An educational initiative to reduce emergency department visits for oncology patients
with febrile neutropenia.
University
PICO
Problem: An increase in patient emergency department sick visits for patients who have received chemotherapy in the last 30 days.
Intervention: Patient educational intervention for patients currently receiving chemotherapy paired with emergency department (ED) providers, to educate and attempt to prevent emergency department visits in oncology patients at a rural hospital.
Outcome: Decrease in ED admissions related to febrile neutropenia for oncology patients who currently have had chemotherapy in the last 30 days.
Background
Cancer is one of the trending topics in healthcare sectors around the world due to its significant impact on global mortality rates. Consideration of all types of cancers in the United States shows that up 1,735,350 new cases were diagnosed in 2018 (American Cancer Society, 2018). Cancer is a health condition that emanates from abnormal growth or division of cells. According to the National Cancer Institute (NCI), more than 100 types of cancer exist with the most common ones being breast, prostate, and lung cancer (“Cancer Types,” n. d.). In the US, cancer has become the second leading cause of death after heart disease, which makes it a health concern not only for Americans but also for the international community (“Early History of Cancer,” 2018).
In the US, cancer has been a significant health concern since its discovery. The condition has resulted in high mortality rates despite the development of different treatment options. According to the statistics by the NCI, cancer cases have been on the rise from 1975 to 1990 (“SEER Cancer Stat Facts: Cancer of Any Site [SEER],” n. d.). However, from 1990 to date, cancer-related deaths have been declining due to advanced treatment options for both common and rare variations of the disease (“SEER” n. d.). For instance, in 1991, 215.1 out of every 100,000 people died of cancer compared to the 2015 data which revealed that 158.6 out of every 100,000 individuals died as a result of the disease (Siegel, Miller, & Jemal, 2018). The above-mentioned details suggest that significant improvements in treatment protocols as well as the attempt in prevention of the side effects of the treatment have yielded positive outcomes. Howlander, et al (2017) conveys that currently there are 15.5 million people in the U.S. diagnosed or living with cancer. That number, by the year 2040, will climb to above 26 million persons. With the ostensible thought of the number of diagnosed individuals, living with, being diagnosed and treated, outpatient symptom management is key. Although diagnosis and treatments have significantly been enhanced, healthcare providers and patients continue to identify significant gaps in the patients medicinal needs. In their study, Silver, Raj, Wisotzky, Smith, and Kirch (2015) outline that healthcare delivery innovations such as oncology care have been implemented to help in improving these insufficiencies.
Advanced healthcare technology has played critical roles in the evolution of cancer diagnostics as opposed to the previous century in which medical procedures were not fully automated or technology-oriented. Moreover, through such technology, cancer research facilities have established new types of cancers. These discoveries promote understanding of the disease, leading to innovations in treatment approaches. According to Praderio (2018), apart from the common types of cancer, the U.S. experienced a rise in other forms of cancer in 2015 such as renal pelvis and kidney cancer (61,816 cases), thyroid cancer (48,761 cases), and uterine corpus cancer (54,644 cases). Currently, there are more than 100 types of cancer with each one being widespread in the U.S. (“Cancer Types,” n. d.). The pervasiveness of different kinds of cancer in the U.S. is an indication of the evolution of the illness.
Frequently when a patient is diagnosed and started with treatment, within one year of beginning oncology treatments, there is a large number of ED visits. A large number of visits to the ED could be preventable. Panattoni and associates demonstrated that approximately 44% of patients with a diagnosis of cancer visit the ED within the year after the initiation of treatment. Instead of the patient being treated in an outpatient oncology or observational setting, they are sent to the ED, which has proved potentiate a more critical situation for an oncology patient, given that the ED has patients in a common waiting room with the flu, diarrhea, contagious disease to a patient who does not have the cells to protect them from an average common cold, let alone pneumonia. Many times an oncology patients presenting symptoms or complaints is a diagnosis of fever, malaise, dehydration, pain, malnutrition, nausea, vomiting or diarrhea. Symptoms that would not require an admission or even a ED visit given the opportunity to be seen and have symptom management in an outpatient setting.
Home care services do not have the manpower nor the availability to do infusions in the home due to specialized nursing services and specialized training. The result is that cancer patients regularly are being admitted into acute care settings (Earle, Landrum et al. 2008). This dynamic move has two fundamental results: 1) urgent admission is turning into a continuous methodology of admission (Manzano, Luo et al. 2014). The simpler way to a medical clinic is by all accounts the emergency department, which is open throughout the day as well as through the night, opposed to a clinic or home services which has a limited number of hours. The ED can give the immediate comprehensive care. 2) The oncological units, which are expected to give expert care and complex dynamic medication, are habitually utilized for managing chemotherapy induced symptoms (Yates, Barrett et al. 2009). Although many times the units get overflow patients, therefore when an oncology patient is in need of being admitted, they are brought to the floors where they can be exposed and more susceptible to, at the very least, Flu or Pneumonia. Cancer patients are entitled to high caliber, more suitable care. There are special considerations that need to be taken into effect with these patients, one consideration is being more proactive in the outpatient setting with regard to fever, neutropenia, or pain, instead of sending a patient to the ED, attempting to keep those individuals out of both the hospital and the ED. Additionally, hospitalization of cancer patients ought to be viewed as an essential advance in the direction of their disease (Popescu, Schafer et al. 2014); instead of thinking about hospitalization as avoidable or even unseemly, we should expand our endeavors to guarantee quick symptom control and provoke adjustment of acute conditions.
Before, chemotherapy was commonly done in a hospital, notwithstanding generally basic and clear treatment programs without major impending dangers and reactions. Today, be that as it may, treatment has moved to outpatient settings, more commonly the oncologist’s infusion center, but sometimes also to medical outpatient facilities or the home (Mayer, Travers et al. 2011). (EXPAND ON WHY THIS IS COST EFFECTIVE)
Presently, hospital admission for administering chemotherapy is constrained to explicit conditions portrayed by generally acknowledged practice guidelines which developed out of this essential and fundamental change in practice setting. These guidelines presently exist as the “customary way of thinking” of oncologists, yet have not been outlined in an institutionalized composed manner (Aprile, Pisa et al. 2013). These guidelines for hospitalization reflect such clinical parameters as the requirement for a longer direct observation, treatment or prevention of foreseen or genuine symptoms, or the utilization of hospital facilities and the minimization of certain treatment dangers that cannot be successfully managed in an outpatient setting (Rocque, Barnett et al. 2013). A new component has been brought into the practice guidelines by managed care associations: the essentially greater expense of such chemotherapy administration in the hospital in contrast with an outpatient office (Wright, Hatfield et al. 2014). Hence, these rules reflect not only clinical and pharmacologic parameters, but also budgetary ones. The decision of an outpatient setting for administering treatments to a patient in order to manage that gap, or symptom, that is firmly related with the associated requirement for approval from outside payers and rates of drug reimbursement (Brooks, Abrams et al. 2014).
Outpatient symptom management has the following advantages: permits protected, simple medication administration; regards a patient’s desire to avoid being hospitalized; recognizable and ‘safe’ facility improves patient’s physical solace and mental prosperity; the oncologist has immediate and prompt control of medical administration; accessible assistance if issues emerge; more affordable than inpatient care; overnight stay is avoided (anti-nausea drugs and different agents.); encourages “tracking” and control of treatment costs; and treatment can be directed whenever the timing is ideal (Rueben, Tinetti et al. 2014).
Numerous oncology clinics have developed intricate, hygienic, and impressive outpatient chemotherapy and infusion stations, including specific drug-blending stations (generally with vacuum hoods to protect the personnel and satisfy legitimate prerequisites), comfortable medication seats, segments to boost privacy, and diversions, for example, TV and instructive video programs. Within the clinics, oncology nurses expertly handle these facilities and teach cancer patients what to watch for and monitor in the event that symptoms arise, in efforts to bed contain the disease and lessen the chance of being admitted (Foltran, 2014).
