“Time is of the essence” is a phrase we often hear, but it may be inevitable that a lapse in time occurs in clinical practice on occa&shy;sion. In oncology, every second counts, whether it be wait time at a clinic or how quickly a patient gets access to potentially lifesaving care. Although these efforts seem like sec&shy;ond nature to many healthcare work&shy;ers, they aren’t always easily executed.

, you will meet an oncology nurse who has made it her mission to improve the burden that patients with cancer face daily. Lauren Gjolaj, MBA, BSN, RN, direc&shy;tor of clinical operations at Sylvester Comprehensive Cancer Center at the University of Miami Hospital and Clinics, works with her team to create lasting solutions. Two examples in which she has already done so include reducing wait and laboratory turnaround time as well as creating the Neutropenic Fever Task Force team at her clinic.

Gjolaj discusses her keys to success that she says can be used by oncol&shy;ogy nurses everywhere. And while she admits that her award-winning changes didn’t come easy, they certainly paid off in the end for those who it matters to most: patients. Her advice is to start small and build from there.

also addresses sexual health concerns of patients. Often considered a per&shy;sonal topic, it is one that means a lot to patients and their partners. They may be experiencing sexual difficulties as a result of their cancer care and may be too embarrassed to start the conver&shy;sation. That’s where nurses can step in. You may ask yourself, “How do I bring up sexuality?” or “What if I’m uncomfortable talking about sex with a patient?” A fellow oncology nurse offers tips to ease communication on this sen&shy;sitive subject.

Our editor in chief brings to light a growing problem in the healthcare industry: drug and minibag shortages. She examines how it all began and what is currently being done to help alleviate the issue.

In a follow-up to the Professionally Speaking column in our December issue, we examine if it’s ever OK for a nurse to give a patient a gift. Your instinct may tell you one thing, but that action could result in a violation of a professional boundary.

Also in this issue, the use of cryo&shy;therapy to reduce symptoms of chemo&shy;therapy-induced peripheral neuropa&shy;thy, how parental interaction behaviors affect a child’s pain and distress, and how a hula hoop and a dedicated nurse helped regain a patient’s trust in the healthcare system.

We hope you find these articles informative, and as always, thank you for reading.

Articles

From the Chairman

This letter from the Chairman and CEO of Oncology Nursing News® gives an overview of the contents of the February 2018 print issue of the magazine. 

Every Second Counts

When a cancer diagnosis is made, patients immediately ask many questions: What’s the prognosis? What will treatment involve? What are the adverse effects of treatment? Although the questions may not always have sim&shy;ple or concrete answers that patients want, oncol&shy;ogy nurses must be prepared to respond.

But what about the questions that patients are too embarrassed or afraid to pose or may not even know to ask? A cancer diagnosis is life altering in many ways, but one subject that often may be over&shy;looked or avoided entirely is sexuality.

Body image, self-esteem, sexual dysfunction, repro&shy;duction, pleasure, and intimacy are all part of the broad subject of sexuality. This is a challenging topic because it involves so many factors, including a patient’s willingness to discuss sexual concerns, a nurse’s lack of knowledge or comfort level with the topic, religious implications, cultural norms, gender differences, and sexual preferences. Increasing your awareness of sexuality and being proactive in addressing related concerns can greatly affect your patients’ quality of life and psychosocial well-being.

WHEN SHOULD I ADDRESS SEXUALITY WITH MY PATIENTS?

Although sexuality may not top a patient’s concerns upon initial diagnosis, it’s important to address it early on. A pre&shy;treatment sexual assessment will identify a baseline against which posttreatment changes can be measured. Along with the assessment, the nurse should provide education regard&shy;ing treatment-specific adverse effects and late effects related to sexuality. Continue the discussion throughout and after treatment to ensure continuity of care and comprehensive patient support.

The Oncology Nursing Society offers several helpful tips to ease communication when discussing sexual health with patients:

Open with a normalizing statement like, “Many patients have questions about sexual activity during cancer treat&shy;ment” or “The treatment you’ll be receiving can influence sexual function.” This invites the patient to continue the discussion and may help you gauge the patient’s willing&shy;ness to discuss sexuality.

Ask the patient’s permission to discuss sexuality. If it’s not an appropriate time to talk, the discussion won’t be productive.

Use neutral language when referring to the patient’s sig&shy;nificant other (eg, “partner” versus “husband” or “wife”).

Respect the patient’s privacy; this is imperative. Ask vis&shy;itors to step out, or elicit from the patient whether the discussion should take place with their partner present.

Provide only the information the patient needs. Find out what specific issues your patient might be experiencing, and limit education to those topics or concerns.

