Monica Fradkin, RN, BSN, MPH, OCN
Seeing significant growth in the number of patients being treated with immunotherapy within their healthcare system, a multidisciplinary team of nurses and other practitioners at the Smilow Cancer Hospital at Yale-New Haven led a multipronged effort leveraging their electronic medical record (EMR) system to improve the management of these patients across all levels of the healthcare system and help them to stay on these life-saving therapies.
Monica Fradkin, RN, BSN, MPH, OCN, presented the findings from her team’s experience with the initiative so far at the 42nd ONS Congress. She said that a working group was convened last year after seeing the number of immunotherapy patients at the Yale-New Haven network’s clinics increase to 430 from just 9 in 2013.
When examining how best to serve these patients, Fradkin said they discovered wide variation in how patients on immunotherapies were managed and a lack of staff knowledge about the drugs’ potential risks and side effects. One problem they identified involves when these patients have to go to the emergency department (ED) and are seen by a non-oncology provider, or when they visit a primary care physician with subtle symptoms that could have been identified and treated with steroids earlier on if they had consulted their oncologist.
Moreover, she said, “Our EPIC-based EMR didn’t really have the documentation to support the practice.”
Immunotherapy Education at All Levels
To address these gaps, a multidisciplinary group of advanced practice providers, nurses—including staff nurses who see the patients every day—pharmacists, and consulting expert physicians gathered information and set goals and then developed the educational content to be optimized for inclusion in the EMR. They also identified and evaluated the standard patient education materials on immunotherapy.
“We wanted to make sure that [our program] crossed everyone who was going to be in the room,” and addressed all of their needs, Fradkin said.
They developed an educational program that explained the role of the immune system in cancer, mechanism of action, and the specific side effect profiles for all of the drugs and how to manage them. Advanced practice providers served as faculty, Fradkin said, as they are the ones who had been working most closely with and managing these patients early on in the immunotherapy clinical trials.
In the area of patient education, they found the available resources were not patient-friendly or comprehensive. “We liked the idea of an information card that patients could hand to their primary care provider, or if they did go to the ED, to alert them. We also decided to create an interactive patient education video that could be used on our YouTube channel.”
The group is also exploring how to incorporate the video into My Chart, so that it can be distributed through their EPIC system. A patient and family advisory group provided feedback on the materials to make sure medications and side effects were explained in a way they could understand.
Best Practice Alerts and Telephone Triage
Now that they had this information, the team wanted to optimize their EPIC-EMR capabilities to distribute it to the healthcare providers that patients are likely to encounter. To accomplish this, they created a Best Practice Alert, noting that the patient is on an anticancer immunotherapy and directing the provider to call the oncologist before making any treatment decisions.
They also added an “FYI” tab at the bottom of the record with helpful information to guide anyone caring for the patient who is on immunotherapy, including the staff nurse and pharmacist.
Telephone triage guidelines also had to be revisited: “We found that we weren’t asking the right questions specifically around the immunotherapy agents.” When a call comes in, the secretary will create a message that is routed to the nurse, who would then call the patient and ask the standard questions appropriate for chemotherapy. However, “for immunotherapy,” she said, “we weren’t asking enough questions.”
Examples of some of the questions added include: Do you have abdominal pain? Are you cramping, experiencing nausea or vomiting? Do you have blood in your stools? The answers to these questions help the practitioner to make the decision about whether the patient needs to be seen urgently.
They also created an ambulatory-specific flow sheet for immunotherapy, specific to the organ system, so clinicians know what to look for. Bowel movement patterns, for example, illuminate colitis risk. O2
stats when patients are resting versus walking can be clues to pneumonitis. Fradkin said with the latter, they found that staff could miss subtle changes in patients’ oxygen saturation.
“You have the ability to trend when you document in an electronic medical record, and when you do that, you can actually see subtle changes that you may not realize from encounter to encounter, if you’re not looking back at previous encounters.”
And now that the staff has these tools, Fradkin said, “We have the ability to standardize how we perform assessments and also standardize documentation.”
An Ongoing Effort
In addition to improved provider and patient education, the group wants to measure if their work impacts outcomes, such as reduced visits to the ED and reductions in the number of serious immunotherapy-related adverse events. And especially, she said, “Were we able to have patients continue therapy longer because we recognized symptoms earlier than we may have?”
Fradkin highlighted several takeaways for other cancer center staff looking to enhance their immunotherapy treatment efforts: “We learned that what we thought would be a ‘quick, put some education together’ [activity] actually takes a long time, and it took a large group of us working to get this done.”
“We also learned that issues are interlocked. The Best Practice Alert that we thought would make so much sense for the [non-oncology] providers by sharing what we learned, actually impacts the whole system, so there were multiple barriers and layers to get that approved.”
Above all, said Fradkin, “Collaboration across the disciplines was the key to the success of this program, and that was how we have been able to take it to the next step.”