According to Miller, Siegel, Lin, Mariotto, Kramer, Rowland and Jemal (2016), With a mortality rate increasing not due to the dying from the disease itself, rather the symptoms related to treatment or other comorbid conditions. Many times, these symptoms can be preventable or treatable if caught and treated early. However, through oncology care it is provisioned based on three objectives regarding stabilizing cancer patients. These include healthier individuals, smarter spending and better care. In their research, Kline, Adelson, Kirshner, Strawbridge, Devita, Sinanis, and Basch (2017) outline that the primary aim of these clinics is to utilize the aligned financial encouragements to enable improved healthcare coordination and to enhance immediate treatment for patients rather than waiting for three to four hours in the emergency department. Oncology care is used to not only attempt to stabilize the progression of disease but also symptom management of the side effects of those treatments.
Based on a study conducted at Inonu University, department of emergency medicine, the complaint that was addressed to the ED is the abdominal pain issue. This issue had 344 patients out of 1946. Lung cancer was the most common malignancy with 335 patients. Out of the 1946 patients in the emergency room, 610 were receiving chemotherapy while 1052 were not. The remaining 285 were not receiving but at one time had acquired the chemotherapy. Thirty-three patients did not survive out of the emergency department. Kline et al. (2017) outlined that infusion care clinics provide faster diagnosis, quality care, professional staff, and affordable costs. Additionally, the outpatient infusion model offers patients with instant supportive services and treatment. Nonetheless, there are several symptoms relating to the diagnosis or treatment of the diagnosis that can be handled at the infusion clinic. These symptoms can include anemia, infection, low blood counts, hydration, nausea, vomiting, diarrhea and nutrition. The outcome is reduced cost, increased compliance and convenience to a prescribed treatment. The outpatient infusion mechanisms offer clients with the valid, reliable and home-like surrounding. Subsequently, the outpatient infusion is established to not only assist the oncologist to be able to properly treat but also to prevent admissions to the emergency room.
According to Polinski, Kowal, Gagnon, Brennan, and Shrank (2017), outpatient infusions allow patients to regularly maintain daily activities and quality of life rather than going through the emergency department. Miller et al. (2016) state that infusions take about 30-60 minutes and depend on the degree of severity by the patient.
Daly, et al. (2018) conveys that the Centers for Medicare and Medicaid Services (CMS) has determined that there is a major gap in care for oncology patients with regard to care relating to certain diagnosis including but not limited to fever, nausea, vomiting, anemia, dehydration, neutropenia, and sepsis. There are limited guidelines to support the treatment of oncologic patients. Therefore it is apparent that the patients seen there, many times, have an unwarranted admission. The patient has a notably longer admission, due to the apparent diagnosis and treatment needed, sometimes causing a delay in ongoing chemotherapy treatment. Criteria that was initiated by CMS for patients receiving chemotherapy within a 30 day window was initially established in 2016. It has not been placed into effect until the new proposal of 2020, whereas they list specific side effects, post chemotherapy as preventable. When defining a potentially preventable symptom as “a symptom that could be managed safely in the outpatient setting if identified early and managed proactively.” (Daily, et al 2018). A new metric is being proposed for oncology patients in the year 2020 listing up to 10 diagnoses as would be considered able bodied to be handled in an outpatient setting.
Significance
Chemotherapy treatment may cause serious side effects including but not limited to severe dehydration, low blood counts, fever, diarrhea, as well as worsen overall patient’s condition, hence the need for the implementation of treatment interventions such as adequate hydration, monitoring of adverse signs and symptoms, and limiting exposure to sick individuals. Neutropenia, low white blood cell count, which is the primary cell to fight infection, has the potential to decrease with each chemotherapy treatment, resulting in fever, infection, and malaise. (Oun, Moussa & Wheate, 2018). Patients are advised to seek medical help if they experience a fever greater than 100.4, a new onset of a productive cough, or signs of an infection. Patients must be vigilant with hygiene and infection control.
Nausea and vomiting are prevalent chemotherapy side effects that increase dehydration risk in turn reducing the quality of life. Cancer patients should seek professional nutritional consultation and oncology infusion services for hydration advice especially during the chemotherapy treatment for improved outcomes. Healthcare professionals should be able to identify signs of dehydration and establish sufficient intervention. In the event that the symptom is not preventable, infusion centers can aid in intravenous saline solution for severely-dehydrated patients to aid in keeping the patient out of the emergency room.
Timely diagnosis and improved symptoms management are essential in evidence-based care as they improve the overall health outcomes and inhibit the development of preventable conditions, such as dehydration. Ohnishi & Takeda (2015) propose the use of herbal medicines as alternatives for chemo drugs for alleviation of side effects. Patients receiving chemotherapy are able to receive scheduled treatment cycles and phases of rest that allow for ample time to recover from chemotherapy side effects (Tao, Visvanathan & Wolff, 2015). Caregivers should utilize the resting phase of chemo treatment for monitoring and establishment of non-medical interventions for improved symptoms management. Cancer patients require a resilient follow-up before, during, and after chemotherapy treatment for the provision of emotional support and improvement of nutritional practices. Chemotherapy takes away the strength and confidence required for normal duties, hence the family members and caregivers have to establish ways to help the patients and improve their overall wellbeing.
Cancer caregivers must be able to provide treatment information to their patients and identify the side effects of each medication, as compared to the patient’s medical history. This facilitates the identification of allergies and reactions to medication that can deteriorate the condition of the patient and increase vulnerability to infection or fatality. The patients should be informed about the danger signs of chemotherapy treatment, such as consistent vomiting and diarrhea that spur dehydration and inhibit recovery (Traeger et al, 2015). Research asserts that frequent emergency room visits by cancer patients can be harmful in terms of its effects on emotional wellbeing and the physical constraint involved (Palesh et al., 2018).
Prevention is key with oncology patients and caregivers should ensure that their patients are well-informed on the expected side effects and the availability of drugs from remote pharmacies (Salgado et al., 2017). Cancer patients should also be conversant with prescriptions and be able to locate emergency drugs with ease for immediate treatment of danger symptoms. Health care is a collaborative process, and cancer caregivers should be able to interact with other healthcare practitioners for professional consultation and the patient information has to be kept up-to-date.
The healthcare system objects at the maintenance of healthy populations through collaboration efforts in the diagnosis, treatment and follow-up of patients for effective service delivery. Any treatment intervention should improve the condition of the patient, however, in some cases it is different, as proven by the effects of cancer treatment and medication. The main reasons why cancer patients seek emergency treatment is identification of danger symptoms, infections, critical dehydration, malnutrition, renewal of medication, extreme pain, and severe nausea, diarrhea or vomiting (Traeger et al, 2015). Cancer caregivers have to identify chemo toxicity at an early stage and establish clinical interventions before these side effects become severe and life-threatening. On the other hand, cancer patients require eased access to health services due to their vulnerability to severe side effects that require emergency treatment. Patients who experience blood in vomit or stool, severe nausea and vomiting, and extreme fatigue should seek immediate care by contacting an emergency service provider or visiting an emergency room.
According to the researchers, cancer treatment is characterized by a high emotional load and pain that requires support from family, friends, and caregivers (Linder et al., 2017). Cancer patients and their families should be mentored into accepting the condition as part of their lives and keeping up the fight for better outcomes. Research asserts that patient perceptions of health care services have significant effects on the overall health outcomes. Therefore, caregivers have to establish comfortable treatment environments for their patients and establish beneficial relationships with their patients for support, and monitoring.
Community Assessment
Oncology is a medical field of practice concerned with the study and treatment of tumors. Community assessment refers to the evaluation of perceptions of a given population in a selected community about specific health practices. The assessment also entails the determination of the frequency with which this specific population practices the medical aspect under inquiry. Community assessment can be defined from varied points of view. Key among them is geographic or political boundaries. On this basis, community assessment entails evaluating a selected population from a specified region. For example, a population from a given county or state. Regional assessment is significant because the vulnerability of populations differs from one region to another. Thus, the perceptions of people in one region may be different from what occupants in a different region harbor. These differences are partially brought about by the economic activities that prevail in a given region, which may predispose people living there to certain undesirable health conditions.
