The role of the pediatric nurse practitioner in the comprehensive management of pediatric oncology patients in the inpatient setting

The role of the pediatric nurse practitioner (PNP) in the comprehensive management of pediatric oncology patients in the inpatient setting was examined at a large tertiary teaching hospital. This article shows role responsibilities including new diagnosis teaching, procedures, routine chemotherapy, patients' comprehensive medical management, coordination of nursing care across settings, phone triage, and professional development. A PNP's typical day is highlighted to illustrate the innovative merging of traditional ambulatory care roles with that of the PNP as a comprehensive manager of pediatric oncology patients in the inpatient setting. This role provides a more seamless care experience and provides critical links in the delivery of health care to pediatric oncology patients.     

Comparison between ambulatory infusion mode and inpatient infusion mode from the perspective of quality of life among colorectal cancer patients receiving chemotherapy

Lee YM, Hung YK, Mo FKF, Ho WM. International Journal of Nursing Practice 2010; 16 : 508–516
Comparison between ambulatory infusion mode and inpatient infusion mode from the perspective of quality of life among colorectal cancer patients receiving chemotherapy Folfox and Folfiri are active chemotherapy treatments used in advanced colorectal cancer. The total admission for these treatments has been significantly increasing in the study hospital. An ambulatory infusion programme was launched to address the problems of long waiting list and bed shortage. The study objective was to compare the quality of life between patients receiving the chemotherapy treatments in the ambulatory infusion group and the inpatient infusion group. The results showed that some demographic variables of education level, family role and employment status were determinants of the treatment mode. Patients in the ambulatory infusion group of social and global domains performed better than the inpatient group. However, the inpatient group had better quality of life of nauseated symptom at different stages. Some nursing educations should be reinforced to address the symptom management for patients receiving ambulatory infusion at home. The ambulatory infusion programme offered considerable quality of life benefits to colorectal cancer patients receiving chemotherapy.     

Ambulatory emergency oncology: A key tenet of future emergency oncology care

Ambulatory emergency oncology

The challenges of emergency oncology alongside its increasing financial burden have led to an interest in developing optimal care models for meeting patients’ needs. Ambulatory care is recognised as a key tenet in ensuring the safety and sustainability of acute care services. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high‐risk non‐oncological populations. Individualised management of acute cancer presentations is a key challenge for emergency oncology services so that it can mirror routine cancer care. There are an increasing number of acute cancer presentations, such as low‐risk febrile neutropenia and incidental pulmonary embolism, that can be risk assessed for care in an emergency ambulatory setting. Modelling of ambulatory emergency oncology services will be dependent on local service deliveries and pathways, but are key for providing high quality, personalised and sustainable emergency oncology care. These services will also be at the forefront of much needed emergency oncology to define the optimal management of ambulatory‐sensitive presentations.     

Delivering Palliative Care to Hospitalized Oncology Patients: A Scoping Review

ContextEarly, longitudinal integration of palliative care (PC) is recommended for patients with advanced cancer, in both inpatient and outpatient settings. Despite the growth of specialty PC teams in the last decade, the majority of PC is still delivered in the inpatient setting using a traditional referral-based consult delivery model. However, traditional consultation can lead to significant variation or delay in inpatient PC utilization. New care delivery models and strategies are emerging to deliver PC to hospitalized oncology patients who would most benefit from their services and to better align with professional society recommendations.ObjectivesTo identify different care models to deliver PC to ho`spitalized oncology patients and summarize their impact on patient and health system-related outcomes.MethodsWe conducted a scoping review of peer-reviewed articles from 2006 to 2021 evaluating delivery of PC to oncology patients in acute inpatient care. We abstracted study characteristics, the study's intervention and comparison arms, and outcomes related to specialty PC intervention.ResultsWe identified four delivery models that have been reported to deliver PC: 1) traditional referral-based consultation, 2) criterion-based or “triggered” consultation, 3) co-rounding with primary inpatient team, and 4) PC clinicians serving as the primary team. We summarize the known outcomes data from each model, and compare the benefits and limitations of each model.ConclusionOur findings provide guidance to health systems about care delivery models to deploy and implement inpatient PC resources to best serve their unique populations.     

