In June 2016, I was diagnosed with stage II breast cancer with lymph node involvement. The treatment plan included lumpectomy, 4 cycles of chemotherapy over 12 weeks, radiation, and hormone therapy.  It sounded reasonable and I thought it would be uneventful.  I was wrong.

A port was placed and chemotherapy started the last week of July. I experienced high fever and chills on August 13th. I was instructed to call the oncologist if my fever went above 100.5. My fever went to 102 despite applying ice packs and taking acetaminophen every 4 hours. In the morning, I contacted the oncologist on call and was told to come to the emergency room for an evaluation.

I went to the ER where labs and blood cultures were drawn. Intravenous fluids and IV antibiotics were started. I was admitted to the hospital with the diagnosis of sepsis. The fever and chills continued. Blood cultures revealed a staph infection, and the port was infected. It was removed, and arrangements were made for PICC line placement on the day of discharge. The infectious disease doctor prescribed 6 weeks of IV antibiotics 3 times a day. I was taught to administer the antibiotics and discharged.

Having been in the hospital for 4 days, I was happy but scared to be going home. I have been a nurse for over 34 years; however, it is different when the nurse becomes the patient. I was completely overwhelmed by the responsibility of giving myself antibiotics.

The discharge planner arranged for home care. The infusion nurse came the day after discharge providing education and support. The nurses came weekly to change my PICC line dressing, draw labs, and review the antibiotic administration process. They reassured me that the PICC line site looked great and that I was administering the antibiotics correctly. This helped reduce the stress that I had been experiencing. 

The antibiotics finished in late September, and the PICC line was removed after the last chemotherapy session October 7th, delayed by 1 week from the original plan. This infection complicated my treatment and added additional stress. Thankfully, that phase of the treatment is over.

To read about another nurse's experience as patient with a central line, click here.

Articles

Cover Story

A nurse relates her experience with breast cancer and the added stress of staph infection from a chemotherapy port.

Staph Infection From Infected Chemo Port: When the Nurse Becomes the Patient

Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN

Vascular access is an important component to improving quality of life for patients with cancer. Access is required not only for chemotherapy, but also for frequent blood sampling and intravenous supportive measures. Vascular access devices provide reliable venous access, protect peripheral access, and increase patient comfort through reducing repeated and difficult venipuncture.

Today, numerous devices are available for this purpose and selection is dependent upon type and duration of access, patient factors, and physician preference. These include implantable devices, tunneled catheters, and peripherally inserted central catheter (PICC) lines.

Venous access is not without complication. Although insertion and placement problems are rare with modern access and imaging techniques, catheter-related infection, thrombosis, and loss of function continue to be major problems. In order to combat complications, best practices are emerging.

As a nurse for over 40 years in the Emergency Department and Respiratory Intensive Care, I am familiar with the important role venous access devices play in caring for patients who have serious medical conditions as well as the complications that can occur.  

Venous Access Device Team Made All the Difference

When I was diagnosed with a central nervous system lymphoma in 2014, I knew that I was really sick when my hematologist told me I would need to have a PICC line placed so I could get chemotherapy because the tumor was inoperable.

Looking back, I realize I am alive today due to the aggressive treatment protocol prescribed by the hematology team, but also because of the excellent nursing care I received that protected me from infection and the other complications that I was at risk for as a result of my condition. During the early part of my treatment, I was not aware of what was happening to me. My husband was my advocate as I was confused and could not comprehend things.

As I became more alert, I was able to observe what was happening to me as a patient on the oncology floor of the Sylvester Comprehensive Cancer Center at the University of Miami. One thing that stood out for me was the care that I received from the oncology nurses who worked on the inpatient unit as well in the outpatient settings where I was treated.

The systematic processes were very apparent to me, especially in how my PICC line was changed. I had not seen this before, and I was curious to know how such a large team of nurses working across so many settings could work so well together. One of the nurses who came to see me daily to examine and redress my PICC line was open to answering.

Wendy A. Nunez, RN, is a member of the center’s Venous Access Device Nurses. On one of her visits, I asked her what the nurses on her team do and what they look for when working with patients who had central lines.

“We want to know if the patient and the caregivers understand what is needed to care for and maintain a central line,” Nunez explained. “It's important that every patient understands what to look out for to prevent infection. Also, we want to be sure the patient knows when a dressing needs to be changed, and what to expect from the nurses who are caring for the line.”

Importantly, all of the nurses who were involved in my care (inpatient and outpatient) used the same technique when they changed my PICC line. “The Venous Access Team works closely with the education department to be sure that all nurses are practicing according to our policy and procedures as well as standards of practice,” Nunez noted. “We are strict with following these policies because the oncology population is vulnerable to infections.”

