A collaborative interprofessional team of healthcare providers from a regional comprehensive community cancer program established standardized chemotherapy and immunotherapy preadministration documentation in the electronic health record. This quality improvement project facilitated adherence to administration considerations defined within Oncology Nursing Society chemotherapy and immunotherapy guidelines and established organizational accreditation goals. The goal was to foster safe and seamless patient-centered care.
AT A GLANCE
- Interprofessional healthcare providers can utilize teamwork and collaboration to create standardized, evidence-based processes to optimize chemotherapy and immunotherapy documentation.
- A centralized location in the electronic health record to document tolerance, dose adjustments, and ongoing maintenance across all stages of cancer treatment increases quality of care.
- Chemotherapy and immunotherapy preadministration SmartPhrases, or notes, support patient-centered care and rapid access for review of deviations and patient tolerance of treatment regimens.
Chemotherapy and immunotherapy treatment regimens include high-risk medications related to their narrow therapeutic index and high risk for toxicities. Complex multidrug and multiday regimens create a susceptibility for errors if adherence to protocols is inconsistent or if pertinent patient-specific information is omitted (LeFebvre & Smith, 2019). Prior to administration, verification of accurate patient information by two practitioners who are chemotherapy certified is required at Providence Regional Medical Center Everett (PRMCE), a 571-bed medical center and dedicated comprehensive cancer center in Washington state, to meet guidelines and recommendations for safe practice. According to Neuss et al. (2017), dual verification prior to administration needs to include the following components:
• Drugs, including accurate dosing
• Protocol, with or without deviation
• Correct route
• Treatment plan and schedule
• Signed consent
• Accurate height and weight or body surface area (BSA)
• Laboratory work within administration parameters
• Completed patient education
• IV access device and site assessment for patency and condition
Adherence to the dual verification process minimizes professional liability and maximizes patient safety.
Opportunity for Improvement
The interprofessional improvement team at PRMCE observed variation in medication preadministration practices on their 34-bed inpatient medical oncology unit. Lack of comprehensive documentation and adherence to the Oncology Nursing Society (ONS) recommendations and guidelines for chemotherapy and immunotherapy administration generated safety and liability concerns (LeFebvre & Smith, 2019). Informal prechecks were completed on paper and not integrated as part of the electronic health record (EHR). Patient-specific information related to treatment tolerance, protocol deviations, and dose adjustments were not consistently communicated verbally or documented electronically across all stages of care and clinical settings. Without a centralized location in the EHR, this lack of documentation provided a significant opportunity for improvement (Bakshi & Trivedi, 2018).
The quality improvement project goals included (a) standardization of preadministration documentation with dual provider verification and (b) centralization of relevant information in the EHR. This project was implemented during a 13-month period with a primary aim of developing a reliable mechanism for tracking individual patient tolerance, side effects, and complications.
An interprofessional team was formed to implement a standardized process using evidence-based interventions for chemotherapy and immunotherapy documentation (Cantril et al., 2019). The EHR program Epic® was used to establish a cancer-specific template and chart note commonly recognized as a SmartPhrase. This note was subsequently saved and classified as a treatment plan in the EHR. The SmartPhrase incorporated fundamental elements of the ONS recommendations for safe chemotherapy and immunotherapy administration (see Figure 1). Functionality included automatic population of current laboratory values and BSA. Notes could be duplicated and edited between caregivers to identify all dates of therapy, communicate nursing interventions, assess treatment plans, and monitor patient tolerance. This electronic intervention prompted the provider to complete all fields using hard stops. Hard stops forced each user to enter all relevant information in order to sign and save the SmartPhrase. This redesigned workflow also required a cosignature to be applied for the dual verification process between two oncology certified providers before initiation of the treatment plan.
Ongoing feedback was solicited from oncology nurses and pharmacists during several cycles of testing and revision. Three audits were performed: baseline, three months, and postimplementation of the final version. Audits included preadministration criteria along with cosignature of a verification note by two chemotherapy-certified individuals. The final revision of the SmartPhrase was approved by clinical informatics, the ChemoCare committee, and the committee on cancer. Based on approval by all parties, it was then pushed out by clinical informatics. This intervention ultimately led to improved adherence and utilization of the SmartPhrase.
Nine components defined within the ONS guidelines to assess documentation completion of chemotherapy and immunotherapy preadministrative checks were analyzed (see Table 1). The final audit exhibited 100% adherence of six components from August 2018 to February 2019, including dual verification by two chemotherapy-certified individuals. A 6% decrease was noted in documentation of two components (see Table 2). Practitioner utilization of the SmartPhrase exceeded the 95% project goal.
Chart audits identified key opportunities for quality improvement; however, there were some limitations. The number of patients receiving chemotherapy and/or immunotherapy was limited on this unit, which admitted internal medicine patients and patients with cancer. Expert nurses were often assigned to patients receiving chemotherapy and/or immunotherapy, and, therefore, novice nurses were less represented in the audits. Because of the lack of opportunity to complete the note, it was difficult for nurses to bridge the gap from novice to expert (Herena et al., 2018).