Boundaries are broadly known to the public and serve as categories for data collection on health status. To solicit this health-related data, an Advanced Practice Community Health Nurse (APCHN) categorizes the selected population based on some specified parameters. For example, on one side people living in the same neighborhood may form one category. Other classifications can encompass people sharing common interests, those having common values, those within the same age group among other classifications.
There are various field activities that are affected to ensure the success of community assessments. Key among these exercises is data collection. Essentially, data collection entails the gathering of pertinent quantitative and qualitative information about a population or community. After completion of the data collection exercise, the researcher analyzes this data to derive meaning and conclusions from it. To derive this meaning, the analyzed data is then synthesized via combining elements derived from several data sets to develop a coherent picture of what is known or unknown about the study population. However, to ensure the conclusions drawn are valid, it is imperative that this data and information be examined with the application of knowledge of the public health sciences as well as research, theories, and models from nursing.
Attempting to explain a gap in coverage in oncology patients in an outpatient setting within rural Pennsylvania. Managing patient care in an outpatient setting rather than an Emergency Department visits or unwarranted admissions.
According to Mayer, Travers, Wyss, Leak, & Waller (2011), while visiting the emergency department (ED) is essential for managing acute ailments, it may also be indicative of problems not fully addressed via routine care. Accordingly, patients should aim at minimizing their visits to the ED because such frequency may hamper recovery than facilitate it. As Mayer et al. (2011) observe, EDs are often overcrowded and serve a large number of patients. Not surprising, as indicated in this case study, while the majority of cancer visitations resulted in hospitalizations, 283 deaths were recorded in the ED. As such, EDs may not be the ideal environments to treat oncology patients requiring urgent health care services.
Based on a study conducted by Bozdemir et al. (2009), 38% of cancer patients had more than one visit to the ED employed in the study. Surprisingly, close to half of those patients (49.4%) lost their lives within three months after the ED visit. In yet another study in Ontario, 83.8% of cancer patients who died had sought treatment in the ED within the last six months of their life (Barbera, Taylor, & Dudgeon, 2010). In yet another survey conducted by Leak, Mayer, Wyss, Travers, & Waller (2012), in 2008, of the ED visits related to cancer, 2843 culminated in death. Notably, while 71% died during their very first visit, 52% died during their subsequent visit, 17% during their third, and 13% on either their fourth through sixth visits. Based on these adverse outcomes from the oncological ED visits above, it is clear that this treatment option may not be the best option because, more often than not, it makes a patient’s health condition worse off. The implication is that going to an oncology clinic is preferable. With many of the symptoms that an oncology presents to the ED with, being preventable, now dire to their health with presentation to the ED.
Based on the survey conducted by Mayer et al. (2011), it was established that many ED visits were related to poorly controlled symptoms. Specifically, while breakthrough pain was the primary most cause of ED visitations, Dyspnea was the second most cause of these visits. Evidently, such insignificant causes are indicators of poor prognosis. Notably, ED visits were found to be common in cancer patients exhibiting clinician-related pain or a Karnofsky performance status of equal to or less than 80% (Mayer et al., 2011). Based on these results, it can be inferred that, while these symptoms may signify an onset of acute problems, they may also be indicative of a failure to effectively manage common challenges cancer populations faced during their treatment. Thus, owing to this failure, it may lead to unwarranted ED visits and subsequent hospitalizations. Notably, as Mayer et al. (2011) observe, in 2008, for example, an approximated ten percent of hospital admissions for people suffering from chronic and acute conditions could be prevented without necessitating an ED visit.
According to Andrews (2017), keeping cancer patients out of the emergency room is a viable option for various reasons. As Andrews argues, many of these rooms have compromised immune systems, which put patients at risk of being exposed to other sick people. For instance, patients with any stage cancer, specifically receiving chemotherapy, are prone to contracting pneumonia or bronchitis from other patients in the ED waiting room. Apart from that, the author highlights, some emergency physicians and nurses are not confident of their competence in treating cancer patients. When this is the case, they may admit cancer patients when such an admission is not necessary. When this is done, the health prospects of the pertinent cancer patient deteriorates rather than improve. As the author pinpoints, new immunotherapy medications that ignite the immune system to fight tumors can foster sudden adverse serious reactions if healthy body tissues are attacked as opposed to the ailing ones as required. To eliminate such adverse consequences, the author suggests that offering same-day services is the most viable option because it fits in with a desirable shift in oncology towards patient-centered care.
As previously discussed, given the prevailing practice of admitting cancer patients in ED even when such admissions are not necessary, the Federal Centers for Medicare and Medicaid Services (CMS) has instituted new regulations on the same. On this note, new payment as well as delivery models have developed effective cancer care. In fact, to exhibit the seriousness with which this issue is regarded, as Andrews (2017) reveals, starting 2020, hospitals may be penalized if their outpatient patients receiving chemotherapy visit the ED or are admitted to the hospital.
Now, narrowing it specifically to rural Pennsylvania (PA), the imaging relay has the same identifying factors. A sample group from 2018 to present, over 3900 subjects, with a current or past medical history of cancer were viewed. The implications of this study are utilized to reinforce supportive evidence in the need for additional outpatient treatment options. The highest symptom a patient was seen for in 2018 was abdominal pain. Out of 3902 patients, 1369 patient presented with a variety of pain symptoms, 522 with respiratory complaints, 341 with musculoskeletal issues, 312 with neurological issues, 271 with gastrointestinal complaints, 194 with blood or adverse lab findings, 172 with systemic issues such as allergic reactions, hives, or chills, 125 with cardiac presentations, 104 with GU issues, 54 surgical related issues, 30 psychosocial, 28 swelling, 25 reproductive organ complaints, 15 nutrition, and 299 “other” visits not conforming to the subsets listed. Of the 3902 visits, 1,508 patients were admitted to the hospital. 1,265 inpatient and 238 observation. Other ED dispositions include 2,078 discharged, 23 against medical advice (AMA), 52 Left without being seen (LWBS), 191 transferred to another facility, 7 eloped, 5 expired, and 4 unknowns.
ED Visits by days of the week:
Sunday 503, Monday 617, Tuesday 563, Wednesday 543, Thursday 586, Friday 579, Saturday 511
ED Visits by hours of the day:
0000-0700 when oncology clinic department was closed 365 visits
0700-1700 when oncology clinic department was closed on Sat and Sun 616 visits,
While department was open Mon-Fri 1,878
1700-0000 ED visits when department was closed 1,043
Total ED visits while oncology clinic department was closed 2,024
Total ED visits while oncology clinic department was open 1,878
My goal is to implement an intervention to aid with the foreseeable nature of the lack of awareness in oncology care needed. An educational powerpoint as well as tools to help raise with the tools to determine if an oncology patient would meet the criteria for admission rather than outpatient symptom management in this rural PA hospital. Delivery of healthcare in the rural areas faces many challenges. In the US (US), 97% of its land is considered the rural area, with a population of 60 million, which amounts to about 19.3% of its population (United States Census Bureau, 2016, para. 4). Out of 5,534 hospitals registered in the US, 1,825 hospitals are located in the rural areas, as seen in Table 1 (American Hospital Association, 2018). Critical Access Hospitals” (CAH) is a classification that is given to eligible rural hospitals by the Centers for Medicare and Medicaid Services (CMS). According to RHIHub (Rural Health Information Hub)
Barriers to a rural hospitals:
● Payment/reimbursement and financial information
● Regulations and information regarding CAH status and the Flex Program
● Key organizations in the field
● Funding opportunities
● Challenges to operation
Oncology is among the most extensive medical fields given the many forms of tumors that continue to emerge every day. Given that tumor development is usually associated with cancer, many patients who experience mild symptoms rush to the ED. While this department offers specialized care for these findings and symptoms, research shows that a habit of rushing to this department even when one experienced treatable symptoms is risky. Accordingly, one is likely to be exposed to many other ailments. Indeed, research has shown that a considerable number of patients who visit the ED frequently die within a year. To evade this unfortunate eventuality, seeking treatment from an oncology clinic is recommended. Thus, based on the pieces of evidence discussed in this essay, it can be conclusively inferred that while ED is a good alternative for treating tumors, the patient frequency of visit to this department should be minimized because of the numerous health risks the patient is exposed to when they make such visits overly frequent.