Emphasize the importance of addressing sexual health concerns, and encourage your patients to ask questions at any time.

The PLISSIT Model, created by Jack S. Annon in 1976 and outlined below, also provides a framework to help nurses dis&shy;cuss sexual health with patients:

Permission: Allow patients to share their feelings by pro&shy;viding an open and trusting environment.

Limited Information: Provide education limited to the specific sexual adverse effects of the patient’s medication and treatment.

Specific Suggestions: Offer these after performing a thor&shy;ough sexual health assessment that includes the patient’s beliefs, attitudes, and baseline sexual function.

Intensive Therapy: This is indicated when severe psycho&shy;social or sexual issues are identified that are outside the scope or comfort level of the nurse.

WHAT IF I’M UNCOMFORTABLE DISCUSSING SEXUALITY?

A vital step toward addressing this important topic with your patients is recognizing how you feel about it and assessing your knowledge level. Acknowledge that you may have differ&shy;ent personal beliefs than your patients do. Most important, if you recognize that you simply can’t bring up the subject, know your resources. Discuss strengths and weaknesses regarding sexual considerations with your colleagues, and reach out to those who demonstrate interest and knowledge regarding the topic. A referral to a social worker, fertility specialist, sexual health specialist, or gynecologist may be indicated.

Baron RH. Psychosocial management. In: Gobel BH, Triest-Robertson, Vogel WH. 

Advanced Oncology Nursing Certification Review and Resource Manual

. 2nd ed. Pittsburgh, PA: Oncology Nursing Society; 2016:737-773.

is a clinical nurse specialist at Via Christi Health in Wichita, Kansas, where she supports the Via Christi Cancer Institute, as well as the medical/surgical cardiac, resource pool, emergency department, and oncology.

Fast Facts for the Frontline

A veteran nurse offers practical advice for addressing sexual health with oncology patients.

An Intimate Conversation: Cancer and Sexual Health

The fight against cancer has gotten tougher because of shortages of drugs and minibags. At cancer treatment facilities across the country, pharmacy and nursing staff now have to keep a keen eye on drugs and admixture supplies, anticipate the needs of patients being treated, and, when necessary, identify alternate preparation and administration techniques when a drug is unavailable and minibags are in short supply.

So how did we get here? What can we as clinicians do about these shortages that affect patient care? Oncology drug short&shy;ages are not new. For more than a decade, certain drugs—primarily older generic drugs like methotrexate&mdash;have been in short supply from time to time. In some cases, drugs have been unavailable for weeks to months.

According to the Food and Drug Administration (FDA), at the height of the drug shortage in 2011, the number of drugs in short supply had more than tripled, from 74 in 2005 to 267 in 2011. To address these escalating shortages, the 2012 Safety and Innovation Act gave the FDA the flexibility to identify new sources of drugs and expedite FDA inspections of manufactur&shy;ing facilities. The act also requires drug manufacturers to notify the FDA when production problems affecting lifesaving drugs occur. The FDA then alerts the public and provides updates via its 

. Clinicians can sign up on this site to receive e-mail notifications of drug shortages as they happen.

Since 2012, the FDA notes, drug shortages have been decreasing, with an average of 175 active shortages in 2017. Six drugs used in the treatment of cancer currently are in short supply (as of January 2018): dexrazoxane, ethiodized oil (used for chemoembolization), etoposide, leucovorin, methotrexate, and asparaginase 

Compounding this shortage is the shortage of intravenous (IV) minibag solutions used to administer these drugs. The minibag shortage has been attributed to hurricane-damaged manufacturing facilities in the Caribbean. However, manufac&shy;turing or quality problems at other facilities not affected by weather events, as well as mergers, acquisitions, and plant clo&shy;sures, have also contributed to the current shortage of minibags.

To address the shortage, the FDA is temporarily allowing US manufacturers to import IV fluids from other countries. For example, minibags of 9% sodium chloride manufactured by Baxter’s facility in Ireland and marketed in Europe are being imported into the United States. Clinicians need to be aware that bar codes on imported IV fluids may not register accurately on US scanning systems, and procedures should be followed to assure that the correct IV fluid is being used. Also, although the administration ports appear similar to those of US products, the administration port for Baxter’s imported VIAFLO (non-PVC) containers needs to be twisted off rather than pulled off.

Another concern about the importation of drugs and fluids into the United States is the stability and extent of the inter&shy;national supply. While importation has reduced shortages in the United States, it is possible that drug and minibag short&shy;ages could become worldwide shortages. The implications for patient care, especially cancer treatment, are disturbing. Drug shortages lead to drug substitution and, in some cases, omission of a needed drug in a cancer treatment regimen. The potential effect on treatment outcomes is unknown but most likely not beneficial.