Educating Patients About Caring for Their PICC Line

As I progressed in my treatment, I realized that I and my husband had an important role to play in my plan of care. One thing the nurses stressed who cared for me was how to care for the PICC line when we were home.

“The venous access team strongly believes that patient education is key,” stressed Nunez. “Patients who are knowledgeable in the care and maintenance of their line report problems sooner, protect their dressings more, and have less fear about the central line. Teaching the patient and caregiver reportable signs and symptoms and when to call the doctor cannot only save their line, but, more importantly, can save their life.”

“We let patients know it is important for everyone to perform hand hygiene before touching the central line,” she continued. “We teach how often the dressing should be changed, that the dressing change must be done using sterile technique, and everyone should wear a mask while the dressing is changed. We make sure the patient understands that the hub of the central line must be scrubbed appropriately between each injection and connection to the central line.”

In addition, the nurses explain that the dressing should always look pristine, clean, dry, and intact, and who to call if it is not. “It's important as nurses to arm the patient with knowledge about central lines in their fight against cancer. The central line is central to their treatment, so it's important for them to be well informed about it.”

I could see that the education Wendy’s team provided was working because regardless of where I was in the system, each person took their time, explained what they were going to do, and followed the same protocol. As a result, I felt safe and secure in their care. My husband, as the main caregiver, understood what he needed to do in order to care for the PICC line when we were home. He was given the resources to allow me to shower and the information he needed so he could pick up on a problem and who to call if a problem arose. This gave us both peace of mind.

As a nurse, I know that hospital-acquired infections are serious problems across our country. As I thought about what I was observing, I wanted to know if the training and standardization of processes throughout the University of Miami Healthcare System/Sylvester Comprehensive Cancer Center helped to decrease infection rates. Nunez shared that, “Yes, we did see a decrease in infection since the standardization on all of our inpatient units.”  

I know it is a challenge to do system-wide training, so I asked Nunez how they accomplished this task: “The Venous Access Device Nurse Team worked closely with the education department to train incoming nurses. During orientation, we train them on the policies and procedures for central line care and maintenance. We make sure all nurses are on the same page when they are employed. We want nurses to be vigilant and aware regarding central line care and maintenance, as well as educating patients to care for their line.”

As a patient, I am grateful to all of the professionals who cared for me. I feel fortunate that I had a good outcome and continue to heal. As a nurse, I know that complications can occur, but with the focus on education and instituting a culture of vigilance and caring, positive outcomes do occur. Today, it is being recognized more and more that the challenges we face in the healthcare system will not change until we ensure the patient and the caregivers are recognized as members of the care team.

To read about another nurse's experience as patient, with staph infection from a chemo port, click here.

Association for Professionals in Infection Control and Epidemiology (APIC)

APIC Implementation Guide to Preventing Central Line—Associated Bloodstream Infections

National Institute for Health and Care Excellence (NICE)

Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2

Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN, is a healthcare leader with over 40 years of experience as a critical care nurse, case manager, professional patient advocate, educator, digital journalist, and most recently as a patient with cancer, having been diagnosed and successfully treated for a central nervous system brain tumor. She is involved in a number of educational projects in the state of Florida and nationally. To contact Anne, send an email to 

Venous access devices can come with major problems, such as catheter-related infections, thrombosis and loss of function.

The Power of Patient-Centered Care in Preventing Infections 

Many cases of sepsis are discovered in inpatient settings as comorbidities occurring with other, more prominent medical issues. Frequently diagnosed in ICU settings, sepsis has usually progressed past its early stages once identified. Patients with cancer are at particularly high risk for developing sepsis, and severe septic infections are a factor in at least 8.5% of all cancer-related deaths.

Sepsis risk in the oncology setting is due to a variety of factors. Frequent hospital stays, surgeries, catheter insertions, and other procedures all increase the risk. These patients also already have depressed immune systems and are likely malnourished and frail as a result of treatments and therapies.

It is vitally important that sepsis be diagnosed as early as possible to ensure immediate, appropriate treatment. However, sepsis is usually diagnosed only after patients arrive at hospitals, when critical treatment windows might have already passed.

With so many patients arriving to inpatient facilities with severe sepsis, there is clearly a need for protocols and procedures to help with identification of sepsis in ambulatory facilities, where nurses are on the frontlines of healthcare and in a prime position to recognize sepsis and refer patients for immediate treatment.

