center and hospital when necessary. The team then votes as to whether the admission was related to chemotherapy toxicity or to the disease itself. The meeting also provides a forum in which clinicians can discuss variations in practice patterns and attempt to identify best practices; the team notifies the cancer center's professional practice committee when meaningful variations have been uncovered so that the committee can investigate issues and act to standardize care.
- Entry of toxicity admissions into registry: Once the team determines that an admission is due to chemotherapy toxicity, a research assistant enters the patient's information into an electronic spreadsheet that serves as the chemotherapy toxicity registry.
- Periodic analyses to identify trends and improvement opportunities: Twice each year, the team reviews all the chemotherapy toxicity admissions entered into the registry. The purpose of this review is to identify clusters of patients with certain types of cancers who are admitted to the hospital with chemotherapy toxicity. If trends are discovered, the team analyzes potential causes and develops quality and safety initiatives specific to the identified patient population. For example, through this process the team found that patients with multiple myeloma and colorectal cancer were admitted more often for toxicity related to their chemotherapy treatment, and they instituted the following quality improvement processes:
- Glucose monitoring in patients receiving high-dose dexamethasone: During a registry analysis, the team realized that several nondiabetic patients with multiple myeloma who received a chemotherapy regimen including high-dose dexamethasone were admitted to the hospital for hyperglycemia. The team developed and implemented routine glucose monitoring guidelines (e.g., by adding a blood glucose test order on the standardized order sheet) for all patients receiving a treatment regimen that includes this agent. If a patient has a blood glucose greater than 250 milligrams per deciliter, the patient receives treatment (e.g., insulin) to lower this level.
- Program to reduce treatment-related diarrhea in colorectal cancer patients: Another analysis revealed that gastrointestinal toxicity (mostly diarrhea) accounted for 76 percent of colorectal cancer patient admissions, including three fatalities. The team noted that a particular treatment regimen seemed to be associated with most of these admissions, communicated this information to oncologists, and suggested that that they consider an alternative chemotherapy. The team also developed a flow sheet for infusion nurses to use to track the presence of diarrhea on the day of treatment and the use of antidiarrheal medication to premedicate patients 24 hours before treatment. Nurses use the sheet as a communication tool to inform the oncologist of this risk factor and inquire about the potential to withhold treatment or adjust the dose.
Context of the InnovationThe North Shore Medical Center, part of the Partners Health Care System, is a 400-bed facility located in Peabody, MA. The Mass General North Shore Medical Center Cancer Center, a freestanding outpatient cancer facility, provides onsite chemotherapy and radiation services to a service area of approximately 200,000 adults. Each year, cancer center clinicians evaluate more than 1,000 new cancer cases and administer approximately 3,000 chemotherapy treatments. Dr. Joseph Jacobson, chairman of medicine at the North Shore Medical Center and a practicing oncologist at the cancer center, came up with the idea for the registry after one of his patients died from toxicity following the initiation of treatment with a standard regimen of palliative chemotherapy. Dr. Jacobson wanted to track how often chemotherapy administered at the center caused severe toxicity, believing that such aggregate information could help clinicians to monitor trends and modify practices to minimize toxicity.
ResultsThrough June 2009, the registry includes more than 30,000 new chemotherapy starts and more than 440 episodes of severe toxicity, including more than 20 fatalities. Two quality initiatives were developed because of trends detected during the review of all chemotherapy toxicity-related admissions in the registry. These efforts eliminated hospital admissions among nondiabetic multiple myeloma patients due to hyperglycemia and reduced the risk of treatment-related diarrhea in colorectal cancer patients.
Moderate: The evidence consists of pre- and post-implementation comparisons of the number of hospital admissions due to chemotherapy-related hyperglycemia in nondiabetic patients with multiple myeloma and the percentage of colorectal cancer patients experiencing treatment-related diarrhea.
- No admissions for hyperglycemia in nondiabetic patients: Since implementation of the glucose monitoring guidelines, no nondiabetic cancer center patient has been admitted to the hospital due to chemotherapy-related hyperglycemia. In 2002, when the trend was detected, six nondiabetic multiple myeloma patients were admitted to the hospital for hyperglycemia.