Strategies to address minibag shortages have been com&shy;piled by the American Society of Health-System Pharmacists (ASHP) and the University of Utah Drug Information Service. Suggestions include inventory control and pharmacy operational strategies. For instance, the amount and location of drugs and fluids should be assessed on a system-wide basis, rather than unit-level, and the areas of greatest need should be prioritized. When appropriate, some drugs that are usually administered via a minibag infusion can be administered as an IV bolus (push) or, if an oral equivalent agent is available, administered by mouth.

Because of the potential for inadvertent intrathecal admin&shy;istration, anticancer drugs are rarely, if ever, administered by syringe and instead are typically infused via minibags. Therefore, temporarily administering anticancer and other drugs in syringes requires that nursing staff review the proper procedures for verifying the medication, especially the route of administration, and review how IV bolus drugs should be administered. Many facilities are now preparing premedications used with cancer treatment regimens in syringes. Consequently, patient education is also needed so that patients are informed about changes in how their treatments are delivered.

One of the cautions outlined in the ASHP and Utah Drug Information Service guidelines to address the minibag shortage is to not underestimate the informatics resources that are needed during the time of this shortage. Medication records, order sets, and treatment protocols need to be revised for route changes of some IV medications. Making these changes and then reviewing them for accuracy is labor intensive but necessary.

It’s predicted that the shortage of drugs and minibags is not one that will be resolved in the near future. Clinicians need to use available resources, such as the FDA’s drug shortage website and guidelines for managing shortages. Most of all, whenever drugs are substituted or given by a different route, patient safety measures need to be implemented.

NOTE (added after the February print Oncology Nursing News—in which this article first appeared&mdash;went to press): 

On February 1, 2018, the Food and Drug Administration (FDA) released 

, and extended the expiration dates of some products after new safety tests found that extended expiration dates meet FDA safety standards.

Nurse's Notes

The fight against cancer has gotten tougher because of shortages of drugs and minibags. At cancer treatment facilities across the country, pharmacy and nursing staff sometimes even have to identify alternate preparation and administration techniques when a drug is unavailable and minibags are in short supply.

Drug and Minibag Shortages: How We Got Here and What We Can Do

During my time as a nuclear medicine nurse, I had the privilege of caring for many wonderful and memora&shy;ble patients. I coordinated certain scans and thera&shy;pies, including iodone-123 (123I) — metaiodobenzylguanidine (MIBG) scans and iodine-131 (131I) – MIBG therapy. MIBG is chemically similar to norepinephrine.

When bonded with radioactive iodine and used as a tracer in molecular imaging, MIBG has a high specificity in con&shy;firming the presence of neuroendocrine tumors (NETs), such as pheochromocytomas and paragangliomas. 131I-MIBG therapy is a systemic cancer treatment for patients with MIBG avid nonsurgical NETs. The scan and therapy coordi&shy;nation required direct nurse involvement, because each entailed in-depth clinical review and patient teaching. Insurance authorizations also required detailed clinical information from a nurse or physician for approvals.

After some time, I became known as the “MIBG lady” and received calls from all over the country. My experiences led me to a greater understanding of cancer care within radiology, and I apply many lessons from those nuclear medicine days in my current role as a thoracic oncology nurse navigator.

One day, I received an MIBG scan order for a patient whom I’ll never forget. Let’s call him Bob. This was an internal referral from a hypertension specialist who frequently ordered this scan for her patients. Bob had uncontrolled hypertension, as well as high catecholamine levels in his urine, indicating he may have an adrenal NET. I reviewed Bob’s chart, noting his height, weight, medications, and insurance. The authorization request was submitted.

Bob was given my office number, and he called several times over the next 2 weeks. I recall being taken aback by his direct nature and at first a little confused about his con&shy;cerns. His first questions were, “Are the techs nice to patients, and do they act professionally?” I answered affirmatively, but he pressed on, asking how he would be treated during his scan and stating that he would not tolerate being mistreated. I assured him every which way that the staff was not only professional and kind but also technically proficient — he was coming to a great place for radiology care.

I asked if he had experienced unprofessional conduct at my organization or elsewhere. He said yes, elsewhere. He explained that he had acromegaly and once required mag&shy;netic resonance imaging (MRI). When he called to sched&shy;ule his appointment, he gave his height and weight and explained his condition. Bob went in for the scan, and the technologist acted annoyed and overwhelmed by his size and proportions. Bob didn’t fit on the table, and the technologist couldn’t figure out how to position him to include the entire area of interest in the exam. Bob explained that he was bul&shy;lied a lot as a kid and made to feel like a “freak.”