According to the Sepsis Alliance, more than 1.6 million Americans, including many patients with cancer, are diagnosed with sepsis every year,

 but significant obstacles to early sepsis recognition remain after these patients are discharged from acute care facilities.

Septic infections begin outside of the hospital for nearly 80% of patients,

 but the public is generally unfamiliar with sepsis as a medical condition; in fact, only 55% of American adults have even heard of it.

 Lack of community awareness presents a huge hurdle to effective sepsis management and can have severe implications for patients with cancer when they return home. Patients and families might receive sepsis education before discharge, but there is no guarantee that the information, if provided, will be effective in illustrating the necessity of sepsis monitoring and the need for urgent treatment if symptoms develop.

Healthcare provider familiarity with sepsis is also an issue, suggesting a need to educate nurses, physicians, and emergency medical technicians on the signs and symptoms of early sepsis. Sepsis, by its very nature, looks like many other diseases. Since many of the early signs of sepsis could apply to a variety of other conditions or diseases, it is especially hard to diagnose.

Sepsis screening tools and bundles have been around for about a decade,

 but these are not commonly utilized in outpatient settings. Nurses might not even know what symptoms of early sepsis to look for in patients with cancer.

As Laura Messineo, RN, MHA, and Sepsis Alliance Board Member explained, “There is a lack of screening in the [outpatient] environment. How many patients come in that have some source of infection, and are [providers] really looking for any kind of systemic inflammatory response out of these patients? I think the core problem is that we aren’t screening for it.”

“Nurses don’t necessarily come out of school with a comprehensive understanding of sepsis,” she continued, “and that really leaves it on the employer, whether in the acute care setting, the outpatient setting, or skilled nursing facilities. I do believe there’s a need for ongoing education in whatever setting nurses practice in.”

) has valuable resources for patients and healthcare practitioners, including handouts and patient education counseling points, along with a special “Nurses Know Sepsis” series, featuring first-person nurse-focused case examples describing their clinical experiences with sepsis.

Seven in 10 patients with sepsis have recently used healthcare services or have chronic conditions requiring frequent medical care,

 and nurses in oncology outpatient settings are in a unique position to educate and screen patients for signs of sepsis.

Current efforts in inpatient settings to develop sepsis screening tools could be applied in the outpatient setting. Several healthcare facilities across the nation, including the University of San Francisco Medical Center, Banner Health, and Presence Health, are developing sepsis screening tools that continually evaluate patient data as it is populated into electronic health records, flagging those patients most at risk for developing sepsis for more careful monitoring.

“There is great opportunity to transfer this type of screening process to the outpatient setting. If you really think about the outpatient setting, the question of, ‘Does the patient have infection, or is there suspected infection?’ becomes important,” said Messineo.

“If we could hardwire sepsis screening into outpatient settings, I think we could catch more patients that are heading toward severe sepsis, and get them the right treatment, so they don’t escalate to septic shock and acute care treatment. There should be actionable steps taken by clinicians for those patients who are identified,” she continued.

Bigger organizations are also working to expand the healthcare provider knowledge base regarding sepsis. The Sepsis Alliance is currently “working on lots of different educational tools for all settings that have recorded dialogue so you wouldn’t actually need a physical person coming out there to provide education. The same message would get to every clinician.”

Resources are geared toward clinicians and patients to aid in the identification of early sepsis. Additional efforts to increase public and provider awareness of sepsis and its early signs continue in the community outside of healthcare facilities.

“I started seeing, on social media alone, patients saying ‘I never knew what [sepsis] was. If I knew the signs, I would have come in for treatment,’” said Messineo. “That really started a movement to increase awareness through special community events. One is a 5K that is solely focused on bringing healthcare clinicians and our community together to recognize those early sepsis warning signs.”

Because so many patients die from septic infections, it is more crucial than ever for healthcare providers, patients, and their caregivers to receive education so they can recognize the early signs—especially outside of acute care facilities. Nurses are in a unique position to educate patients with cancer and their families, but they have to have adequate knowledge of sepsis personally before meaningful education can occur.

“These patients should be armed with this information. Many times, oncology patients die of sepsis and not the actual cancer. We know that sepsis is the third leading cause of death in the United States, so there should be just as much focus on sepsis as there is on heart disease or stroke,” Messineo concluded.

Williams MD, Braun LA, Cooper LM, et al. Hospitalized cancer patients with severe sepsis: analysis of incidence, mortality, and associated costs of care

Seymour CW, Rea TD, Kahn JM, et al. Severe sepsis in pre-hospital emergency care. 

CDC Vital Signs. Making Health Care Safer. Think sepsis. Time matters. 