Utilization review and containment for hospital utilization: some implications of providing care in the "most appropriate setting".

The study examines the potential for savings in the use of hospital resources if utilization review policies succeed in curtailing excessive use of hospital facilities. Excessive use is defined as the utilization of hospital care when ambulatory care is medically feasible and acceptable. A utilization review policy would be expected to counteract the tendency to substitute inpatient for outpatient treatment by assuring that all patients with identical medical problems and demographic traits would be treated in an identical least cost setting regardless of their social and economic circumstances. It might, thus, ascertain that the use of hospital facilities would not be systematically affected by patients' non-medical or socioeconomic characteristics. Specifically, the study distinguishes between two types of utilization control policies, pre-admission certification and concurrent or continuing-stay review of hospital episodes, and asks how each can contain excessive utilization. It concludes that continuing-stay review is not likely to have any appreciable effect on shortening hospital episodes because the effects of nonmedical factors on extended stay are small and concentrated among patients whose diagnoses might not qualify them for hospitalization under a pre-admission screen. However, pre-admission certification has a considerable potential for containment of hospital utilization through the reduction in the number of admissions. Also, as a corollary, the study shows that utilization review policies should not be evaluated, as they often are, in terms of their effect on length-of-stay, but rather in terms of their effects on hospital admissions and case mix.     

Finding new bearings: a qualitative study on the transition from inpatient to ambulatory care of patients with acute myeloid leukemia

Purpose

Treatment of adult acute myeloid leukemia (AML) is intensive, with induction treatment initiated in an inpatient setting and subsequent consolidation therapy often conducted in an outpatient setting. The purpose of the present qualitative paper is to provide insight into the experience of patients in the transition from inpatient to ambulatory care.

Methods

Participants were 35 AML patients who were interviewed about their experience of the illness and treatment. Utilizing the grounded theory method, we describe the adjustment of participants to the transition to ambulatory care.

Results

As outpatients, participants described adjusting to the intensity of ambulatory treatment and to the need to assume greater responsibility for their care. They also expressed a growing desire to understand their long-term care plan, compared to their preference to focus on the present prior to discharge, and they were struggling to construct a new sense of identity.

Conclusions

AML patients are now leaving acute care settings sicker and earlier. Considering their perceptions can inform interventions to facilitate adjustment during the transition to outpatient care.     

Pain beliefs and pain management of oncology patients

Cancer pain is estimated to occur in 30% to 70% of patients with early-stage cancer and 60% to 95% with advanced cancer. Current research shows that cancer pain continues to be undertreated despite the availability of analgesics and established guidelines to maximize their effectiveness. The purpose of this study was to describe oncology patients' pain experience during an episode of hospitalization with particular emphasis on exploring the relationship between oncology patients' beliefs about pain and the treatment they received. Consecutive patients (n = 126) were interviewed 48 hours after admission to an urban and a regional hospital in Australia; 47.6% of patients had experienced moderate to severe pain in the previous 24 hours but had only received 40.4% of available analgesic. Patients held varying beliefs about pain and pain treatments in particular, 41% held strong beliefs about the potential for addiction to narcotics. Patients who held this belief reported higher current pain, worst pain intensity, and higher average pain intensity in the previous 24 hours. Effective pain management in the inpatient oncology setting continues to be an important clinical issue, and patients do not receive all available pain treatment. There may be an important association between patients' beliefs about pain and pain management and the pain management they receive.     