The MRI experience was horrible, Bob said, and he feared a repeat during the MIBG scan. I assured him that our depart&shy;ment would treat him with the utmost respect.

Bob’s next concern was about fitting on our scanning table. He did not want to receive the MIBG injection if he could not complete the test due to his size. I asked for his height and weight; Bob was 5 ft 11 in and weighed 195 lb. I confirmed that he did not exceed the scanner’s limits, but Bob was not satisfied. He insisted that while his numbers seemed typical, the width of his shoulders and size of his rib cage might still be too large for the gantry — the opening of the computed tomography scanner through which the patient passes during the test. I agreed to obtain its measurements.

Bob proceeded to provide his suit measurements, shoulder width, neck circumference, and leg length. All were within the parameters for the scanning table and gantry circumfer&shy;ence, yet Bob was not satisfied. I consulted the manager for ideas on how to allay the patient’s fears. She sug&shy;gested having him step through a hula hoop with his arms above his head. If he could fit through the hoop, then he could undergo the MIBG scan in full.

I called Bob back and asked, “Do you have a hula hoop?” (I’ve asked patients stranger questions.) He said no, but he’d be willing to get one. I thought our dilemma was solved.

I proceeded to describe how Bob needed to stand in the hula hoop with his arms raised like a diver’s, while another person lifted the hoop to the tip of his fingers. Bob began to cry. “I have no one,” he said, explaining that he had no family or even a close friend he felt comfortable asking for help. I wondered if he could ask a coworker. He said, “Not a chance.” It seemed he didn’t like any&shy;one at his work.

He sobbed at times during our next few calls and confided in me about how lonely he was — but then he’d follow with how annoyed he was by most people. I felt as though I had opened a Pandora’s box of deep childhood wounds mixed with depres&shy;sion, apathy, and general disdain for the world. All I could think about was how terrible this would be if Bob had a NET, too.

The insurance approval came through, and the manager and I decided to schedule Bob for a dry run of the scan at the end of a workday. I enlisted one of our kindest technologists to assist in the dry run and actual scan. The technologist and I were a bit perplexed when Bob walked in. We would have never known that he had acromegaly had he not been so forthcoming. Luckily, he made it through the dry run success&shy;fully. The CT gantry accommodated Bob without any issues, and we all were relieved. The technologist spent a good hour walking him through the entire scan portion, and he was happy that he had agreed to the extra visit.

Thankfully, Bob’s MIBG scan was negative, and we ruled out a NET. He called me twice the following week to thank me again and share his good news.

This story stands out as an example of how a single bad experience in healthcare can prevent patients from address&shy;ing their medical concerns. Due to Bob’s negative interaction with radiology, he was ready to avoid a critical test that could evaluate the presence of cancer.

Bob was a challenging patient who forced us to get cre&shy;ative and go the extra mile, but I’m sure glad that we did. I hope this positive experience in nuclear medicine softened his view of healthcare providers, if only just a little.

earned a bachelor’s degree in nursing from Wilkes University in 2001. She has worked at Penn Medicine, in Philadelphia, since 2008, first as the nuclear medicine therapy nurse, then transitioning to oncology nurse navigation, focusing on patients with lung cancer, in 2016. She is working toward her doctors of nursing practice at Capella University.

Nurse Navigators

A nurse uses her creativity to gain the trust of a patient who was skeptical of an MIBG scan.

Do You Have a Hula Hoop?

®, we explored the question, “Do you or don’t you accept a gift from a patient?” The short answer was “maybe.” Small token gifts may be acceptable, but what about giving a patient a present, either bought or handmade? That gets more complicated.

Our instinct as nurses is that when we see a need, we want to fulfill it. We simply desire to fix things for our patients or show a little kindness. For example, suppose your patient who knits needs more yarn to keep occu&shy;pied during treatment; another is short of cash for a bus, taxi, or ride share; or a strapped care&shy;giver craves a gourmet coffee. You happen to have cash and can easily meet this need.

However, using your own money or even lending your belongings can not only violate a professional boundary but also may be illegal. Even a small pur&shy;chase can cause significant legal implications, because it can be seen as inducement. Laws prohibit individuals and healthcare organizations from purchasing anything that persuades or influences a patient’s healthcare. What we think of as kindness may be viewed as a type of kickback or incentive. Today’s regulatory environment is complex.

Often, the social work team or care coordina&shy;tors and navigators work behind the scenes to help coordinate appropriate resources for all those in need. Many facilities have a patient assistance or petty cash fund to provide immediate help. But if not properly coordinated, it may be viewed as unfair or unequal treatment.