ECRI Institute. Sepsis: Combating the Hidden Colossus

Khurana HS, Groves RH Jr, Simons MP, et al. Real-time automated sampling of electronic medical records predicts hospital mortality. 

Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Johns Hopkins School of Nursing. Oncology Interdisciplinary Early Goal-Directed Sepsis Management Protocol for IPOP & HIPOP Clinic. 

Schell-Chaple H, Lee M. Reducing sepsis deaths: A systems approach to early detection and management. 

Nurses should be aware of how to identify sepsis in patients with cancer to facilitate early diagnosis and immediately treatment.

Early Sepsis Recognition in Outpatient Settings: Challenges and Progress

Vincristine has been around for decades, and for at least the past 10 years, safety experts and organizations have recommended infusing vincristine in minibags rather than administering it in a syringe using a bolus or “push” administration technique. Inadvertent intrathecal administration of vincristine is neurotoxic and depending on when the error is detected (eg, during administration when a partial dose has been given versus following administration when the entire dose has been administered), patients may be permanently paralyzed or even die.

Making the simple change to administering vincristine in minibags has not been universally accepted. Tragically, in some oncology facilities, vincristine continues to be administered using a syringe and inadvertent intrathecal administration has occurred. It seems unfathomable that this could occur since vincristine is packaged with multiple warning stickers and overwraps, and the recommendation to infuse vincristine in minibags has been around for at least 10 years.

How are these horrific events still occurring? The National Comprehensive Cancer Network (NCCN) notes that 125 deaths have been reported in the United States and abroad since the inception of vincristine use in the 1960s. In addition to published case reports, an unknown number of inadvertent intrathecal vincristine administration events have gone unreported. The commonality in these events is twofold: vincristine was prepared in a syringe, and policies and procedures were not followed. Vincristine was mistakenly injected into the central nervous system rather than given intravenously. This type of error is entirely preventable.

The NCCN, which is best known for its evidence-based chemotherapy treatment and symptom management templates and guidelines, took the unusual step on November 16, 2016 of launching a formal campaign called Just Bag It to promote vincristine safety. It is the first time the NCCN has taken a narrow and very specific safety issue and mandated a practice change for NCCN institutions. The NCCN now joins the Institute for Safe Medication Practices (ISMP), The Joint Commission, the World Health Organization, and the Oncology Nursing Society in advocating for vincristine minibag infusions.

In addition, the updated 2016 American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards (in press) now explicitly state that vincristine is administered in minibags in facilities in which intrathecal medications are administered. 

Pushback about vincristine minibag infusions has centered around two concerns. The first is what some have called the unintended consequence of vincristine infusions, which is an increased risk of vesicant extravasation injuries. However, data suggest that this risk is very low regardless of how vincristine is administered.

When 68 cancer treatment centers in Australia standardized vincristine administration to minibag infusions only, researchers tracked the incidence of vinca alkaloid extravasations. When syringes were previously used to administer 37,084 doses of vincristine, 11 extravasations occurred (0.03%). When 7255 doses of vincristine were administered as minibag infusions, 3 extravasations occurred (0.041%). The researchers concluded that the extravasation incidence was similar and infrequent.

A second issue is the cost differential between syringe and minibag vesicant administration. A minibag of intravenous solution and tubing exceed the cost of a syringe. In addition, a greater amount of pharmacy and nursing time is required to prepare and administer minibags of chemotherapy. However, these concerns are minimal when considered in the context of the degree of harm that may occur from inadvertent intrathecal vincristine administration.

One component of NCCN’s campaign for vincristine safety is recognizing healthcare facilities that have implemented vincristine minibag infusions. All 27 NCCN member institutions have policies that align with NCCN’s recommendations for vincristine safety and are listed on the Just Bag It website (

Other facilities are invited to notify NCCN of their adherence to the Just Bag It campaign by tweeting 

and completing an online form. The question for oncology nurses is: Is 

 facility on the list, and if not, how soon will it be?

Gilbar P & Carrington CV. Vinca alkaloid extravasation: Incidence from administration via syringes and minibags [Abstract 94]. 

Asia-Pacific Journal of Clinical Oncology

Lisa Schulmeister, MN, RN, ACNS-BC, FAAN, is an oncology nursing consultant and editor-in-chief of

Nurse's Notes

The NCCN's Just Bag It campaign looks to put an end to the inadvertent inthrathecal administration of vincristine.