Readmission
Patients receiving treatment for cancer often experience readmission after the initial therapy. These individuals are at increased risk of readmissions to hospitals after the initial visit due to the disease (Brown, Burgess, Li, Canter, & Bold, 2014). Such incidences increase the expenses in healthcare facilities and may show poor quality of services to cancer patients. Therefore, hospitals often seek all possible methods to limit the readmissions of patients to improve outcomes in the healthcare facility.
A study by Brown et al. (2014) involving 2,517,866 hospitalized cancer patients provided rates of readmission in the United States. According to the study, the readmission rate of cancer patients in the seven days period was 2.2%. The rates of readmissions in 14 days increased to 3.7% and 5.6% in 30 days periods. Another study done by Mehta et al. (2016) confirms that cancer patients have high readmission rates after 30 days in the United States. Such analyses from the articles indicate that an increasing number of cancer patients are at risk of readmissions as the period after initial admission increases. The study further highlights that infections among cancer patients caused the highest rates of readmissions. Nonetheless, side effects associated with dehydration that coincides with vomiting and nausea also contributed to the incidences of readmissions.
Readmission of cancer patients depends on the nature of cancer affecting patients, treatment side effects and progression of the disease. Cases of complications due to metastatic cancer and infections are some of the primary reasons for readmissions. Age of individuals and the presence of comorbidities also contribute to cases of readmission among cancer patients. Cancer patients have significant health problems that they need to overcome. Chemotherapy presents many side effects that affect the quality of the patients’ lives. During the treatment, cancer patients experience high rates of readmissions that are primarily due to side effects of chemotherapy.
Theoretical Framework
According to the study carried out by Handley, Schuchter, and Bekelman (2018), dehydration is known to be a great point of concern to cancer patients. One of its main side effects of chemotherapy as a cancer treatment method includes deprivation of the body fluids and electrolytes (Burstein et al., 2010). The problem arises because the body uses the water that requires replacement. The loss of water is known to be fastened by other symptoms such as vomiting, diarrhea, fever, and sweating, which lead to higher chances of the cancer patients who have gone through the chemotherapy treatment being taken to the emergency care after the chemotherapy treatment. Keeping the patients in emergency care has been known to be among the most expensive models of care in the United State. Such practices include: identifying the patients that are likely to experience the need for unplanned care and enhancing and ensuring that there is coordination of care put in place by the health professionals. In addition, it is important to make the clinical pathway that can be recognized as symptoms for the care management standards. As such, this study will be guided by the theory of symptom management (TSM), a middle-range theory.
TSM was first created by several researchers in San Francisco School of Nursing, University of California in 1994. The theory’s developers delved on three primary dimensions: experience of the symptom, management strategies and symptom outcomes with the tenet that managing symptoms of the disease should focus on the three aspects. In 2001 the model was reviewed and several aspects added. Further revision was performed in 2008 before the theory could be consolidated to symptom management. The choice of this mode for the analysis of dehydration for patient undergoing chemotherapy is based on the principles that are based in the perception of the individuals’ experiences about their symptoms and self-reporting detection of dehydration by the patients, and knowing that post-chemotherapy patients are at high risk of developing thirst symptoms which can lead to planning, executing prevention, conducting examination and management in advance. At the same time, the model recognizes that symptoms management can be directed towards a group, family member, or work environment to prevent dehydration and that a patient is an individual that depends on the nurses to influence the treatment and recovery process.
According to Conchon, Nascimento, Fonseca, and Aroni (2015), symptoms management theory takes into account the domains of the health state of the patient. Dehydration is important for maintenance of electrolytes and fluids in the body and serves as a regulatory incentive for the intake of water. Surgical patients are usually exposed to the confluence of factors that cause dehydration. As such, symptoms management theory addresses three major dimensions of treatment: symptom experience, strategies for management and outcomes. Hoffman (2013) performed a study that used exemplars to describe how cancer nurses can apply the theory of self-management in their clinical practices to optimize patient outcomes through patient self-efficacy. Hoffman (2013) denotes that symptom experience is critical factors that encompass individuals’ experience, examination of the symptoms, and response to it. The author noted that only 13% to 18% of the post-chemotherapy patients verbalize their dehydration, which is one of the factors which are likely to cause great discomfort during the treatment process. Lack of knowledge of the approaches that can alleviate thirst without putting the patient at risk is a primary contributor to the patients not raising their dehydration concerns. Additionally, Hoffman (2013) asserts that evaluation of symptoms is a key element of the management of dehydration among post-cancer treatment plans since it encompasses assessing the threat and danger imposed by the symptom. Therefore, the researcher affirms that theory provides a means of understanding the dynamic of symptoms and provides a framework that can be used to enhance interventions both patients and oncology nurses to improve functional status as well as the quality of life of patients in their clinical practices. Further, Hoffman, Von Eye, Gift, Given, Given, and Rothert (2016) affirms that oncology nurses can work together with patients to tailor or design treatment approaches that recognize, prevent, relieve, and decrease distress, intensity, unpleasant and concurrence of symptoms during chemotherapy.
The aspect of symptom management strategies of the theory of symptom management is a critical step that is meant to delay or prevent negative consequences using alleviating approaches. Ryan and Sawin (2009) delve on outlining the background and perspectives of self-management theory and asserts that the process starts by examining a person’s experience and determining an intervention that relates to the symptom. Different strategies have been shown to relieve dehydration that may be implemented. Aroni, Nascimento, Fonseca (2012) performed quasi-experiment to assess thirst relief methods for patients with a postoperative period. The research discovered that ice can be used to reduce the intensity of dehydration. Yooh (2010) conducted pre-test and post-test to identify the impact of gargling cold water to relieve thirst and the subjects that received the intervention showed a decrease in thirst. Also, Cho, Kim, and Park (2010) did a quasi-experiment to assess the impact of utilizing gauge with cold saline or ice to relieve dehydration. The group that was given a frozen gauge with saline exhibited a significant reduction in the intensity of thirst. Therefore, the methods that entail using low temperature have greater efficacy of relieving the feeling of dehydration in post-chemotherapy patients.
The symptoms outcome is another important aspect of symptoms management theory that comprises dimensions such as functional status, self-care, and symptoms status. McCorkle et al., (2011) show that managing dehydration has a considerable positive impact on the patients’ functional state. McCorkle et al. (2011) further assert that distress caused by dehydration causes significant emotional changes and leading despair. Brant, Beck, and Miaskowski (2010) performed a study and observed that after the administration of the strategies of cancer symptom management, particularly, ice patients report immediate relief of discomfort going to a state of sleep after relief. In addition, identifying the level of risk that the patient is facing is likely to result in planned treatment in case the patient conditions worsen. This increases the probability of the patient and the entire support team applying the concept of self-care agency. One of the ways that the medical professionals can assist the patient includes the provision of the information on the side effects of the chemotherapy treatment (Handley, Schuchter & Bekelman, 2018). Cancer patients who have gone through chemotherapy treatment might not be able to take care of themselves. The patients and the support team of the patients might recognize deviation in the patient’s health. Further, the theory suggests that the ability of the patient to understand the side effect that will come as a result of the chemotherapy treatment will make the patient handle the situation much better because of the psychological preparedness (Handley, Schuchter & Bekelman, 2018). Therefore, the symptom management theory is a fundamental model that proposes a direct link between the components of symptoms: perception, evaluation, and response and aspect of management strategies such as self-care. As a result, it has the potential for exploring the relationship between patients and nurses and components of symptom experience for post-chemotherapy patients.
For the purpose of this study, the theory has been chosen since it will serve a guide in several ways. First, it will provide a framework for critiquing the current literature relating the post-chemotherapy dehydration symptoms, patient experience and self-care strategies. At the same time, the component of the model: perception, evaluation of the symptom, and responses will provide a focus for the research questions. Specifically, symptom management theory will allow the researcher to describe the participants’ experiences of dehydration symptoms following their chemotherapy procedures. Also, since the model encompasses dimensions of symptom experience, it will serve as a guide to the development of a hypothesis about the relationship between patient experience and dehydration symptoms and self-care approaches after the treatment process. Similarly, the components of the theory will provide a structure for presenting as well as discussing the research findings. Understanding the patients’ symptoms experience has great relevance for improving nursing practice. Self-care is a concept that ensures that all people achieve optimal goals in life, which implies that introducing the patients to palliative care increases the ability to manage the side effects that come hand in hand with the chemotherapy treatment.