As nurses, we sometimes confuse giving some&shy;thing to patients with providing extraordinary care. Think of the countless ways you can go the extra mile that do not involve buying something or personal spending for care.

So, what do you do if you see an unmet need or want to give a gift? First, ask yourself these questions:

Would giving the gift change my professional ther&shy;apeutic relationship (outside the zone of helpful&shy;ness) with this patient or any of my other patients?

At what point do I draw the line to meet my patient’s needs?

Could the gift be viewed by others as inducement? Could it cause me or my organization harm?

What happens if another patient realizes that I provided something for someone else but I am not providing it for them?

Will I inadvertently create a difficult dynamic with team members who have a different set of bound&shy;aries and don’t use their own money? Could this alter my relationship with my colleagues?

Would the patient or their caregivers feel the need to give or do something in return?

What do my organizational policies or profes&shy;sional standards say?

Next, talk with your social work team, naviga&shy;tors, or manager. If you see a recurring need, con&shy;tact your manager to become part of the solution for all patients, not just the one you are caring for that day.

Consider the following real-life example: One metroplex clinic treating uninsured patients with cancer found that many of their patients did not have sneakers, so they could not participate in their survivorship exercise program. By partnering with a local professional organization and a sporting goods store, they continuously collect financial donations to provide shoes for those in need.

As a seasoned oncology nurse, I have seen the struggles of many patients with cancer and their families. And yes, I have been tempted to sim&shy;ply share my many blessings—money, items, and time on my day off. Personally, if I did that for one, I would need to do it for all. I decided early in my career that my gift to my patients would be that I would be the best oncology nurse possible

Professionally Speaking

A nurse examines whether using her own money to fulfill a need crosses a professional boundary

Giving Gifts to Patients: Acceptable or Unacceptable?

) is a gram-positive, spore-form&shy;ing bacterium noted to be the leading cause of hospi&shy;tal-acquired diarrhea in patients with cancer undergoing chemotherapy.

rates to be twice as high in the oncology population compared with all patients in the United States. Oncology patients are at a partic&shy;ularly high risk of 

infections (CDIs) due to treatment or disease-related immunosuppression and neutropenia. 

is a life-threatening complication for neutropenic patients that can result in septic shock and death.

The inpatient, 26-bed, medical oncology unit at the University of California, Los Angeles, Santa Monica Medical Center (SMUCLA) had an alarming rate of CDIs. The unit practice coun&shy;cil (UPC) identified the need for environmental disinfection of patient care areas through the adaptation of an evidence-based intervention, high-touch wipe down (HTWD). Due to its sus&shy;tained success in a vulnerable oncology population, HTWD has been implemented hospital wide.

is screened for upon admission and once a shift. A positive screen is indicated by 3 or more loose stools in a 24-hour period. The nursing bun&shy;dle is then activated, prompting staff to place the patient on contact-spore isolation, send a stool sample to rule out 

, maintain proper hand hygiene, wear personal protective equip&shy;ment (PPE), and notify the physician. Despite consistently adhering to the organizational policy for early identification of 

, CDIs on the oncology unit were above the national median. Our goal was to reduce these rates by 50% from 2014 to October 2015.

The Centers for Disease Control and Prevention recommends the routine cleaning of environmental surfaces with 

sporicidal Environmental Protection Agency—registered disinfec&shy;tant. High-touch surfaces, or those with frequent hand contact, should be cleaned more often than regular housekeeping areas.

 One report revealed a 40.5% decrease in CDIs on a geriatric unit when it was disinfected with bleach versus a neutral detergent.

 A later comparison of 2 intensive care units led to fewer CDIs in both units when adjunct bleach cleaning was performed in all patient rooms and known 

The following HTWD practices were adopted on the SMUCLA oncology unit:

Store Clorox germicidal bleach wipes in every patient room and at nursing stations.

Nurses and care partners wipe down high-touch surfaces with bleach wipes once a shift for all patients and twice a shift for neutropenic patients.

Wipe down all high-touch areas, including the bed frame, call light, doorknobs, countertops, side table, nightstand, monitor cables, and work stations.

rates monthly to monitor effectiveness and results.

prevention was assessed with a pre-survey, followed by a tailored education plan and a subsequent post survey. The outcome was an overall improvement of staff understanding of HTWD. Employees were edu&shy;cated with informational flyers and a PowerPoint presentation during huddles, staff meetings, and annual skills labs.