Just Bag It Campaign Promotes Safe Vincristine Administration

Nurses are the vanguard of so many aspects of delivering cancer treatment, perhaps nowhere more than in ensuring safety protocols are faithfully followed. This applies not only when patients are in the hospital but when they go home.

takes a close look at some of the potential safety landmines that need to be top of mind for the oncology nursing professional. I admit that I was surprised to learn that the vast majority of septic infections—nearly 80%&mdash;begin 

In our cover story this month, we hear from nurse experts on how clinicians can help avoid this life-threatening complication—not only by employing best practice themselves, but by arming their patients with the education and information they need to continue their therapies safely and effectively when they get home.

We also hear from nurses who had cancer themselves—one who witnessed firsthand how a nurse well-trained in proper venous access procedures can make all the difference in reducing the risk of infection. Another nurse diagnosed with breast cancer had a very close call when after she was discharged, she contracted a staph infection from an infected port.

In that vein, the NCCN has just launched a “Just Bag It” campaign to underscore the critical importance of minibag administration of the chemotherapy drug vincristine, and Editor-in-Chief Lisa Schulmeister urges her peers to make sure the facilities where they work are in compliance with this life-saving protocol. And, in “Fast Facts for the Frontline” this month, the focus is on wound care issues which oncology nurses are likely to encounter, such as those resulting from surgical incisions or radiation burns.

Also in this issue, we learn more about why building an evidence base is so important to obtaining leadership buy-in for nurse-led navigation and survivorship care initiatives. You know these programs improve patient outcomes and quality of life, but in today’s environment their value must be documented for administrators and payers. This, the experts featured in this issue remind us, means that nurses must add a business mindset to their all-important clinical focus when working to establish and sustain navigation and survivorship programs where they work.

Finally, during this holiday season, we hope you will have some time to pause, recharge, and relax with your families and friends. We extend our very best wishes for the holidays and the new year, and as always, thank you for reading.

From the Chairman

Back to Basics: Spotlighting Safety in Oncology

If one day for any reason you stopped going to your job as a navigator, would the people who follow you be able to pick up where you left off, or would they be stuck trying to reinvent the wheel? Are you building a legacy with your role so that those who come after you can stand on your shoulders and go even further than you, or are you setting them up for failure? Navigators need to start thinking of how we can sustain the progress we have worked so hard to attain.

The way that you help patients overcome barriers to care may seem second nature to you, but you may well find that your common sense is quite uncommon, and the process is more complicated than you had imagined.

Experienced navigators need to write down our common processes. For example, you may refer all of your patients with head and neck cancer to a nutritionist as part of your care coordination. Write down exactly how you accomplish this, what information is required, and to whom the referral is sent. Include the referral form as an appendix, along with any common problems with the referrals and how you have overcome them. Be as detailed as possible, and try to make the language accessible so that anyone can read it.

Put together a binder of all of your processes, or make an electronic document if at all possible so that you can disseminate the knowledge efficiently to all who need it. Remember that process manuals are living documents. Be prepared to make changes as they come.

Navigators need to start thinking of how we can sustain the progress we have worked so hard to attain.

There seems to be a ubiquitous binder in every case manager, navigator, and social worker's shelf full of notes about resources that may or may not actually work. These binders often contain outdated information, making the binder an unreliable waste of space even though it may contain some useful resources.

Our team came up with a simple but effective replacement for the binder; we created a spreadsheet database. It wasn't the most elegant solution, but it was free, and we were able to distribute it across our entire state instantly.

First, we vet all of the resources before placing them in our approved resource list. We exclude resources that do not return our calls or emails. As we communicate with the resource agencies, we confirm and record eligibility information. For continuity's sake, we commit to vet the resources as a team every 6 months. It is surprising how many resources can become defunct within that time span.

Second, we take the approved resource list and enter all of the relevant information onto uniform factsheets created for each resource. The template includes space for contact information, eligibility requirements, nature of assistance offered, and any special notes that could be relevant to the navigator or patient. The factsheets are saved in an electronic folder.

Third, we enter the basic information created for each resource into a spreadsheet, organized across 3 columns: (1) resource name hyperlinked to its respective factsheet, (2) location, and (3) resource type, for example, transportation, support, non-medical bills, and housing. We restrict the resource types to 20 unique terms to make it easier for the navigator to sort the terms for the patient’s specific needs when looking for resources.

Fourth, we use zip software to combine the spreadsheet and resources into a single folder, making sure that all patient health information is deleted from the resource files to prevent violating HIPAA. We upload to a cloud service like Dropbox or Google Drive, enable sharing options, and send the link to all personnel who should access it.

If your hospital system employs database programmers, by all means, use them to create a more refined version, but always take the time to vet the resources periodically. This database can be an invaluable tool to your team and serve them well in case you are absent.

