Oncology nurse navigators are known for identifying gaps in cancer care, being proactive in setting goals to address them, and designing specific interventions that lead not only to better—and measurable—outcomes but also to increased patient satisfaction.
“That’s what makes the difference between navigation and other types of nursing within oncology,” said Teresa Labovich, RN, MSN, OCN, a gastrointestinal (GI) nurse navigator at St. Francis Hospital in Colorado Springs.
Nurses who led successful GI navigation projects at their hospitals and in their surrounding communities provided some real-world examples of how navigation can change practice and improve outcomes in oncology during a podium session at the ONS 40th Annual Congress held April 23-26 in Orlando, Florida.
A Creative Approach to Screening
The American Cancer Society’s (ACS) colorectal cancer screening goal of “80% by 2018” inspired Heather Askren, NP-C, RN, OCN, and colleagues to seek an accessible, effective—and fun—way to increase awareness in the communities where they work of the importance of screening.
Askren is Oncology Program Coordinator with Franciscan St. Elizabeth Health in Lafayette, Indiana, a state where colon and rectal cancer rank among the top four cancer diagnoses and are often diagnosed at a later stage, and where nearly one in three adults are not getting their recommended screening, said Askren.
To meet the ACS 2018 screening goal, the group sought a program that would be fun and educational, Askren explained, and—also important—portable, so that it could be taken to sites throughout their home county of Tippecanoe and to remote rural areas up to an hour away from the hospital.
Their solution: purchasing an inflatable, walk-through colon that people could experience where they are—at places like shopping malls and community events. They discovered the largest demonstration colon available for purchase cost $7000, and with the help of their hospital’s foundation department, Askren’s team wrote a grant application and received the funding they needed.
The inflatable colon is 10 feet tall, 12 feet wide, 20 feet long, and weighs about 180 pounds. It comes in a giant sleeping bag–like a sack and folds down to a manageable size for transporting. It comes with an inflator; one person can erect it, but it requires about four people to take it down.
The colon they purchased has enough space for up to eight educational displays. On the advice of a surgeon, the team decided to illustrate normal colon tissue, Crohn’s disease, diverticulitis, polyps, malignant polyps, colon cancer, and advanced colon cancer. There is also a display on keeping your colon healthy. A description is provided at each of the stations in both English and Spanish. Upon exiting the colon, individuals are given information on screening guidelines and ways to reduce their risk, as well as a fetal occult blood test kit with information on talking with a primary care provider about scheduling an outpatient appointment for a colonoscopy.
The team debuted the colon in the entrance lobby of the hospital. It created such a buzz that within just 24 hours, they had requests to display it from local businesses, churches, and other organizations.
Askren said that when they take the giant colon to shopping malls, “We find that children really like the display. From a distance, they think it’s a bouncy house, so they run at us at full steam. They’re slightly disappointed when they get there, but since they’ve made it that far, they make their parents and grandparents go through it.”
Over the first 6 months, Askren reported, “We’ve had almost 2000 people go through our colon, so we’re really getting it out there. We are really making a difference, and I think by 2018, we will get many more people screened.”
Best Practices in GI Navigation
NCCN guidelines recommend starting adjuvant chemotherapy within 30 days of surgical resection in colon cancer, and each 30-day delay results in a 14% drop in overall survival. In the first of 3 navigation initiatives Labovich shared at ONS, she and her colleagues designed a project with the goal that 90% of colon cancer patients at her hospital would meet the <30-day standard, knowing that variables such as postsurgical complications could delay the start of chemotherapy for some patients.
To meet this target, Labovich reviewed pathology reports and charts and worked to get patients in to see a medical oncologist and move them through the system as soon as possible. “We’ve actually done really well,” she said: For the 61 patients receiving the intervention, the average time to start of adjuvant therapy was 30 days.
Labovich and her colleagues also set a therapy initiation goal for hospital patients with rectal cancer, and the results were similar. National benchmarks recommend treatment within 6 months of diagnosis for patients with rectal cancer, Labovich said, but no one on her multidisciplinary team felt comfortable with that time frame. Extrapolating data from their colon cancer project, they decided to set a goal of neoadjuvant chemoradiotherapy within 30 days of diagnosis, again setting a target of 90% of patients in treatment within 1 month.
“This is a patient population that I stayed very, very close to for several reasons,” Labovich explained. Four types of subspecialists are involved (gastroenterologists, and medical, surgical, and radiation oncologists), and each has a different role. Additionally, patients have several treatment modalities, requiring a complex staging and planning phase before their treatment can start.
The intervention yielded another success story: out of 73 patients, the team achieved 29 days as the average time to treatment.
The third project Labovich presented involved increasing uptake of Lynch syndrome screening among patients with colorectal cancer. In 2012, NCCN guidelines recommended that all colorectal cancer patients younger than age 50 get screened [the recommendation is now expanded to those <70 years].
Lynch syndrome is a known risk factor for colon cancer: incidence in the general population is 5.5%, but among individuals with Lynch syndrome, the rate is 52%-82%, Labovich said. Knowing whether a patient has the syndrome is important, as treatment decisions may be impacted. Having the syndrome requires more frequent and careful follow-up screening among survivors and family members, and some patients may have prophylactic procedures to reduce their increased risk of other malignancies, such as endometrial and ovarian cancer.
At Labovich’s institution, Lynch syndrome screening in 2012 was 61% for patients <50 years (n = 18). Her committee decided to set a goal of universal Lynch syndrome screening for their patients with colorectal cancer, regardless of age.
Labovich said that her team found “a huge knowledge deficit about Lynch syndrome among physicians,” and thus, the navigation intervention focused on provider and staff education, tracking and monitoring pathology reports, and facilitating patient flow through the multiple GI disciplines.
In 2014, after 2 years of the intervention program, the percentage of colorectal cancer patients being screened for Lynch syndrome increased to 93%.
Despite the barriers to navigation, which include institutional resistance to change and an increasingly complex healthcare system, “We all have the ability to impact the outcome of patients, to impact the delivery of care, and to improve the cost delivery of care,” Labovich said.
Askren offered some practical advice for nurses hoping to establish navigation programs where they work: focus on just 1 or 2 goals that offer the potential of having a real impact in your institutions and communities, a strategy that may also help navigators to secure outside grant funding for their projects.
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