HTWD was initiated on the oncology unit in February 2015. The rate of CDIs per 10,000 patient days (PDs) decreased from 14.99 in 2014 to zero from February to July 2015. We exceeded our goal of a 50% reduction when comparing 

rates from 2014 to recent years. In 2016, just 6.1 cases per 10,000 PDs were reported, and the most current data from 2017 shows a further decrease to 3.4 cases per 10,000 PDs. The HTWD is simple and inexpen&shy;sive but can be highly effective (

FIGURE 1. Oncology Unit C. diff Rates: July 2014-February 2016

Note: 2014 baseline CDIs = 14.99 per 10,000 PDs. HTWD implemented February 2015 with no CDIs for 6 months. Blue bar is incidence per 10,000 PDs. Red line is number of cases.

C. diff indicates Clostridium difficile; CDI, C. diff infections; HTWD, high-touch wipe down; PD, patient day.

FIGURE 2. Oncology Unit C. diff Rates: January 2017-October 2017

Note: 2017 most recent C. diff rates = 3.4 per 10,000 PDs. Significant reduction compared with baseline. Blue bar is number of cases. Red line is incidence per 10,000 PDs.

C. diff indicates Clostridium difficile; PD, patient day.

Several barriers were identified upon adding HTWD to unit workflow. Oncology patients endorsed sensitivity to the smell of bleach, exacerbating symptoms such as nausea and diz&shy;ziness. By offering aromatherapy or encourag&shy;ing ambulation during HTWDs, patients were agreeable to using bleach wipes and eager to have HTWDs completed.

Feedback from staff included problems with skin irritation and uniform staining. The Association for Professionals in Infection Control and Epidemiology suggests the use of PPE when cleaning with bleach.

Wearing masks, gowns, and gloves has been an effective solution for employee protection.

Finally, the lack of formal HTWD documentation posed a great challenge. Ongoing discussions to integrate HTWD into the electronic record ended due to concerns surrounding scope of practice. Oncology staff recognize the importance of HTWD in protecting our patients and currently document completion on paper.

The success of the HTWD was recognized by the chief nursing officer and transformational lead&shy;ership shared-governance Magnet council as a nursing best practice and key strategy for fiscal year 2017-2018. SMUCLA implemented HTWD in February 2017 after extensive interprofes&shy;sional collaboration and planning with stake&shy;holders. UPCs and unit leadership provided stan&shy;dardized education materials, campaign flyers, and hands-on training for staff. 

rates will continue to be evaluated over time as HTWD is applied to the broad patient population within the organization.

Performing HTWD as part of a bundle dramati&shy;cally reduced 

rates on a medical oncology unit. CDIs were eliminated for 6 months follow&shy;ing the project’s initiation, during which time intensive education and daily reminders were given. Ramphal, Suzuki, McCracken, and Addai demonstrated a 60% increase in compliance with HTWDs through repeated training.

rates, continued education, peer-to-peer accountability, and a follow-up tool are essential to the sustainability of this practice. The oncology unit will begin a trial using ultravi&shy;olet light audits next year to evaluate consistency and compliance.

New 2017 Joint Commission and CMS guide&shy;lines have brought nosocomial CDIs to the fore&shy;front of nursing quality indicators. Incorporating nurse-driven environmental cleaning into hospi&shy;tal-based infection control practices may provide the comprehensive program needed to decrease 

rates and improve patient outcomes in the acute care setting.

1. Kamboj M, Son C, Cantu S, et al. Hospital-onset 

infection rates in persons with cancer or hematopoietic stem cell transplant: a C3IC network report. 

2. Fuereder T, Koni D, Gleiss A, et al. Risk factors for 

infection in hemato-oncological patients: a case control study in 144 patients. 

3. Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities (2003). CDC website. 

cdc.gov/infectioncontrol/guidelines/environmental/background/services.html#

. Updated November 5, 2015. December 10, 2017.

4. MacLeod-Glover N, Sadowski C. Efficacy of cleaning products for 

: environmental strategies to reduce the spread of 

-associated diarrhea in geriatric rehabilitation. 

5. Association for Professionals in Infection Control and Epidemiology. Guide to preventing 

apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325-e8be75d86888/File/2013CDiffFinal.pdf

. Published 2013. Accessed December 10, 2017.

6. Ramphal L, Suzuki S, McCracken IM, Addai A. Improving hospital staff compliance with environmental cleaning behavior. 

Feature Story

Following a high rate of CDIs, the inpatient medical oncology unit at the University of California, Los Angeles, Santa Monica Medical Center adapted an evidence-based intervention.

High-Touch Wipe Down: Decreasing C. diff Rates in Adults With Cancer

Oncology patients and their caregivers face a wide array of challenges, both large and small. Lauren Gjolaj, MBA, BSN, RN, direc&shy;tor of clinical operations at Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, sees those difficulties firsthand.

