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Objective: To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication. Background: Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes. Methods: This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians ( n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews ( n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis. Results: Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients. Conclusions: Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.

OBJECTIVES: This study examined the association of ED use in the first year of diagnosis and patient experiences in care among older adults with hematologic malignancies. MATERIALS AND METHODS: Cross-sectional design using SEER-CAHPS® data from 2002-2015 to study Medicare fee-for-service enrollees with a primary diagnosis of leukemia or lymphoma. We linked the CAHPS survey data (patient-reported experiences with health services) to patients’ cancer registry information and Medicare outpatient claims from the SEER-CAHPS resource. We estimated associations of ED use and clinical characteristics with two CAHPS outcomes – “getting care quickly” (timeliness) and “getting needed care” (access) – with bivariate and multivariate analyses. RESULTS: The analytic sample included 751 patients, 125 of whom had an ED claim in the first year of cancer diagnosis. The most frequent ED diagnosis clusters were fever and infection (n=17, 13.6%), orthopedic and injury (16, 12.8%) and pain (16, 12.8%). Significantly more enrollees with an ED claim were diagnosed with lymphoma (p < 0.01), lived in rural areas (p < 0.01), and lived in areas with many families living in poverty (p < 0.01). In adjusted models, enrollees with an ED claim reported significantly worse access to care (β −4.83; 95%CI −9.29,−.38; p = 0.03). CONCLUSION: The management of urgent care concerns for adults with hematologic malignancies remains an important clinical and quality improvement imperative. Further study is warranted to enhance the management of emergent complications in older adults receiving care for hematologic malignancies, with efforts that enhance coordination of ambulatory oncology care.

Objective To examine the feasibility of soliciting outcomes from adults who received chemotherapy treatment for cancer and describe the patterns and correlates of patient-reported toxicities. Data sources Patient survey data from 29 Michigan ambulatory oncology practices collected in 2017. Study design Secondary analysis of patient survey data. Descriptive statistics were generated at the patient and practice levels. Thematic analysis of open-text comments identified clusters of frequently reported toxicities. Data collection methods Patients completed 11 items from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events. Using a 5-point Likert scale, patients rated the frequency of nausea, vomiting, diarrhea, and pain; the severity of nausea, vomiting, constipation, numbness/tingling, and pain; and how much numbness/tingling and pain interfered with usual or daily activities. Patients could also report two toxicities in open-text comments. Finally, patients reported unplanned health care service for toxicity or side effect management. Principal findings Of 3565 eligible patients, 2245 participated (63%) and 457 (20%) rated at least one toxicity as severe/very severe. Across practices, the proportion of patients who reported at least one severe/very severe toxicity ranged from 8% to 50%. Troubling toxicities included pain frequency (mean 2.3, SD 1.3), pain severity (2.1, 1.1), and diarrhea frequency (1.9, 1.0). From completed assessments, 1653 (74%) reported at least one toxicity in open-text comments; fatigue (n = 182), stomach discomfort (n = 53), and skin/nail changes (n = 41) were most frequently reported. Regarding consequences, 156 patients (7%) reported unplanned health care service use: 41 (26%) visited an emergency department and 32 (21%) were admitted to a hospital. Conclusions Querying patients on chemotherapy treatment experiences and toxicities was feasible. Toxicity rates varied across practices, which informed quality improvement. Toxicity severity and service use incidence exceed previously published trial data, particularly for pain, fatigue, and gastrointestinal issues. Open-text questions enabled exploration with newer treatment regimens.

PURPOSE: Timeliness of care has increasingly become a central focus of quality clinical practice. In oncology, chemotherapy treatment delays potentially jeopardize patient safety and impede progress towards disease remission. Few investigations have examined the social and technical factors influencing chemotherapy treatment processes in ambulatory oncology practices, despite evidence that patients are receiving more outpatient chemotherapy than ever before. The purpose of this study was to examine the causes and consequences of chemotherapy treatment delays and possible solutions to improve quality of care. PARTICIPANTS AND SETTING: We selected a purposive sample of eight ambulatory oncology practices for ethnographic site visits, which lasted five days each. METHODOLOGIC APPROACH: We conducted 290 observation hours, including clinician shadowing, and 46 semi-structured interviews with clinicians (oncology nurses, physicians, advanced practice providers). We performed deductive and inductive thematic analysis on all data. FINDINGS: We identified four primary themes from our analysis that affect delays: discrepancies in care plans and missing orders, uncommunicated day-of-treatment order changes, orders not signed in advance by physicians, and laboratory testing processes. IMPLICATIONS FOR NURSING: Future investigations must examine nurses’ communication practices in the context of timely chemotherapy administration as communication and documentation technologies within health care settings continuously evolve.