Laboratory Service Provider
A change in the contracted outpatient laboratory service provider mid-project created another limitation. To verify that laboratory tests were within administration parameters, results needed to be obtained from an outside source and then copied and pasted into SmartPhrase versus automatically populating (Doyle-Lindrud, 2015) from the internal EHR. This likely contributed to missing or incomplete laboratory results in the chart note during audits.
Value of Free Text
Audits revealed inconsistency in the free text (comments) entry box under treatment plan and dose verification sections of the note. Protocols that required multiple doses within a 24-hour timeframe represent the potential for errors to occur. An example of this would be a patient scenario that requires a treatment protocol with Ara-C every 12 hours. If the patient received the first dose at 10 pm and the second dose 12 hours later at 10 am, day 1 spanned two calendar days instead of one. Without communicating this pertinent information, a nurse could inadvertently miss administering a dose.
Staff education was less comprehensive for SmartPhrase revisions and subsequent push outs by informatics. Methods employed were emails, staff huddles, one-on-one communication, and job aids. Verification that the information was obtained or understood was not tracked. Multiple versions of the note being used simultaneously because of patient treatment occurring during the revision process created confusion. The lack of mandatory simulation or hands-on training for the final version did not allow for reinforcement of information or return demonstration.
One goal of the interprofessional team included dual verification to optimize chemotherapy/immunotherapy documentation and minimize professional liability. The pharmacy had an established interdepartmental system for dual verification between two pharmacists. The pharmacy department felt it was redundant to participate by cosigning the SmartPhrase. The significance of the RN performing a bedside assessment to confirm patient-specific information such as accurate height and body weight versus information obtained from the EHR was underappreciated. Without confirmation via the nursing assessment, erroneous documentation in the EHR could be used for incorrect dosing, leading to a possible sentinel event.
The copy-forward electronic feature in the EHR made edits easier for providers; however, the process may contribute to errors if information is not updated or incorrect documentation is carried forward (Patterson et al., 2017). Because the purpose of this improvement project was to assess SmartPhrase documentation completion, this limitation was not evaluated.
Implications for Nursing
In today’s complex oncology work environment, it is paramount that nursing expertise, bed or chair availability, drug cost, admission or appointment time, and clear documentation are all considered with every patient encounter. Chemotherapy and immunotherapy treatments have a narrow therapeutic index and are expensive. The SmartPhrase verification note is recommended for completion before scheduled treatments. A second nurse assigned to the patient could copy forward the SmartPhrase and further individualize their interventions. This allows for collaboration prior to the scheduled treatment time and avoids delays in care by ensuring that all prechecks are completed.
This process also minimizes the possibility of incorrect dosages and prevents remixture of drugs. For example, one common scenario is reflected in patients who adversely react to rituximab. On subsequent rituximab infusions, the oncology nurse could reference the SmartPhrase to review previous adverse reactions, patient tolerance, and length of infusion time to anticipate complications and promote safer administration. The SmartPhrase template was designed for all treatment plans, regardless of routes or combination of treatments, and offers a universal means of documentation in healthcare settings that utilize Epic systems.
Implications for Practice
Collaboration between multiple stakeholders, including clinical informatics and bedside providers, is encouraged to redesign workflow. This project led to adoption and centralization of an EHR SmartPhrase to locate a concise summary of the patient’s cancer treatment plan. Results included improved documentation, safer drug administration, liability risk reduction, and facilitation of communication between providers across inpatient and outpatient settings.
Many organizations and healthcare systems utilize Epic EHR systems, which offer them the ability to create SmartPhrases that promote replication and consistency (Bakshi & Trivedi, 2018). SmartPhrases can be shared within an individual facility and/or network of healthcare delivery systems to promote adherence to the ONS guidelines and recommendations for practice, as described by LeFebvre and Smith (2019). Adaptation of similar mechanisms within other EHR systems should be encouraged.
The interprofessional team generated a custom-built SmartPhrase that standardized preadministration documentation for an inpatient and outpatient EHR. The note was centrally located and easily accessed from shift to shift or on subsequent encounters to review prior patient tolerance and side effect management. This template incorporated ONS guidelines and recommendations with protocol verification to ensure safe drug administration and patient-centered care based on clinical status at the time of treatment. Collaboration between oncology disciplines and expert practitioners led to approval by senior leaders and the cancer partnership American College of Surgeons committees. This initiative also decreased liability concerns and fostered a culture of patient safety while avoiding the following nursing conundrum: If it wasn’t documented, it wasn’t done.
The authors gratefully acknowledge Elizabeth Ser, BA, Renee Porter, and Dana Utter, for the development of SmartPhrase.
About the Author(s)
Mary Jo Sarver, ARNP, AOCN®, CRNI, VA-BC, LNC, is a clinical nurse specialist in oncology and infusion services at Providence Regional Medical Center Everett (PRMCE) and the chief executive officer of Sarver Better Living Products, LLC, both in Everett, WA; and Monica McManus, BSN, RN, OCN®, is a unit supervisor, Amy Allen, BSN, RN, OCN®, is a staff RN and chair of the ChemoCare committee, Bethany Johnson, RN, OCN®, is a staff RN and cochair of the ChemoCare Committee, and Dennielle Padgett, BSN, RN, OCN®, is a staff RN, all in medical oncology at PRMCE. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Sarver can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org.
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