A self-described proud third-generation nurse with a desire to serve the oncology patient population, Gjolaj’s commitment to helping patients and advancing her education allowed her to move ahead quickly in her career. She strives to improve the lives of patients and quality of care at the center—and share what she has learned with other centers across the country.

Gjolaj credits much of her interest in process improvement to Six Sigma training, which she says changed her life. Six Sigma is a statistical methodol&shy;ogy that Gjolaj, along with her team, has employed to problem solve many of her award-winning proj&shy;ects. The program, developed by Bill Smith in 1986, takes a dual approach, incorporating both technical and management components.

 The training can be completed in steps, represented by different col&shy;ored belts. Gjolaj possesses a green belt but hopes to obtain a black one in the future.

“The most important part of the process improve&shy;ment to me is not just ‘fixing’ the issue for today but creating long-term, sustainable solutions,” she says. “If you don’t set up the process so that it’s a sustain&shy;able win, people get tired and suffer from change fatigue. Creating collaborative solutions that make it better for everyone are the keys to success.”

Gjolaj describes her leadership style as “transparent and predictable,” with a strong focus on teamwork and recognition for a job well done. “I see interact&shy;ing and teaching as a way to build other nurses and myself into the best caregivers we can be, which, in turn, makes our patients’ lives and experiences bet&shy;ter,” she says. Some ways in which Gjolaj and her team have accomplished this at Sylvester is by creating a neutropenic fever task force and decreasing wait times in the outpatient setting.

Due to their immunocompromised status, patients with cancer face potential life-threatening events, all of which require prompt intervention to circumvent poor outcomes. Although many healthcare providers know that prompt medical intervention is impera&shy;tive when a patient presents with a serious symptom such as neutropenic fever, many settings struggle with workflow issues, creating a potential lapse of precious time. “It’s critical to recognize neutropenic fever early and to initiate empiric systemic antibac&shy;terial therapy promptly in order to avoid progression to a sepsis syndrome and possibly death,” according to investigators.

By implementing a few inventive strat&shy;egies to quickly identify this at-risk pop&shy;ulation, the Sylvester team significantly reduced the time between patient arrival to the emergency department (ED) and administration of intravenous antibiotics. First, they gave patients a neutropenic fever alert card to present to healthcare practitioners and added a correspond&shy;ing question to the ED patient sign-in form. Then they created a neutropenic fever alert system within the hospital, which quickly brings a trained team to a patient’s bedside.

“It was innovative and challenging and, no doubt, has saved hundreds of lives,” Gjolaj says. “I would like to continue to spread awareness and share our best practices with the other cancer centers and hospitals to expand the lives saved.”

The implemented changes took sev&shy;eral attempts to perfect, Gjolaj admits. The project involved members of many departments and required an interdis&shy;ciplinary approach to problem solving, but it ultimately benefited patients and improved outcomes.

The hard work paid off: The task force won 2 awards, Overall Showcase and Greatest Customer Impact, at the 2017 Florida Sterling Conference Team Showcase competition. “None of this is just me. These [changes] could not have been created and implemented without a team. I’m just the conductor,” Gjolaj says.

In 2014, the competition honored Sylvester’s Comprehensive Treatment Unit (CTU) team for their work surrounding an issue that plagues outpatient oncology clinics nationwide. The team received first place for “Systematically Decreasing Wait Time in an Outpatient Oncology Treatment Unit.”

The project began by collecting data on outpatient workflow processes and exam&shy;ining potential areas for improvement. A new process was created using existing staff and resources, redistributing them to improve efficiency. The result: a major reduction in patient wait times—an esti&shy;mated 53% less for laboratory results and a 26% decrease in overall wait time. The CTU team took 14 minutes off arrival-to-chair time and reduced laboratory turn&shy;around time from 52 to 24 minutes.

The team’s efforts were well received, and patient satisfaction increased greatly. Oncology patients spend so much time waiting at outpatient infusion centers, and the team gave them back a little bit of what they desire most—time away from the hospital. “Performance improvement efforts are a great motivator, because the outcomes are tangible; [for example] what used to take 20 steps now takes 5, [or a] wait time that used to be 100 minutes is now 10,” Gjolaj says. The CTU team also was honored in 2014 with the “Innovation of the Year in Patient Care Award” by the Florida Hospital Association.