The novel coronavirus (COVID-19) pandemic has created an unprecedented global health challenge. There is risk that the outbreak will create a “second pandemic” of mental health crises in health systems and communities. Thus, a comprehensive public health response to the pandemic must include (a) attention to the psychological aspects of hospitalization for patients, families, and staff affected by COVID-19; (b) planning for emergency and acute psychiatric patient care if hospitals become overwhelmed with COVID-19 patients; and (c) innovations for providing mental health care in communities while social distancing is required and health system resources are strained. Nurses and nurse leaders must anticipate these mental health challenges, assist with preparedness in health systems and communities, and advocate for a coordinated response to promote mental wellness and resilience.

BACKGROUND: Gabapentinoid use for cancer-pain control may be problematic, given unclear mechanisms of action and increased concerns for physical dependence. The purpose of this report is to examine trends of gabapentinoid use among US adults with cancer from 2005–2015. METHODS: We conducted a serial, cross-sectional study using data from the Medical Expenditure Panel Survey (MEPS). We performed multiple logistic regression to examine the annual percentages of gabapentinoid users, which were adjusted for age, sex, and US region of residence. RESULTS: The amount of gabapentinoid prescriptions filled in 2015 was also estimated. The adjusted percentage of gabapentinoid users in 2015 was 5.60% (3.79%, 7.41%), 2.39 times greater than the percentage in 2005 (p < .001). By 2015, the number of gabapentinoid prescriptions had grown to approximately 3.52 million (2.40 million, 4.65 million). CONCLUSION: We observed greater than a two-fold increase in the trend of gabapentinoid medication use among US adults with cancer. Investigations on the long-term efficacy of gabapentinoids for complex pain syndromes, and mitigation of risks, is essential to guide informed clinical management and keep patients safe.

RESEARCH OBJECTIVE: In the United States, adult patients with cancer receive most chemotherapy treatments in ambulatory settings. Yet outside of clinical trials, these setting rarely collect and report patient‐reported outcomes (PROs), such as treatment‐associated toxicities. As novel cancer treatments expand, we examined the feasibility of collecting PROs from adults with cancer receiving chemotherapy treatment and described the patterns and correlates of patient‐reported toxicities. STUDY DESIGN: We conducted secondary data analysis from a multisite study of ambulatory oncology care quality and safety. On‐site practice champions identified eligible patients who completed an anonymous questionnaire at their appointment check‐in. Patients receiving chemotherapy completed 11 items from the Patient‐Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO‐CTCAE), with a recall period of the past seven days. Patients rated each item on a 5‐point scale across three domains: frequency, severity, and interference with daily activities. Patients rated the frequency of nausea, vomiting, diarrhea, and pain (1 = never, 5=almost constantly); the severity of nausea, vomiting, constipation, numbness/tingling, and pain (1 = none, 5 = very severe); and how much numbness/tingling and pain interfered with usual or daily activities (1=not at all, 5=very much). Patients could report two additional side effects in an open‐text section. Descriptive statistics were calculated at both the patient and practice levels to generate practice‐level data summaries. POPULATION STUDIED: Adults with invasive, nonmetastatic cancer and received systemic intravenous chemotherapy treatment at one of 29 medical oncology practices that participated in a statewide quality improvement collaborative. Patients either read English or had a nonclinician proxy available. PRINCIPAL FINDINGS: Of 3,565 eligible patients, 2,245 participated (63%). A total of 1,302 (58%) were female, 389 (17%) were nonwhite, and 257 (11%) were treated in rural settings. A total of 457 patients (20%) rated at least one toxicity as severe/very severe. At the practice level, the proportion of patients per practice who reported at least severe/very severe toxicity ranged from eight to 50 percent. The toxicities rated with the highest severity were pain frequency (mean 2.3, SD 1.3), pain severity (2.1, 1.1), and diarrhea frequency (1.9, 1.0). From completed assessments, 1,653 (74%) self‐reported at least one additional toxicity in the open‐text section. After thematic analysis, the most frequently reported toxicities in the open‐text section were fatigue (n=182), generalized stomach discomfort (n=53), and skin/nail changes (n=41). Regarding consequences of toxicities experienced since the last chemotherapy treatment, 156 patients (7%) reported unplanned health care service use for toxicity management: 41 (26%) visited an emergency department, and 32 (21%) were admitted to a hospital. CONCLUSIONS: Querying patients directly on their toxicity and related treatment experience was highly feasible. Notable variation in reported toxicities occurred across practices and enabled them to act on their own data. Toxicity severity and related service use exceeded the incidence reported in clinical trials. IMPLICATIONS FOR POLICY OR PRACTICE: Soliciting patient‐reported outcomes from patients outside of clinical trials can inform the clinical community on the patient experience and motivate clinical practice changes. Adults treated for invasive cancer continue to report persistent challenges in managing pain, fatigue, and gastrointestinal issues. Providing patients with open‐text sections enabled the study team to explore toxicities emerging from newer treatment regimens. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