Literature Review
Chemotherapy is a cancer treatment that objects at inhibiting the abnormal reproduction of cancerous cells through interference with the cellular growth cycle. Dehydration is a significant side effect of chemotherapy treatment that triggers fatigue and emotional stress. Chemotherapy also affects the bone marrow through inhibition of the reproduction of white and red blood cells, and platelets. This reduces immunity to infections, anemia, and uncontrolled bleeding. Cancer care should prevent effective interventions for the alleviation of dehydration that is predictable after chemotherapy. Treatment interventions such as rehydration and guided imagery to improve the conditions of patients. However, effective symptom management is essential in improving health outcomes for cancer patients. Patient-centered care is critical for cancer treatment as it improves patient monitoring and care coordination for an overall wellbeing and better health outcomes.
Methodology: Search of the Literature
Literature reviews are crucial for any research to have broad perspectives about an issue and ensure that authors that contributed to the investigations are recognized to eliminate bias and copyright infringement. The study utilized two search engines to gather the needed information, Medline and the National Center for Biotechnology Information.
Databases Used
National Center for Biotechnology Information
The NCBI was the first database that was used to find the needed information. The organization aims at promoting health and science in the world by ensuring that it provides access to medical and other related information (NCBI, 2019). Hence, the NCBI established a search engine where various articles are published and made available to the public.
Search strategy. The keywords used included oncology, dehydration, cancer, and hydration. The study used medical subject headings to find relevant articles that proved vital while utilizing the NCBI search engine (NCBI, 2019). Medical subject headings included the effect of dehydration on patients with advanced cancer and the relation between dehydration and oncology patients.
Search results. In the NCBI database, it was preferred to find articles from 2019 to 2014 as this ensured quality and relevance. In this database, 100 articles were found in the first search attempt. The number reduced to 80 after finding 20 duplicated results. In the keywords, oncology produced 25 articles, dehydration – 25 journals, cancer – 25 papers, and hydration – 25 publications.
Medline
Medline was another search engine used to find the relevant sources needed for the literature review. The search engine contains broad publications and instructions needed to properly use the filters and keywords to find the relevant information.
Search strategy. The keywords used included oncology, desiccation, tumor growth, and the emergency department. The medical subject headings used there included treatment methods of dehydration in cancer patients in the emergency department.
Search results. In this database, 56 articles were found in the first search attempt. The number reduced to 20 after eliminating 36 duplicates. The keyword oncology produced 14 articles, desiccation – 14 journals, tumor growth – 14 papers, and emergency department – 14 publications
Snowball search method
The research attempted to save on time during the literature review process by utilizing the snowball search method (Jalali & Wohlin, 2012). The researcher identified a few critical articles that related to the topic and examined their reference sections to find other journals that could be relevant. The process allowed the investigation to find relevant articles related to the topic with ease and save time. The identified articles from the references also had the bibliography analyzed to find other relevant publications on the search topic.
Search Limit
The research also used several search limits to reduce the number of articles to a manageable number and still ensure they were relevant to the investigation. The time limit was the first approach used to ensure that relevant and recent information was gathered. As such, the investigation set up a time limit of five years for the publications. In addition, articles and reports were preferred to other publication types. The Boolean operators “AND” was used among the mentioned keywords to enhance the search results.
Study Flow Diagram
Source: Author (2019)
Inclusion and exclusion criteria
Criteria Exclusion Inclusion
Relevancy Articles discussed cancer and hydration factors but failed to analyze dehydration issues Articles discussed cancer patients and dehydration factors
Topic focus Articles failed to relate oncology patients and dehydration to US emergency departments Journals related to oncology patients and dehydration to United States of America emergency departments
Type of publication Books, news articles and conference proceedings Scholarly articles and technical reports
Author credentials Authors lacked a medical background Authors had an extensive medical background
Author experience Scholars had no experience in managing dehydration in cancer patients or handling cancer patients Investigators had experience in managing oncology patients with dehydration
Sample size A small sample size that risked reduced statistical power and Type I plus II errors Larger sample size that increased statistical power and credibility of the results section
Abstract Articles that lacked an abstract Articles that had an extensive abstract section
Abstract content Articles abstract of which failed to mention the introduction, methodology, results and conclusion sections Publications that had an extensive abstract that covered the introduction, methodology, results and conclusion sections
Source: Author (2019)
Literature Review
Mayer, Travers, Wyss, Leak, and Waller (2011) studied the reasons that cause cancer patients to use the emergency departments of hospitals. According to the authors, dehydration in oncology patients is often common due to reduced oral intake of fluids (Mayer et al., 2011). Lash et al. (2017) also conducted a systematic review of emergency department use among cancer patients. Lash et al. (2017) agree with Mayer et al. (2011) regarding the decrease in oral water intake by oncology patients. However, the authors noted that the phenomena are greater on the advanced stages of cancer. Rivera et al. (2017) conducted a cross-sectional study on how cancer patients are assisted in emergency departments. Rivera et al. (2017) provided a deeper analysis of the relationship between oncology patients and dehydration. The authors first agreed with Mayer et al. (2011) and Lash et al. (2017) that dehydration does occur more frequently in oncology patients and the reduced oral intake is the major cause of this effect. However, Rivera et al. (2017) went further to detail that there are other causes of dehydration in oncology patients such as vomiting, oral cavity lesions, odynophagia, mood disorders, constriction of the bowels and others.
Cancer Network (2017) researched the ways of reducing cancer patients’ visitation to the emergency department. Cancer Network (2017) also agrees with Mayer et al. (2011) and Lash et al. (2017) that dehydration is a common issue with oncology patients and the reduced oral intake is a major cause of the issue. The authors also discovered that other issues such as vomiting, bowel problems, loss of appetite led to dehydration in oncology patients as identified by Rivera et al. (2017) paper. Cancer Network (2017) then showcased that in such incidents, the oncology patients are mostly given parenteral hydration treatment and it is the best approach. Daly et al. (2018) studied the performance rates of cancer patients in emergency departments. Daly et al. (2018) also analyzed some of the factors affecting hydration levels in cancer patients and agreed with Lash et al. (2017), Rivera et al. (2017) and Cancer Network (2017) that dehydration in oncology patients is common. However, Daly et al. (2018) disagree with Cancer Network (2017) that parenteral hydration is the common treatment method of the condition as they found that it is only applied in acute care facilities. DiMartino et al. (2014) analyzed whether palliative care and other procedures helped cancer patients improve their health status. DiMartino et al. (2014) also disagreed with Cancer Network (2017) that parenteral hydration is used in all health facilities as they, similarly to Daly et al. (2018) found that it is only used in acute care facilities. DiMartino et al. (2014) also found that treatment of dehydration in oncology patients is never applied in general hospitals.
Blank et al. (2005) also agree with Mayer et al. (2011), Lash et al. (2017), Rivera et al. (2017), and Cancer Network (2017) that dehydration in oncology patients is common, and there are various issues such as vomiting, reduced oral intake and others that cause the problem. However, Blank et al. (2005) also identified the discrepancies noted in DiMartino et al. (2014) and Daly et al. (2018) studies about the treatment of dehydration in oncology patients. The authors noted that there is no standardized procedure in the treatment of dehydration in oncology patients across the world and this explains why Daly et al. (2018) and DiMartino et al. (2014) research are arguing with each other. Albright et al. (2018) also identified that there is no correct procedure in the treatment of dehydration of oncology patients and it has become a great concern in the medical world. The authors also agree with the causes of dehydration in oncology patients such as reduced oral intake, vomiting, delayed gastric emptying and others. Therefore, the articles point out there is a huge research gap in the treatment procedure of dehydration in oncology patients and research needs to be conducted in this area.