In a 2015 blog post, “The Bottom Line: Break the Silo or Perish,” Gjolaj highlights the importance of collaboration and sharing of information within corporate structures for best possible outcomes and more efficient solutions to com&shy;pany issues. “The worst part about silos is the impact they have on the everyday man—the frontline employee who can become very frustrated with their organization when they have identified problems but can’t do anything about them&mdash;it’s demoralizing and can lead to decreased engage&shy;ment and higher turnover,” she wrote. “When breaking the silos, start with small, manageable projects, remembering that practice makes perfect. Be patient with the process; remember that learning a new skill takes time. Build on small wins, and before you know it, collaboration will be the norm.”

IMPLEMENTING IMPROVEMENTS IN OTHER CENTERS 

Cancer centers that face similar challenges can learn from the team’s success. “Don’t try to fix everything at once. Start small and build from there,” Gjolaj says. She encourages oncology teams to drill down the root of the cause and look to frontline staff for solutions.

Gathering data doesn’t have to be so time-consuming that it backs up the cause, she says, adding that any type of data collected can prove useful. “Go back and tweak your inter&shy;vention. It’s OK,” she says.

Gjolaj shares these additional tips for providers at any level:

Pick a topic that makes an impact, with a call to action, then map the baseline process.

Obtain the voice of the customer—interview key stakeholders.

Form a team with different backgrounds and perspectives.

Gjolaj has her sights set on the next area of focus: apply&shy;ing her hospital experience to clinical research. She plans to tackle the issue by attempting to improve process efficiencies that support patients and families who participate in clinical research studies, further helping oncology patients navigate the often-foreign world of healthcare.

Everyone brings something to the table, a mentor once told her. “Going into teamwork scenarios with this perspective has allowed me to learn from others’ perspectives and become a better nurse and leader,” Gjolaj says.

1. Lean Six Sigma. Six Sigma Online website. sixsigmaonline.org/ six-sigma-training-certification-information/category/lean-six-sigma-cat/. Accessed December 7, 2017.

2. Bow E, Wingard JR. Overview of neutropenic fever syndromes. Wolt&shy;ers Kluwer website. uptodate.com/contents/overview-of-neutropenic-fe&shy;ver-syndromes. Updated October 9, 2017. Accessed December 5, 2017.

3. Gjolaj L. The bottom line: break the silo or perish. Florida Sterling Coun&shy;cil website. floridasterling.com/blog/entry/break-the-silo-or-perish-thats-the-bottom-line. Published June 30, 2015. Accessed December 7, 2017.

Cover Story

To make the lives of patients better, an oncology nurse leads a team to create sustainable solutions.

Reducing the Burden of Cancer

Cryotherapy delivered through frozen gloves and socks during paclitaxel (Taxol) infusion dramatically reduced objective and subjective symptoms of chemotherapy-induced peripheral neuropathy (CIPN) in a small study of patients with breast cancer.

Investigators at Kyoto Hospital in Japan explored the use of therapeutic regional hypothermia by outfitting patients receiving weekly paclitaxel (80 mg/ m2 for 1 hour) with frozen gloves and socks on their dominant side for 90 minutes. Symptoms of CIPN were assessed from baseline using the nondominant side of the patient as the control arm of the study.

The investigators measured the participants' sensitivity to touch, temperature, and vibration, as well as their dexterity before the study started and again after the 12-week chemotherapy regimen.

Of the 40 participants, 36 received the required cumulative dose of 960 mg/m2 of paclitaxel and were evaluable for symptoms. The incidence of tactile sensitivity, the primary endpoint of the study, was significantly lower on the intervention side versus the control side. The tactile sensitivity rate for the hand was 27.8% on the intervention side versus 80.6% for the control side (odds ratio, 20.00); for the foot, those rates were 25.0% and 63.9%, respectively.

Investigators also found that cryotherapy reduced the incidence of thermosensory dysfunction for warm sensations and resulted in lower rates of manipulative dexterity deficits. Patient-reported outcomes for subjective symptoms also improved in the intervention group versus the control group. No patients dropped out due to cold intolerance, the authors said.

The most frequently reported adverse effects were pain (8.2%), sensory abnormalities (0.4%), and feeling cold (4.2%). These effects did not linger after therapy ended. The investigators noted that their study had “severe limitations,” including the placebo effect of patient expectations for the intervention and control sides, as well as the plan not to follow patients after therapy because of the potential confounding impact of any further treatments.

Nevertheless, they concluded that cryotherapy is a “simple, safe, and effective strategy” for preventing CIPN, improving the likelihood that patients will not reduce or delay treatment due to CIPN.

Hanai A, Ishiguro H, Sozu T, et al. Effects of cryotherapy on objective and subjective symptoms of paclitaxel-induced neuropathy: prospective self-controlled trial [published online October 12, 2017]. J Natl Cancer Inst. doi: 10.1093/jnci/ djx178.

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