Manuals and databases sustain navigation by improving continuity, but revenue-generating programs will sustain navigation on many different levels. You could hire more staff, prove your monetary worth to corporate leaders, and give your patients better access to care.

 your navigation procedures in a way that they can be easily disseminated

 a centrally accessible list of patient resources by location and type

 all of the successful cases helped by deploying revenue-generating strategies

One of the strengths of navigation is that we can anticipate problems before they occur and arrange for the appropriate screening. In Georgia, we can screen patients with breast and cervical cancer who are self-pay for eligibility for the Women's Health Medicaid program. We also screen Medicare patients for eligibility for QMB (Medicaid’s Qualified Medicare Beneficiary program), as well as for the “Extra Help” program for individuals who need assistance paying for Medicare’s Part D drug coverage. See if your hospital offers any COBRA premium assistance programs to help the recently unemployed maintain their coverage for treatment. Copay and pharmacy replacement programs can also bring in revenue.

Availability of these programs will depend on your location. Sometimes our own organization's systems are so large and disconnected that they don't share patient insurance information. Share the information with your organization's billers. Sometimes you are referred insured patients that supposedly are not covered for certain services; make the call to the insurance company yourself with the proper ICD-10 and CPT codes to confirm this. I have found many times that patients are covered—by confirming coverage, we retain paying patients.

Keep a record of all of the successful cases you have helped, using these revenue-generating strategies and programs. It is a win—win for both your organization and the patient, who in many cases gains better access to care.

These simple and free strategies will help you to sustain your navigation program, build your legacy, and demonstrate that your team is beneficial to your organization.

Jace Longnecker, BA, MBA, CCL, is a lay navigator at Northside Hospital in Atlanta

Nurse Navigators

Nurse navigators should consider sustainability strategies to ensure that their progress remains.

Sustainability Strategies for Navigation

When you think of factors that place oncology patients at high risk for infection, some of the first that come to mind are probably invasive devices like Foley catheters and central venous access devices. Contact with sick visitors or staff members is also high on the list, but what about that surgical incision or radiation burn?

Wounds are very common among oncology patients and can lead to whole host of problems. As oncology nurses, we need to perform frequent wound assessment, monitor the progress of wound healing, and most importantly, ensure that we help our patients learn to care for them on their own.

Surgical incisions are more than just a source of physical discomfort for patients; they also place the patient at high risk for infection if they’re not cared for appropriately. Patients may find it difficult to manage dressings or look at surgical incisions, either because they’re squeamish or because they’re self-conscious about how the incision has altered their physical appearance. This may ultimately influence their ability to care for the wound independently. It’s important for us as nurses to provide adequate pain relief prior to wound care and to ensure that we’re demonstrating aseptic technique in order to prevent infection. We also need to monitor patients for any signs and symptoms of infection following surgery, educating them on what to watch for and report once they go home.

Make sure to follow the postoperative orders for care of the incision outlined by the surgeon. Frequently, dressings need to remain in place for at least 24 hours following surgery. If excessive bleeding is noted on initial assessment of a surgical incision/dressing, immediately notify the provider and find out if you should change the entire dressing yourself or reinforce it until a surgeon can assess the incision in person. Monitoring for signs and symptoms of localized infection (warmth, erythema, purulent drainage, etc) and systemic infection (elevated WBC/ANC, fever, tachycardia, tachypnea, hypotension, etc) is also vital during the immediate postoperative period. Be aware that some of these symptoms may not manifest in immune-compromised patients—septic shock can occur with little to no warning in this patient population.

The simplest intervention is often the most effective in preventing infection: hand hygiene. Cleanse your hands with soap and water prior to performing a dressing change. When selecting a dressing and tape/adhesive, be sure to assess your patient for allergies or past history of medical adhesive-related skin injury (MARSI).  Immunosuppression, advanced age, malnutrition, dehydration, and several other factors common to the oncology patient population place these patients at high risk for skin tears.

Topical burns (radiation dermatitis) will likely be present over areas of the skin where the patient is receiving radiation therapy, depending on the duration and total dosage of therapy. These burns can range from mild erythema and flaking of the skin (dry desquamation) to severe blisters and broken skin (moist desquamation). Internal burns may also be present. Patients receiving therapy for head and neck cancers may have burns in the oral mucosa or esophagus. Those with anal or rectal cancer may have burns to the perineum that make elimination very painful, and keeping those burns clean is of the utmost importance.