Emergency Ambulatory Management of Low-Risk Febrile Neutropenia: Multinational Association for Supportive Care in Cancer Fits—Real-World Experience From a UK Cancer Center

BackgroundEmergency patient presentations with febrile neutropenia are a heterogeneous group. A small minority of these patients proceed to develop significant medical complications. Risk stratification using scores, such as the Multinational Association for Supportive Care in Cancer score, have been advocated to identify patients who are at low risk of adverse outcome suitable for treatment on an ambulatory care pathway.ObjectivesWe sought to report the experience of 100 patients presenting acutely with neutropenic fever managed in an emergency ambulatory fashion.MethodsPatients presenting as an emergency with low-risk febrile neutropenia managed in an ambulatory setting between January 2017 and February 2019 at a tertiary cancer hospital in England were prospectively studied. Patients with a fever >38.0°C and an absolute neutrophil count <1.0 × 10⁹/L were included. All patients with a Multinational Association for Supportive Care in Cancer score ≥21 and a National Early Warning Score ≤3 were potentially eligible for the pathway. Complications were classified as serious if the patient developed persistent hypotension, respiratory failure, intensive care unit admission, altered mental status, disseminated intravascular coagulation, renal failure requiring renal replacement therapy, electrocardiogram changes requiring antidysrhythmic treatment, and 30-day mortality.ResultsOne hundred patients with low-risk febrile neutropenia consecutively managed in an emergency ambulatory fashion were prospectively analyzed. Eighty-one patients were female and the median age was 51 y (range 17–79 y). No patients developed serious complications. Eight (8% [95% confidence interval 4.1–15.0%]) patients had a 7-day readmission.ConclusionOutpatient ambulatory care for emergency patients with low-risk febrile neutropenia can be delivered in a safe and effective fashion. Collaboration between acute care physicians and oncologists is required to develop local models based on national guidelines to facilitate individualised care for emergency oncology patients.     

Telephone triage. Interview by Jennifer K Mitchell

As the care of patients with cancer has shifted from the inpatient arena to the outpatient setting, the traditional role of outpatient oncology nurses has also changed. Outpatient oncology nurses must not only be knowledgeable about disease processes and care of patients in the clinic, but they must also be skilled in telephone nursing triage.     

Oncology Nursing Considerations when Developing Outpatient Staffing and Acuity Models

ObjectivesObjectives include review of existing benchmarks and nurse-sensitive indicators relevant to the ambulatory care setting. Applying the data to existing ambulatory staffing models with consideration of multiple clinic settings that include medical oncology, infusion, and stem cell transplant clinics. And to describe key considerations needed to optimize oncology care efficiently with an acuity-based staffing model.Data SourcesPublished literature indexed in PubMed, CINAHL, textbooks.ConclusionIn today's complex oncology environment, optimization and utilization of outpatient facilities is essential in providing high-quality care and improving satisfaction of patients as well as providers and staff.Implications for Nursing PracticeNurse leaders should utilize benchmarking data to ensure staffing levels are appropriate, given the size and scope of their facility. Staff nurses should be engaged to ensure that acuity tools are developed in accordance with their experiences and perceptions of patient care.     

Utilization of a clinical pathway in the care of the ambulatory cataract surgical patient

Rapid changes are occurring in healthcare today. Both customers and consumers of healthcare are demanding a change in the way business is being conducted. According to Smith (1993), healthcare organizations are being prompted to explore and implement systems which will enhance quality care as well as promote cost effective resource utilization.A notable change in recent years is the shift of ophthalmic surgical patients from inpatient to an ambulatory setting. This paper will focus on the implementation of a case management model for ophthalmic patients utilizing clinical pathways on an ambulatory unit. Emphasis will be on the provision of quality care resulting in positive patient outcomes.     