BACKGROUND: Oncology settings increasingly use patient experience data to evaluate clinical performance. Given that older patients with hematologic malignancies are a high-need and high-risk population, this study examined factors associated with patient-reported health care experiences during the first year of their cancer diagnosis. METHODS: Cross-sectional study using the 2000–2015 SEER-CAHPS® data to examine patient experiences of Medicare enrollees with a primary diagnosis of leukemia or lymphoma. The primary outcomes were three CAHPS assessments: overall care, personal doctor and health plan overall. We estimated case-mix adjusted and fully adjusted associations between factors (i.e., clinical and sociodemographic) and the CAHPS outcomes using bivariate statistical tests and multiple linear regression. RESULTS: The final sample included 1,151 patients, with 431 diagnosed with leukemia and 720 diagnosed with lymphoma (median time from diagnosis to survey 6 months). Patients who completed the survey further apart from the diagnosis date reported significantly higher adjusted ratings of care overall (p=.008) than those closer to diagnosis. American Indian/Alaska Native, Asian, and Pacific Islander patients had lower adjusted ratings of care overall (p= .003) than Non-Hispanic White patients. Multimorbidity was significantly associated with higher adjusted personal doctor ratings (p=.003). CONCLUSIONS: Unfavorable patient experience ratings among vulnerable and under-represented older adults diagnosed with hematologic malignancies warrant targeted efforts to measure and improve care quality. Future measurement of experiences of cancer care soon after diagnosis, coupled with careful sampling of high-priority populations, will inform oncology leaders and clinicians on strategies to improve care for high-risk, high-cost populations.

BACKGROUND: Hazardous drug exposures are a key occupational health hazard to oncology nurses. Sparse data are available regarding the frequency and characteristics of hazardous drug spills to inform clinical practice improvement. OBJECTIVE: To describe nurses’ hazardous drug exposures and use of personal protective equipment during drug spills. METHODS: The Drug Exposure Feedback and Education for Nurses’ Safety study launched in March 2015. When drug spills occurred, consented registered nurses administering chemotherapy in ambulatory infusion settings completed brief questionnaires to describe the spill event, protective equipment worn during the spill, and spill containment efforts. Descriptive statistics were used to summarize equipment use and spill events. FINDINGS: Spills were common, despite the use of closed system transfer devices. Over 24 months, 51 nurses from twelve participating academic infusion centers reported 61 unique spills. Spilled drug volumes ranged from 1 to 250 mLs. Spills commonly involved highly toxic drugs, including paclitaxel (20% of spills), gemcitabine (15%), and anthracyclines (13%). Personal protective equipment use during drug spills is suboptimal; nurses reported wearing disposable gowns (65% of the time), double gloves (52%), single gloves (41%), respirators (28%), and eye shields (26%). Practicing nurses, clinical leaders, and policymakers must address these practice gaps through concerted education, support, and policy changes.

We developed BMT Roadmap, a health information technology (HIT) application on a tablet, to address caregivers’ unmet needs with patient-specific information from the electronic health record. We conducted a preliminary feasibility study of BMT Roadmap in caregivers of adult and pediatric HSCT patients. The study was registered on ClinicalTrials.gov (NCT03161665; NCT02409121). BMT Roadmap was delivered to 39 caregivers of adult and pediatric patients undergoing first-time HSCT at a single study site. We assessed person-reported outcome measures (PROMs) at baseline (hospital admission), discharge, and day 100: usefulness of BMT Roadmap (Perceived Usefulness); activation (Patient Activation Measure-Caregiver version [PAM-C]); mental health ([POMS-2®]: depression, distress, vigor, and fatigue); anxiety (State-Trait Anxiety Inventory); and quality of life (Caregiver Quality of Life Index-Cancer [CQOLC]). To identify determinants of caregiver activation and quality of life, we used linear mixed models. BMT Roadmap was perceived useful and activation increased from baseline to discharge (p = 0.001). Further, burden decreased through discharge (p = 0.007). Overall, a pattern of increasing vigor and decreasing depression, distress, fatigue, and anxiety was apparent from baseline to discharge. However, overall quality of life lowered at discharge after accounting for BMT Roadmap use, depression, anxiety, and fatigue (p = 0.04). BMT Roadmap was a feasible HIT intervention to implement in HSCT caregivers. BMT Roadmap was associated with increased activation and decreased burden, but quality of life lowered across hospitalization. Findings support the need to further develop caregiver-specific self-directed resources and provide them both inpatient and outpatient across the HSCT trajectory.