Hong et al. (2019) however analyzed part of this research gap and offered some suggestions into how the treatment of dehydration in oncology patients should proceed. The authors first agree with Blank et al. (2005) and Albright et al. (2018) that there is a huge debate on the issue of how to treat dehydration in oncology patients. Hong et al. (2019) suggested that the treatment approach should be individualized and doctors should evaluate the procedure in a collaborative manner that ensured the patient’s goals were factored into the treatment process. Šteinmiller et al. (2015) also agrees with Hong et al. (2019) that the treatment process should be individualized to deal with the specific challenges of the oncology patient. The authors base their recommendations on the fact that a myriad of factors causes dehydration as identified by Lash et al. (2017) and Rivera et al. (2017) and also, they are specific to each oncology patient. Therefore, Hong et al. (2019) and Šteinmiller et al. (2015) idea that the treatment procedure of dehydration in oncology patients should be individualized and collaborative is sound. However, it only increases the research gap as there is a need to study each cause of dehydration, why certain oncology patients are impacted by the specific causes and how the treatment procedure would be effective in healing their condition.
Symptomatic Classification in Cancer Treatment
According to the National Institutes of Health’s (NIH) Common Terminology Criteria for Adverse Effects in cancer treatment, doctors have to avail accurate information on the classification of side effects for timely interventions (Palesh et al., 2018). As a cancer patient, temperature changes, severe digestive problems, development of severe skin peels, unstable consciousness, painful urination, sore throat, mouth infection, and foreign blood in stool or vomit are all danger symptoms that require immediate evaluation and treatment. The NIH Criteria provides symptom descriptions as:
⮚ Grade 1 – Asymptomatic condition that requires diagnostic observations only.
⮚ Grade 2 – Moderate symptoms that are non-invasive but require intervention.
⮚ Grade 3 – Severe, but not immediately life-threatening, symptoms that may require hospitalization due to inhibition of self-care and interruption of daily activities.
⮚ Grade 4 – Life-threatening symptoms that require emergency interventions.
⮚ Grade 5 – Adverse symptoms that are fatal.
The above classification of symptoms can be efficient in the management of cancer treatment side effects through information dissemination. The basic logic is the identification of symptomatic severity through self-observation or the use of caregivers in monitoring daily health progress (Salgado et al., 2017). Patient safety is a vital component of evidence-based care and each patient is entitled to receive the most efficient care interventions for improved quality of life. Therefore, the healthcare system has to provide standard practices for cancer treatment. The process of symptom management is critical in minimizing fatalities, establishing effective treatment interventions, and improving the quality of life.
Cancer treatment side effects can occur during or after chemotherapy sessions and they affect patients in diverse ways and inhibit normal daily activities, thereby reducing the quality of life. Cancer patients have to be informed on the high vulnerability to dehydration after chemotherapy, and they should intake recommended amounts of fluids and water for significant rehydration (Linder et al., 2017). Medical teams should inform their patients on side effects of surgeries, radiation, or medication and the effective management interventions established in settings that are easily accessible to the patients. Effective recording of medical information by both the medical teams and the patients also facilitates the tracking of symptoms and treatment side effects. According to Palesh et al. (2018), cancer treatment is a tiresome and complex process that requires self-motivation and support from family, friends, online groups, psychiatrists, and other support groups for the elimination of mental health risks, such as depression.
Cancer-related fatigue is a common symptom that is caused by all cancer treatment interventions. It is prolonged, unpredictable, and requires more than some period of rest (Traeger et al, 2015). Cancer patients have to develop a culture of exercise, which is considered as the most effective way to increase energy, eat balanced diets, intake 8-10 glasses of water or fluid, practice meditation or in-depth breaths, and ensure restful sleep for improved quality of life (Salgado et al., 2017). Normal body functioning requires adequate presence of body fluids for temperature control and metabolism. The side effects of cancer treatment drugs are identifiable and the healthcare system preserves patient health information that can be used by medical teams in clinical decision-making, such as drug prescriptions. In emergency treatment, patients may be unable to interact with the medical teams and health information systems play a vital role in the access and use of medical histories of patients.
Chapter 3: Research Methodology
As reported previously in chapter 1 and 2, patients receiving treatment for cancer often experience readmission after the initial therapy. These individuals are at increased risk of readmissions to hospitals after the initial visit due to the disease. Such incidences increase the expenses in healthcare facilities and may show poor quality of services to cancer patients. Therefore, healthcare organizations normally look for alternative techniques to ensure reduced readmissions of patients and to ascertain that the facilities’ healthcare outcomes are significantly improved. One of the most common interventions often emphasized by these organizations is educational intervention to decrease the emergency department admissions in patients diagnosed with febrile neutropenia who have received chemotherapy. Based on this, the study implemented an intervention to aid with the foreseeable nature of the lack of awareness in oncology care needed. Specifically focusing on a rural PA hospital, the study implemented an educational intervention to help determine if oncology patients would meet the criteria for admission rather than outpatient symptom management.
Thus, this chapter extensively carries out the descriptions of the study methodology that was adopted to achieve the aforementioned educational intervention goal. Research methods refer to specific techniques or procedures employed in identifying, selecting, processing, and analyzing data regarding a given topic. Therefore, research methods play an integral role in allowing the readers to carefully assess the overall reliability and validity of a study. It responds to two key questions: how did the investigator collect the generated data? And how did the investigator perform analysis of the data? Against this backdrop, the chapter incorporated a range of sections in the paper, such as the research design and methods; tools of data collection and its associated processes; population, sampling, and sampling considerations, participants’ inclusion and exclusion criteria; data analysis; and ethical procedures; to implement the evidence-based practice.
Researcher design
Involving two groups, including routine care versus experimental intervention, with repeated measures, the study used a two-arm randomized controlled trial design. Using a computer-generated allocation sequence (Ingham-Broomfield, 2016), the research participants were randomly assigned to either the intervention group or the control group in this design. For all the patient allocations, the research marked, folded, and finally fixed a sealed envelope. Notably, an independent person who works in the emergency department and neither had the knowledge of the patient’s medical history provided the allocations. At three different cycles of the chemotherapy, including cycle 1, cycle 2, and cycle 3 denoted as T0, T1, and T3, respectively, the research findings were gathered at three
Routine care: control group
In the control group, the patient participants were given routine care that the rural PA hospital offered to each of the oncology patients. In particular, the lead investigator distributed a booklet before the chemotherapy was administered. The book was made up of multiple pages and paid attention to a range of elements, such as chemotherapy introduction, the common chemotherapy side effects and how to care for the side effects, dietary recommendations, in-patient ward, the cancer center introduction, chemotherapy administration logistics, central line care, and resource center. The physician, nurse and pharmacist distributed a sheet of information regarding treatment during the first chemotherapy teach session. In the information sheet, there was a range of content that was incorporated; it included common side effects, the regimen schedule, and certain special points to note down. Some receive chemotherapy on the same day. A thirteen-minute standardized video session that broadcast a variety of elements to the oncology patients with febrile neutropenia before chemotherapy was administered to them. The video explained the chemotherapy, its method of administration, the anticipated side effects and their measures of self-help, as well as, when and how to look for medication assistance. Overall, routine care’s main objective was to provide standard information. Notably, the hospital did not provide any reinforcement or follow-up to oncology patients, including those with febrile neutropenia.
Education program on febrile neutropenia prevention: The Intervention group
Unlike the control group that received standard information, the intervention group also received additional information not offered in the control group, including individual education sessions and follow-ups to assess their emergency department visits.
Individual education sessions
In addition to the standardized educational intervention that the control group patients were given, the researcher provided a thirty-minute education session in a room to the new chemotherapy participants who were included in the intervention group following the video session and prior to the administration of chemotherapy. As evidenced in Appendix A (extracted from Mak & Ching, 2015), a protocol of a neutropenia education program was designed with the goal of empowering the participants in identifying values and goals; understanding the manner in which their behavior impacts their health; developing confidence, skills, and values in deciding their health that most effectively give them the opportunity to accomplish the goals and remain committed (Bravo et al., 2015). The intervention program offered standardized guidelines by integrating the Empowerment Process Model six major principles, such as competence, knowledge, self-efficacy, impact, action, and goal, into the 5-steps of protocol of behavior change that was the underlying behavioral strategy employed in interventions that seek to empower patients (Funnell, Tang, & Anderson, 2007), consequently reducing readmissions and hence health burden to the care hospital.