A review of the role of emergency nurses in management of chemotherapy‐related complications

Aims and objectives. To examine the role of emergency nurses in caring for patients who receive chemotherapy in ambulatory oncology settings. Reasons for emergency department presentations are examined, specific sources of clinical risk for patients receiving chemotherapy who require emergency care are discussed and cost implications of emergency department presentations related to chemotherapy are analysed. Background. Given the increased administration of chemotherapy in ambulatory settings, emergency nurses play an important role in the management of patients undergoing adjuvant chemotherapy. Emergency departments are the major entry point for acute inpatient hospital care of complications arising from chemotherapy. Design. Systematic review. Results. Chemotherapy‐related emergency department presentations have considerable clinical and cost implications for patients and the healthcare system. Strategies to improve emergency department management of chemotherapy complications and reduction in preventable emergency department presentations has significant implications for improving cancer patients’ quality of life and reducing the cost of cancer care. Conclusions. Nurses are well placed to play a pivotal role in chemotherapy management and lead interventions such as a specialist oncology nursing roles that provide information and support to guide patients through their chemotherapy cycles. These interventions may prevent emergency department presentations for patients receiving chemotherapy in ambulatory settings. Relevance to clinical practice. Patients receiving chemotherapy require access to specialised care to manage distressing symptoms, as they are at significant clinical risk because of immunosuppression and may not exhibit the usual signs of critical illness. A team approach both within and across nursing specialities may improve care for patients receiving chemotherapy and increase effective use of healthcare resources.     

Investigating the self-perceived educational priorities among oncology nurses

AimTo understand the self-perceived educational priorities among oncology nurses.BackgroundOncology nurses are the main providers of care to people affected by cancer. However, little is known about the educational needs and priorities of oncology nurses when providing care to people living with cancer.DesignA national online survey.SettingThe Cancer Nurses Society of Australia (CNSA) is an Australian wide professional body for cancer nurses. At the time of conducting the research, there were approximately 1300 members. All members were invited to participate in the survey. CNSA provided access to nurses working in all areas of cancer care, including inpatient wards, outpatient centres, ambulatory day oncology units, radiation oncology, bone marrow transplant units, educational, and research units.ParticipantsRegistered nurses involved in direct care of people affected by cancer who were members of CNSA, and ability to communicate in English.MethodsThe instrument consisted of a 15-item online questionnaire which included demographic and professional questions related to the self-perceived oncology educational needs which were free-text. This survey was hosted using an online electronic data capture system (i.e., SurveyMonkey®), and the electronic link was sent to the CNSA who then sent an email invitation to the 1300 members.Results610 educational needs were identified and ranked. These individual answers were grouped into seven overarching categories with various sub-categories within each group. The oncology nurses identified important educational topics which included: a) cancer biology, b) treatments, c) direct patient care, d) age-specific cancer care, e) leadership and research, and f) law and ethics.ConclusionAs the number of people affected by cancer continue to rise, addressing the educational needs and priorities of oncology nurses has never been so important. Higher educational institutions and healthcare institutions should consider these findings in addressing the learning needs for the current oncology nursing workforce.     

Factors affecting the evolution of oncology nursing care

Oncology nursing has evolved in response to population growth and changing demographics, changing regulatory requirements, decreasing lengths of inpatient hospital stays, and ongoing advances in cancer treatment, information, and biotechnology. Changes in societal perceptions of cancer and increased access to information have enabled patients to seek out knowledgeable and skilled oncology nurses. Nurses also play an ever-increasing role in rehabilitation as patients live longer with the effects of cancer and treatment. Significant outcomes achieved through nursing research include increased access to care and patient education; improved patient satisfaction, cost-effectiveness of health care, and treatment adherence; fewer hospital admissions; decreased lengths of stay; lower readmission rates; fewer emergency room visits; and lower healthcare costs. Oncology nurse researchers also have studied the economic burden of cancer treatment, limited employment options, and survivorship issues. The progress in professional oncology nursing parallels the progress in surgical, radiologic, biologic, medical, and genetic approaches to cancer treatment. The role and practice of the oncology nurse will continue to evolve in the coming decades as population demographics and healthcare systems change and new scientific and technologic discoveries are integrated into cancer care.     