- Less risk of treatment-related diarrhea: The risk of treatment-related diarrhea among colorectal cancer patients treated at the center decreased from approximately 15 percent in 2003 (before implementation of the initiatives targeting this problem) to roughly 4 percent in 2005.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Forming the team: North Shore Medical Center created a project team to lead the effort that includes the director of medical oncology, a staff oncologist, two oncology practice nurses, an infusion nurse, and a pharmacist.
- Mapping current chemotherapy processes: The team mapped the current chemotherapy administration processes to help inform the creation of a system to identify patients admitted to the hospital with life-threatening or fatal chemotherapy-related toxicity experienced within 30 days of chemotherapy administration.
- Creating and disseminating data collection form: The team created the standardized data collection form to capture information about a patient's admission. A practice nurse on the team presented the form to each of the cancer center's nurses, while the head infusion nurse presented the form to her nursing staff.
- Creating the registry: The director of pharmacy designed a spreadsheet to store information entered from the data collection forms and serve as the chemotherapy toxicity registry.
Resources Used and Skills Needed
- Staffing: A part-time research assistant enters data into the registry and assists with data analysis.
- Costs: Program costs consist primarily of salary and benefits for the part-time assistant, which run approximately $19,000 annually.
Funding SourcesNorman Read Family Trust
Between 2005 and 2010, the cancer center has received grants totaling $92,000 from the Norman Read Family Trust in Salem, MA, to fund the part-time research assistant position.
Getting Started with This Innovation
- Identify devoted champion and willing participants: A project of this nature needs a committed champion passionate about its value and willing to devote time to the effort. (The chairman of medicine did much of the work on a voluntary basis until he could secure funding for a research assistant.) The champion should identify like-minded clinicians interested in participating, rather than assigning participation to a potentially unwilling staff member.
- Emphasize quality and safety benefits to nurses: Nurses at the cancer center readily embraced the initiative, including their role in collecting data, once they saw the potential quality benefits for patients. Nurses also appreciated the fact that the forms could serve as a communication tool to help them approach physicians to express concerns about the potential for chemotherapy toxicity in a particular patient.
- Involve frontline staff: Assign the data collection task to individuals (typically nurses) involved in key processes, particularly those who interact frequently with patients.
- Simplify data collection and analysis: For example, the standardized data collection form requires little nurse time (less than 5 minutes), and the team schedules its monthly meeting during lunch to facilitate participation. In addition, the team found creating a spreadsheet to be the quickest and easiest way to track and analyze toxicity data.
Sustaining This Innovation
- Encourage involvement of different clinicians: Bringing physicians, nurses, and pharmacists together on a monthly basis has created a new dialogue about the safety of chemotherapy regimens. The monthly meeting has improved knowledge among all clinicians that can be applied to future care decisions and enhanced professional rapport among colleagues who might not otherwise have an ongoing relationship.
- Do not take sustainability for granted: Shifting responsibilities and priorities can easily derail quality improvement initiatives, even low-cost initiatives that produce meaningful benefits. Consider how physician incentives may affect the sustainability of a project; physicians paid purely on the basis of productivity (patient volume) may not actively support small-scale quality improvement projects that take up a lot of their time.
Contact the InnovatorJoseph Jacobson, MD, MSc
Chief Quality Officer
Dana-Farber Cancer Institute
450 Brookline Avenue
Boston MA 02215
Phone: (617) 632-5431
Innovator DisclosuresDr. Jacobson has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesKrzyzanowska MK, Treacy J, Maloney B, et al. Development of a patient registry to evaluate hospital admissions related to chemotherapy toxicity in a community cancer center. J Oncol Pract. 2005;1(1):15-19. [PubMed]
Jacobson J. Creating & Managing Primary Data. PowerPoint presentation. April 1, 2010. (Available by request from the innovator.)
Original publication: February 02, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: December 17, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.