: When managing radiation dermatitis, use mild soap and lukewarm water to cleanse the skin. A soft washcloth is best for applying soap, and the skin should be gently patted dry or allowed to air dry after bathing. Patients should also be advised to avoid using products that may make burns worse, such as deodorants that contain aluminum. Encourage your patients to use mild unscented lotion to moisturize dry, flaky skin.

: A provider may prescribe steroid cream to be applied prior to treatment in order to prevent and/or manage erythema, inflammation, and pruritis. However, if moist desquamation develops, use of steroid cream should be discontinued. Silver sulfadiazine cream, an antimicrobial agent, may then be used to help prevent infection. Keep in mind that the cream will have to be removed prior to subsequent radiation treatments; apply a thin layer over the burn to aid in easier removal.

: Mild dermatitis can be managed by applying moisturizer and leaving the burned area open to air. When dressing areas affected by moist desquamation, hydrocolloid or hydrogel dressings will promote healing and prevent further trauma to the skin during removal. Loose-fitting cotton clothing and undergarments should be worn to prevent excess moisture from being trapped against burned skin.

Melissa Grier is a Clinical Nurse Specialist at Via Christi Health in Wichita, Kansas, where she supports the Via Christi Cancer Institute and the nurse residency program.

Fast Facts for the Frontline

An oncology nurse's overview of wound care.

Fast Facts for the Frontline: Wound Care

Mary Ellen Smith Glasgow, PhD, RN, ACNS-BC, ANEF, FAAN

Marcella Williams is an assistant professor at Lansing Community College in Michigan. She completed her doctor of nursing practice degree program at Duquesne University School of Nursing, where Mary Ellen Glasgow is professor and dean.

With the advent of major cancer centers and the trend to provide increasingly aggressive treatments, the dilemma of what constitutes best care for patients with advanced cancer is an important one. Rapid response teams (RRT) are used extensively in many hospitals, including major cancer centers; however, research shows that adverse outcomes are more common for patients who require RRT intervention than among the general hospital population.

Furthermore, RRT calls for patients with preestablished Do Not Resuscitate orders occur for a surprising number of patients,

 with as many as one-third of RRT calls involving patients at the end of life.

 Equally important are the timing of palliative care consultation, issues related to quality of life, and patient and family satisfaction with end-of-life care.

The role played by RRT members in end-of-life care is recognized and supported by research.

A recent clinical review revealed an increasing proportion of hospital deaths in the intensive care unit (ICU) involve the withdrawal or withholding of life support measures.

 However, research focusing on family member perception of care quality for 1146 patients with cancer who died found that end-of-life care was rated as “excellent” most often when patients were not admitted to the ICU within 30 days of death and did not die in the hospital.

Providing care for individuals nearing the end of life in the ICU is particularly important when such care often costs more than $4000 per day.

 Moreover, the study revealed that better quality of care was perceived when clients had received hospice services for more than 3 days prior to death.

In their clinical review of intensivist and RRT roles in end-of-life care, Hilton, Jones, and Bellomo reported that 1 in 10 RRT calls result in new decisions to limit medical intervention, and one-third of calls involve end-of-life concerns.

 The authors suggest there may be limited resources on hospital wards to support early identification of patient deterioration and presented a timeline identifying key aspects of decision making and end-of-life discussions by clinicians and intensivists.

Efforts to improve early identification of critical illness in patients with cancer resulted in the development of an admission and discharge ICU protocol for intensivists and yielded significant changes in placement for individuals with advanced cancer.9 Others have suggested end-of-life care is improved with the introduction of RRTs, particularly if end-of-life care training is an intentional part of team member education.

Retrospective chart reviews revealed the most common RRT call is typically initiated for elderly individuals with multiple comorbid conditions, who often reside in nursing homes; most calls are made for individuals with orders for full resuscitation.

Most of the individuals in these studies were admitted to the ICU unless decisions to alter resuscitation orders were made during the RRT event itself.

 A retrospective chart review of RRT calls made over a 2-year period conducted by Austin and colleagues showed that of the 557 clients seen by the RRT team, 135 were diagnosed with cancer. The oncology patient population had significantly higher mortality rates and used RRT resources at a much higher rate than those without cancer.

Efforts to prolong life via ICU admission can have a negative impact on the quality of life for patients and their loved ones, while integration of palliative care into the ICU environment can help reduce those costs and improve care quality.

In a multisite study in US hospitals examining patient mental health and caregiver bereavement for individuals with advanced cancer, Wright et al found that end-of-life discussions were associated with earlier hospice enrollment, as well as decreased resuscitation and ICU admissions; however, aggressive care was associated with decreased patient quality of life and increased risk of major depression in caregivers.