Staff stress, work satisfaction, and death attitudes on an oncology palliative care unit, and on a medical and radiation oncology inpatient unit

Professional caregivers for cancer patients are at high risk for work-related stress, but it is not clear how this relates to exposure to death and dying, and to professional satisfaction. This study compares work-related stress and staff satisfaction on an academic acute palliative care unit (PCU) with that on a medical and radiation oncology inpatient unit (OIU) at the same cancer centre. PCU staff tended to report less work stress-particularly related to terminal care-than those on the OIU, and higher work satisfaction and team support. PCU staff were more likely to perceive their work experience as having "positively altered their attitude to death" (p = 0.007). These results show that a supportive team environment can exist on an academic PCU and suggest that support currently offered to PCU staff in terms of caring for terminally ill patients should also be extended to those working in general oncology settings.     

Evaluating diagnosis-based case-mix measures: how well do they apply to the VA population?

BACKGROUND: Diagnosis-based case-mix measures are increasingly used for provider profiling, resource allocation, and capitation rate setting. Measures developed in one setting may not adequately capture the disease burden in other settings. OBJECTIVES: To examine the feasibility of adapting two such measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), to the Department of Veterans Affairs (VA) population. RESEARCH DESIGN: A 60% random sample of veterans who used health care services during FY 1997 was obtained from VA inpatient and outpatient administrative databases. A split-sample technique was used to obtain a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. METHODS: Concurrent ACG and DCG risk adjustment models, using 1997 diagnoses and demographics to predict FY 1997 utilization (ambulatory provider encounters, and service days-the sum of a patient's inpatient and outpatient visit days), were fitted and cross-validated. RESULTS: Patients were classified into groupings that indicated a population with multiple psychiatric and medical diseases. Model R-squares explained between 6% and 32% of the variation in service utilization. Although reparameterized models did better in predicting utilization than models with external weights, none of the models was adequate in characterizing the entire population. For predicting service days, DCGs were superior to ACGs in most categories, whereas ACGs did better at discriminating among veterans who had the lowest utilization. CONCLUSIONS: Although "off-the-shelf" case-mix measures perform moderately well when applied to another setting, modifications may be required to accurately characterize a population's disease burden with respect to the resource needs of all patients.     

Validity and reliability of a pediatric hematology oncology patient acuity tool

Appropriate use of nursing resources in the pediatric hematology and oncology inpatient settings demands a patient acuity system that is easy to use and accurate, and that objectively measures nursing care needs of a specialized patient population. Structured survey of 13 comprehensive cancer centers and a review of the literature show no valid and reliable acuity tools for this pediatric population. The purpose of this project was to study the validity and reliability of a newly developed pediatric hematology and oncology acuity system designed to quantify patient care needs. A new acuity tool for this pediatric population was developed based on the patient classification tool used at Johns Hopkins Hospital Oncology Center (JHHOC). The levels of care from the JHHOC tool were adopted, with therapeutic indicators modified to reflect nursing diagnoses relevant to the pediatric inpatient. Nursing care hours required for each level of care were also identified. Validity was studied using a content validity index (CVI). Experts from the pediatric unit where the tool would be used were asked whether each therapeutic indicator was assigned to the correct level of care (1 thru 5) based on patient care hours. CVIs for items ranged from .5 to 1.0; the overall CVI for the tool was .93. Interrater reliability was studied using two raters from the unit. Data were collected for 150 patient observations on a 12-bed pediatric hematology and oncology inpatient and short-stay outpatient unit. The resulting Pearson correlation coefficient was r = .97 (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Psychosocial nursing care for adolescents with cancer

Psychosocial care for adolescents who have cancer acknowledges the growth and developmental tasks they are mastering within the context of the experience of cancer. This article discusses developmentally focused approaches to providing care for adolescents with cancer. These include establishing trust, understanding, being present, setting mutual goals, and providing social support. Pediatric oncology nurses who practice in inpatient and outpatient care settings are in an ideal position to support continued psychosocial growth and development of adolescents with cancer because of the intimate and sustained contact they have with them.