In addition to the information that the control group obtained, the nurse care professions further paid attention to improving the self-efficacy and competence of individual patients in order to permit them to have improved self-care behavior regarding the febrile neutropenia prevention. The educational intervention lay more emphasis on patient empowerment in order to embrace behaviors aimed at preventing febrile neutropenia in their everyday lives. During the education sessions, the lead investigator attached great value to two-way communication. Similarly, follow-up sessions were emphasized. The educational program’s major objective was agreeable mutually. To realize the goals of reducing readmissions and encouraging behavior changes, the participants were motivated. The respondents themselves pointed out the problems, and they also addressed the problems by themselves. Depending on the participants’ knowledge level, competence, self-efficacy, and behavior adherence, different levels of support, reinforcement, reassurance, and encouragement were afforded. To help the interventions provided in a consistent manner, the researcher developed a neutropenia education teaching cards and program protocol.
Follow-up
The study scheduled follow-up sessions every time when the selected participants returned to the hospital for a checkup or medical consultation. To perform the follow-up sessions, the study used a room set aside specifically for this. The study conducted the protocol of behavior change similar to the individual education sessions. Five oncology expert members made up of two advanced practice nurses, one oncology manager, one nurse consultant, and one nurse educator validated the education program.
Setting and sample
The researcher completed the investigation at a rural hospital. The facility is a publicly supported, multi-hospital system serving as the “safety net” care facility for the rural residents, and it is the only level one cancer center in that particular part of the US (Davies, 2009). In addition, the hospital is a teaching hospital and is affiliated with the pharmaceutical, nursing, and medical schools. Also, the facility is responsible for a wide variety of patients with complex medical conditions, a number of whom are underserved and vulnerable. Similar to other rural care facilities, delivery of healthcare in this rural hospital faces many challenges related to payment/reimbursement and financial information, regulations and information regarding CAH status and the Flex Program, key organizations in the field, and funding opportunities.
This hospital has 300-beds and offers services to an estimated 70,000 individuals in that part of the country. The control and the intervention units (each having approximately a 26-bed capacity) have approximately 80 registered nurses and annually more than 800 patients diagnosed with cancer are admitted. Based on the expected change in scores, the Knowledge and Attitudes Survey Regarding Pain (KAS) was used in measuring sample size calculations for the outcome (readmission reduction to the ED). A power of 80% and a significance level ᾳ of 0.05 (two-sided) was needed for about 30 patients for every group. On the other hand, for the secondary outcome measure, the sample size calculations for the BPI-SF have primarily been based upon a 1.8-point expectancy scale concerning the item present pain intensity between participants in the intervention group in comparison with those in the control group. Similarly, on the basis of a power of 95% and a significance level ᾳ of 0.05 (two-tailed), this would need a patient group of 25 patients each for the control and intervention group.
Inclusion and exclusion criteria
This quality improvement intervention focused on patients diagnosed with febrile neutropenia who had received chemotherapy in the last 30 days. In order to be involved in the research, the potential patient participants were screened to ensure they were eligible. Specifically, to be part of the research, the patients had to fulfill certain inclusion criteria conditions. They included being at least eighteen years and above, have the capacity to speak and understand the English language, they must have received chemotherapy in the last 30 days, have undergone chemotherapy in the last 30 days, and must have been oncology patients diagnosed with febrile neutropenia. On the other hand, participants were excluded if they had known cognitive impairment, known psychiatric illness, were visual or hearing impaired, and had a greater performance status of more than 4 as measured against Eastern Cooperative Oncology Group (ECOG) (Oken et al., 1982). As a result, the participants who were not able to perform tasks related to self-care did not form part of the research.
Research Instruments
Primarily, the study used a structured questionnaire in order to gather the data. The outcomes for the investigation were wide-ranging and included action, competence, knowledge, self-efficacy, and impact in line with the Empowerment Process Model. Overall, having greater scores on these elements would lead to reduced readmissions at the rural PA hospital. The study adopted 4 instruments, such as handwashing competency checklist, neutropenia questionnaire, medical information sheet, and demographic data sheet, which are described in detail under their subsections.
Demographic datasheet
This sheet is shown in Appendix B (extracted from Mak & Ching, 2015), and the researcher employed it in collecting data related to the participants’ demographics. In particular, personal data, such as marital status, gender, age, living area, education level, and nature of the job were all gathered. The questionnaire was self-administered.
Medical information sheet
The incidence of admission was used to assess the impact, and as represented in Appendix C (extracted from Mak & Ching, 2015), the study documented it in the medical information sheet. In addition, medical data, such as ECOG performance status, concurrent or previous radiation therapy, presence of open wound, renal and cardiovascular illness, comorbidities including liver, serum albumin level, ANC, hemoglobin level, utilization of antifungal or antibiotic prophylaxis and granulocyte colony-stimulating factor (G-CSF), staging of disease, and diagnosis were all gathered. This information provides a list of risk factors for febrile neutropenia development among patients.
Neutropenia questionnaire
This questionnaire is shown in Appendix D (extracted from Mak & Ching, 2015) under the appendix section, and it has three parts. In the first section, the study used Hibbard, Stockard, Mahoney, and Tusler’s (2004) Patient activation measure (PAM) used to assess self-efficacy, thereby allowing for self-management assessment among patients. The other parts of the febrile neutropenia questionnaire were used to assess the level of knowledge regarding the prevention and care of febrile neutropenia and adherence to self-care behavior. This was also developed by the investigator, and prior to adoption, it was tested for validity and reliability. For item relevance in this questionnaire, the content validity index was that which showed good content validity (Polit, Beck, & Owen, 2007). For this particular research, different questionnaire sections for Pearson’s correlation coefficient varied between 0.723 and 0.976, indicating strong-very strong relationships (Mak & Ching, 2015).
Febrile neutropenia Prevention knowledge level
Under the knowledge level questionnaire, the researcher divided it into sections. The first section contained thirteen multiple-choice questions to assess the level of knowledge of participants regarding the febrile neutropenia prevention and care, such as information about management of neutropenic infection, personal hygiene, dietary factors, infection in environmental factors prevention, and white blood cells. The researcher developed questions based on educational intervention content.
Self-care behavior adherence
Under the category behavior, adherence category formed part of the second part of the questionnaire, and it contained a total of 23 questions. It specifically addressed issues on oral hygiene, dietary habits, hand hygiene, and personal hygiene constituted. This section evaluated the self-care behavior of patients in the last three weeks. It employed a Likert scale ranging from 1-5, with choices varying from “Never,” “Seldom,” “Sometimes,” and “Always.” In order to determine a participant’s overall behavior, all of the 23-response answers were added (that is, “Always” = 4, “Sometimes” = 3, “Seldom” = 2, and “Never” = 1). On the other hand, the score reversal was provided based upon the dietary behavior (for instance, “Always” = 1, “Sometimes” = 2, “Seldom” = 3, and “Never” = 4)
Self-efficacy in self-management
Self-efficacy related to personal management was the third part of the questionnaire. The Hibbard established PAM to evaluate an activation that is a condition of a scale ranging from a belief that active responsibility is vital through having the know-how and confidence to make a move, followed by taking action and lastly staying on the track of the action (Hibbard et al., 2005). Notably, PAM is among the specifics of cancer and personal-management, individual efficacy outcome techniques (Davies, 2009). It includes twenty-two items to examine a patient’s traits such as confidence, skills, and knowledge of the patient for personal management. The topics subjected their responses on the measure, the Likert scale with 4 major points. The four points include, Strongly Agree, Agree, Disagree, and Strongly Disagree. Several pieces of evidence as observed strongly support its consistency and reliability (Hibbard et al., 2005). This version of PAM was initiated by Hsu (Hibbard et al., 2004) and characterized by a high level of self-consistency, the constant of Cronbach’s alpha=0.882, has been embraced in the research. The overall tally is achieved by adding up the feedback to the twenty-two queries. For instance, Strongly Agree=1, Agree=2, Disagree=3, and Strongly Disagree=4, the vice versa of this score is, Strongly Agree=4, Agree=3, Disagree=2, strongly Disagree=1.