Two multicenter studies completed in academic hospitals in Toronto showed a higher prevalence of palliative care consultations over a 5-year period after RRTs were introduced, but also demonstrated that those clients receiving RRT services were less likely to have a palliative care consultation, a spiritual care consultation, or an order for sedatives.

Both studies led the authors to conclude that although there is a huge need for RRT members to be involved in end-of-life care, opportunities to facilitate end-of-life care discussions and treatment may be missed, and ultimately the introduction of an RRT did not improve the quality of care being provided for those facing end-of-life concerns.

Oncology nurses play a vital role in every point along the trajectory of care. As frontline providers, the nurse is often the individual initiating a rapid response event and may be the first healthcare provider to begin a conversation regarding advanced care planning and end-of-life care.

The crucial conversation should include data that less intense care does not equate to poor quality of life or limited productive lifespan for patients.

 Therefore, nurses’ familiarity with research related to RRT events, the role RRT members play in end-of-life care discussions and decisions, and the potential impact of RRT events on client and family outcomes, can guide future interactions and care provision.

Including palliative care content in nursing curricula is another vital aspect of effectively addressing best practice for end-of-life. Finally, the use of nurse-driven palliative care consults throughout the hospital, including the emergency department, has the potential to optimize care.

Jones D, Warrillow S. Clinical deterioration in cancer patients--the role of the rapid response team. 

Coventry C, Flabouris A, Sundararajan K, Cramey T. Rapid response team calls to patients with a pre-existing not for resuscitation order. 

Jones D, Moran J, Winters B, Welch J. The rapid response system and end-of-life care. 

Hui D, Kim S, Roquemore J, Dev  R, Chisholm G, Bruera E. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. 

Wright AA, Keating NL, Ayanian JZ, Chrischilles EA, Kahn KL, Ritchie CS, et al. Family perspectives on aggressive cancer care near the end of life. 

Austin CA, Hanzaker C, Stafford R, Mayer C, Culp L, Lin FC, et al. Utilization of rapid response resources and outcomes in a comprehensive cancer center. 

Hilton AK, Jones D, Bellomo R. Clinical review: the role of the intensivist and the rapid response team in nosocomial end-of-life care. 

Huynh TN, Kleerup EC, Raj PP, Wenger NS. The opportunity cost of futile treatment in the ICU. 

McGovern J, Brash J, Eckhardt S, Rodriquez A, Hoag JB. Improvements in early recognition of critical illness in cancer patients through a combined nursing-physician admission/discharge criteria protocol. American Journal Respiratory Critical Care Medicine online abstracts. Accessed July 14, 2016. 

http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2014.189.1_MeetingAbstracts.A5246

Nelson JE, Mathews KS, Weissman DE, Brasel KJ, Campbell M, Curtis JR, et al. Integration of palliative care in the context of rapid response: a report from the improving palliative care in the ICU advisory board. 

Tan LH, Delaney A. Medical emergency teams and end-of-life care: a systematic review. 

Downar J, Rodin D, Barua R, et al. Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: a multicentre retrospective study. 

Downar J, Barua R, Rodin D, et al. Changes in end of life care 5 years after the introduction of a rapid response team: a multicentre retrospective study. 

Jones DA, McIntyre T, Baldwin I, et al. The medical emergency team and end-of-life care: a pilot study. 

Sulistio M, Franco M, Vo A, Poon P, William L. Hospital rapid response team and patients with life-limiting illness: A multicentre retrospective cohort study. 

Tam B, Salib M, Fox-Robichaud A. The effect of rapid response teams on end-of-life care: a retrospective chart review. 

Jones DA, Bagshaw SM, Barrett J, et al. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. 

Curtis JR, Engelberg RA, Bensink ME, Ramsey SD. End-of-life care in the intensive care unit: can we simultaneously increase quality and reduce costs? 

Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. 

Dartmouth Atlas Project Report. Inpatient days per decedent during the last six-months of life, by gender and level of care intensity. Accessed Oct 1, 2015. 

http://www.dartmouthatlast.org/data/topic/topic.aspx?cat=18

Middlesex Hospital Nursing Annual Report 2014. Engaging the interprofessional team in scholarly practice: validating the decision aid palliative referral (DAPR). Accessed August 1, 2016]. 

https://middlesexhospital.org/nursing-annual-report/2014#page/18

Partner Perspectives

Rapid response teams (RRT) are used extensively in many hospitals, including major cancer centers; however, research shows that adverse outcomes are more common for patients who require RRT intervention than among the general hospital population.

December 2016