Health information technology (HIT) has great potential for increasing patient engagement. Pediatric hematopoietic cell transplantation (HCT) is a setting ripe for using HIT but in which little research exists. "BMT Roadmap" is a web-based application that integrates patient-specific information and includes several domains: laboratory results, medications, clinical trial details, photos of the healthcare team, trajectory of transplant process, and discharge checklist. BMT Roadmap was provided to 10 caregivers of patients undergoing first-time HCT. Research assistants performed weekly qualitative interviews throughout the patient's hospitalization and at discharge and day 100 to assess the impact of BMT Roadmap. Rigorous thematic analysis revealed 5 recurrent themes: emotional impact of the HCT process itself; critical importance of communication among patients, caregivers, and healthcare providers; ways in which BMT Roadmap was helpful during inpatient setting; suggestions for improving BMT Roadmap; and other strategies for organization and management of complex healthcare needs that could be incorporated into BMT Roadmap. Caregivers found the tool useful and easy to use, leading them to want even greater access to information. BMT Roadmap was feasible, with no disruption to inpatient care. Although this initial study is limited by the small sample size and single-institution experience, these initial findings are encouraging and support further investigation.

PURPOSE: We know little about how increased technological sophistication of clinical practices affects safety of chemotherapy delivery in the outpatient setting. This study investigated to what degree electronic health records (EHRs), satisfaction with technology, and quality of clinician-to-clinician communication enable a safety culture. METHODS: We measured actions consistent with a safety culture, satisfaction with practice technology, and quality of clinician communication using validated instruments among 297 oncology nurses and prescribers in a statewide collaborative. We constructed an index to reflect practice reliance on EHRs (1 = “all paper” to 5 = “all electronic”). Linear regression models (with robust SEs to account for clustering) examined relationships between independent variables of interest and safety. Models were adjusted for clinician age. RESULTS: The survey response rate was 68% (76% for nurses and 59% for prescribers). The mean (standard deviation) safety score was 5.3 (1.1), with a practice-level range of 4.9 to 5.4. Prescribers reported fewer safety actions than nurses. Higher satisfaction with technology and higher-quality clinician communication were significantly associated with increased safety actions, whereas increased reliance on EHRs was significantly associated with lower safety actions. CONCLUSION: Practices vary in their performance of patient safety actions. Supporting clinicians to integrate technology and strengthen communication are promising intervention targets. The inverse relationship between reliance on EHRs and safety suggests that technology may not facilitate clinicians’ ability to attend to patient safety. Efforts to improve cancer care quality should focus on more seamless integration of EHRs into routine care delivery and emphasize increasing the capacity of all care clinicians to communicate effectively and coordinate efforts when administering high-risk treatments in ambulatory settings.

The 340B Drug Pricing Program is a complex federal program that is intended to provide financial relief to hospitals that provide care to greater volumes of low-income, uninsured, and underinsured patients. The body of literature is growing on how cancer care has transformed since freestanding cancer hospitals became eligible for the 340B program. Currently, community oncology practices are not eligible for the 340B program.

Multisite research is an important strategy to strengthen the external validity of nursing science (O'Mara, BauerWu, Berry, & Lillington, 2007). In contrast to single-site studies, research projects conducted with multiple sites offer potentially larger, more diverse participant samples and reduce the likelihood of idiosyncratic research findings. Conversely, multisite studies are more complicated to conduct and administer. New complexities also arise when research participants are staff, as opposed to patients or clients.Workplace intervention studies are increasing, due in part to growing awareness that improved worker health and safety have downstream societal benefits (Anger etal., 2015). Specifically, the NationalInstitute for Occupational Safety and Health (NIOSH) has launched the Total Worker Health initiative to respond to this challenge (NIOSH, 2016; Weisfeld, Lustig, & Board of Health Sciences Policy, 2014). Healthy workers are associated with lower turnover, improved economic productivity, and enhanced personal well-being. Due to labor shortages, high acuity, long shifts, and physical demands, NIOSH has identified healthcare workers as a vulnerable labor sector for intervention (NIOSH, 2013). For the past 10 years, our interdisciplinary team has documented the specific concerns of oncology nurses employed in ambulatory oncology settings. These nurses face an unusual occupational threat of hazardous drug exposure given the high patient volume, the explicit emphasis on chemotherapy treatment, and associated continuous risks of exposure.Our team documented that 18% of surveyed ambulatory oncology nurses experienced an unplanned hazardous drug spill in the preceding 6 months (Friese et al., 2014). Hazardous drug exposure is correlated with substantial short- and long-term health effects, such as nausea, vomiting, airway irritation, reproductive problems, and rare cancers (NIOSH, 2004). Despite 30 years of data to support the need for increased vigilance when handling hazardous drugs, surprisingly few nurses wear personal protective equipment as recommended (Connor & McDiarmid, 2006; Polovich & Clark, 2012). Except for the current project, only one published study examined an educational intervention for nurses, conducted in one Malaysian hospital (Keat, Sooaid, Yun, & Sriraman, 2013). Thus, we lack sufficient evidence on how to improve nurses' use of personal protective equipment when handling hazardous drugs.The Drug Exposure Feedback and Education for Nurses' Safety (DEFENS) study is a 4-year, multisite cluster randomized controlled trial (Friese, MendelsohnVictor, et al., 2015). The study compares one-time static educational information about hazardous drug exposure prevention to quarterly feedback on study results, coupled with tailored messages designed to reduce barriers to protective equipment use. In planning for the project, we reviewed the sparse literature that describes multisite research project management with registered nurse employees as participants. In the current article, we review successful study implementation strategies and identify important considerations for future research projects that plan to incorporate nurses as participants.ApproachThe DEFENS study is a cluster randomized controlled trial. Nurses who work 16 hr a week or more in ambulatory infusion within 12 large cancer centers in the United States were invited to participate. Full details may be found in the published protocol paper (Friese, Mendelsohn-Victor, et al., 2015) or in the ClinicalTrials.gov registry (National Institutes of Health [NIH], 2016a). Guided by extant models of health behavior and risk reduction, we hypothesized that one-time educational content is insufficient to improve nurses' use of personal protective equipment when handling hazardous drugs (McCullagh, Ronis, & Lusk, 2010). Rather, we compared static educational content (control intervention) to quarterly feedback about data gleaned from our study, coupled with video messages tailored to participants' reported barriers to protective equipment use (experimental intervention). …

Purpose Health information technology (IT) is an ideal medium to improve the delivery of patient-centered care and increase patient engagement. Health IT interventions should be designed with the end user in mind and be specific to the needs of a given population. Hematopoietic cell transplantation (HCT), commonly referred to as blood and marrow transplantation (BMT), is a prime example of a complex medical procedure where patient-caregiver-provider engagement is central to a safe and successful outcome. We have previously reported on the design and development of an HCT-specific health IT tool, BMT Roadmap. Methods This study highlights longitudinal quantitative and qualitative patient-reported outcomes (PROs) in 20 adult patients undergoing allogeneic HCT. Patients completed PROs at three time points (baseline, day 30 post-HTC, and day 100 post-HCT) and provided weekly qualitative data through semistructured interviews while using BMT Roadmap. Results The mean hospital stay was 23.3 days (range, 17 to 37 days), and patients had access to BMT Roadmap for a mean of 21.3 days (range, 15 to 37 days). The total time spent on BMT Roadmap ranged from 0 to 139 minutes per patient, with a mean of 55 minutes (standard deviation, 47.6 minutes). We found that patients readily engaged with the tool and completed qualitative interviews and quantitative PROs. The Patient Activation Measure, a validated measure of patient engagement, increased for patients from baseline to discharge and day 100. Activation was significantly and negatively correlated with depression and anxiety PROs at discharge, suggesting that this may be an important time point for intervention. Conclusion Given the feasibility and promising results reported in this study, next steps include expanding our current health IT platform and implementing a randomized trial to assess the impact of BMT Roadmap on critical PROs.

Objective To review and summarize nurses’ roles in the care of the older adult undergoing an allogeneic hematopoietic cell transplant (HCT) for the treatment of leukemia. Data Sources Published literature indexed in PubMed, CINAHL, textbooks, and clinical expertise. Conclusion Nurses are a vital component of the highly specialized care delivered before, during, and after an allogeneic HCT. Implications for Nursing Practice Nurses who are prepared for the complex HCT care trajectory will be able to optimally meet the complex needs of the older adult patient and their caregiver(s).

6549Background: We know little about clinicians’ documentation and communication challenges and how these might affect the safety of ambulatory oncology care. The present study investigated variati...

e18721Background: The National Cancer Institute and other key stakeholders endorse soliciting patient-reported outcomes to understand cancer treatment experiences outside of clinical trials. We exa...