Hand washing competence checklist
The rural PA hospital in which the study was conducted also offers a checklist for hand washing (this is evidenced in Appendix E extracted from Mak & Ching, 2015) for evaluating the local communities’ hand washing. During handwashing, fourteen criteria are assessed, which are in line with the pamphlet that the local healthcare agency produced. In order to score every item under this section, the “0” mark was scored for patient participants who never met the criteria and “1” for those who did meet the criteria. Study participants who scored fourteen were classified as competent based on the checklist for hand washing (Thomé, 2009). The study checked the intra-rater reliability test for competence on handwashing, and the outcome of the intra-class correlation coefficient was established as 0.985.
Data analysis
In this paper, data analysis was done through version 17.0 of the Statistical Package for the Social Sciences (SPSS) created by the IBM Company. The degree of the statistical importance of the research work was initially set at a percentage of _______%. Similarly, there were two types of tests used in conducting scores of knowledge comparison between control lot and intervention lot.
Protection of human subjects and ethics
In any research that includes the human aspect, it is very important to include ethical concerns. As such, this research covers various ethical issues such as privacy initiatives for patient’s health information and also the disruption of the Health Insurance Portability and Accountability Act (HIPAA). The other ethical issue in the research was the probability of damage or intimidates the physical welfare of the patients involved in the study. Besides, the emergence of conflict of interest was another ethical issue that was pointed out during the research.
The research was appraised and accepted by the Research Ethics Committee of the involved health institutions and the IRB. Precisely, those patients who met the requirements of inclusive standards on involvement in theatre wards were automatically selected to assist in the research by a consultation from the ED or from a sick visit within the oncology clinic. Furthermore, the researcher provided the verbal data and written information about the research and the study procedures. For privacy and confidentiality, the involvement and outcomes of the topics in the research well-kept and all the information safely locked in cardboard. During the study, conflicts of interest were eliminated through not giving out financial assistance and or any other form of monetary benefit to the researchers and the patients.
Chapter 4
Outcomes
Introduction
The purpose of this DNP project was to understand the challenges and barriers that the rural, PA patient and hospital faces in the delivery of evidence-based care for an oncology patient. The development of an order set for oncology related febrile neutropenia management prototype was meant to address concerns by providing us a synced E HR order set tool in which the outpatient provider, ER provider could use more efficiently to manage the guidelines associated with febrile neutropenia. The next purpose of this project was to gain a deeper understanding of the chemotherapy related toxicities based on age, chemotherapy, toxicity of treatment, and requirement of an admission versus outpatient triage. In previous chapters the methods for data collection were detailed, as well as how the data was to be used. In chapter 4, the findings of this project are discussed based on the research question posed and Chapter 1 and Chapter 3.
Strengths
Limitations
Summary
Chapter 5
Conclusions
Summary:
Limitations:
Significance:
Recommendations:
Conclusion:
Appendices
Appendix A
In the video, the chemotherapy regimen of doxorubicin and cyclophosphamide and its side effects were introduced. Neutropenia is one of the common side effects of chemotherapy. We would discuss the neutropenia care in detailed today.
● 1. Define or redefine meaningful, power-oriented goals and objectives
● 1.1 Clarify feelings and meaning Firstly, according to your understanding, what is neutropenia? What are your thoughts about this? What are your thoughts about neutropenia related infection/febrile neutropenia (FN)?
Are you feeling (worried/fear/nervous) because (neutropenia related infection/FN)?
Provide support for the subject
If the subject has positive thought and attitude, give encouragement and support
If the subject has negative thoughts and attitude, give reassurance and support
● 1.2 Set a goal — We hope to increase your competence of self-care management though the program, thus the risk of neutropenia related infection/FN would be decreased.
Explain the consequence of FN and the importance of the prevention of FN, such as admission, delay treatment What is your goal? What do you want? How important is it, on a scale of 1 to10, for you to do something about this?
The education part:
A. Knowledge of neutropenia
Function of white blood cell –The neutropenia nadir commonly occur 7-14 days after chemotherapy
The benefit of good self-care: reduce the risk of infection, reduce the chance of admission due to FN and reduce the postponement of treatment plans. We can change our lifestyle to prevent FN. There are five cards which cover the content of the education program. Please choose the cards according to your interest.
B. Personal hygiene
C. Dietary hygiene
D. Oral hygiene
E. Information about seeking medical help
F. hand hygiene
●2 Develop a plan
How would this situation have to change for you to achieve the goal?
Please develop some strategies for facilitating you to implement the plan on personal hygiene,
hand hygiene, dietary hygiene and oral hygiene.
Who could help you?
● 2.1 Commit to action
Are you worthy to do what you need to do to reduce FN?
When are you going to do it?
How confident are you that you can accomplish this plan, on a scale of 1-10?
What is one thing you will do when you leave here today?
It is time to stop here. Wish you all the best. Do you have any questions? Let’s summarize our
conversation today. I will discuss the progress with you next time while waiting for the medical
follow up. This education program focuses on the FN only. You need to be aware of other side effects of chemotherapy as well. You can read the related information in the education booklet provided.
Follow up session
● 2.2. Observe and reflect on the impact of actions in relation to goal achievement
● 2.3 Experience and evaluate the plan Do you remember the goal we set before? What barriers did you evaluate? Any solutions? What, if anything, would you do differently next time? (Provide encouragement)
What will you do when you leave here today?
Appendix B
Study No.:__________ (T____) Date: _________________
Personal Data
Age: __________________ years old
Gender: ◻Female ◻ Male
Education: ◻No schooling completed ◻ Graduate HS ◻ Some College ◻ Bachelor’s or above
Medical Information Sheet
Diagnosis: ________________
Cancer Staging: 1 ◻ 2 ◻ 3 ◻ 4 ◻
Chemotherapy Treatment: ___________________ Date of Tx: ________________
Use of G-CSF: ◻ YES ◻ NO
Use of antibiotic/antifungal prophylaxis: ◻ YES ◻ NO Please specific: ________________
Hemoglobin level: ________________g/dL
ANC: ________________ 10^9/ L
Presence of open wound: ◻ YES ◻ NO Please specific: ___________________________
Previous or concurrent radiation therapy: ◻ YES ◻ NO Please specific: ________________
ECOG performance status: 0 ◻ 1 ◻ 2 ◻ 3 ◻ 4 ◻ 5 ◻
Incidence of admission: ◻ YES ◻ NO Please specific: ___________________________
underwent FN teaching ◻ YES ◻ NO
Eastern Cooperative Oncology Group (ECOG) Performance Status (Oken et al., 1982)
Grade 0: Fully active, able to carry on all pre-disease performance without rest
Grade 1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (e.g., light house work, office work)
Grade 2: Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
Grade 3: Capable of only limited self-care; confined to bed or chair more than 50% of waking hours
Grade 4: Completely disabled, cannot carry on any self-care; totally confined to bed or chair
Grade 5: Dead
Appendix D
Study No.:__________ (T____) Date: _________________
Part 1: Knowledge of neutropenic care
To evaluate your understanding of neutropenic care, please circle the correct answer to the following questions.
1. What is the function of white blood cells?
A. Remove toxins
B. Coagulate
C. Transport oxygen and nutrients
D. Fight infection
E. Unknown
2. How many days will the neutropenia nadir occur after commencing chemotherapy?
A. 1-2 days
B. 3-5 days
C. 7-14 days
D. 1 month
E. Unknown
3. Which of the following is a symptom of infection?
A. Petechiae/bruise
B. Hair loss
C. Redness, swelling and pain on the wound site
D. Nausea
E. Unknown
4. Which of the following is the obvious symptom of sepsis?
A. Vomiting
B. Headache
C. Chills and rigors
D. Running nose
E. Unknown
5. Which of the following measures must be carried out every day in order to prevent infection?
A. Exercise
B. Shower
C. Take vitamins
D. Drink milk supplement
E. Unknown
8. Which of the following measures must be taken for a patient receiving chemotherapy to stay in the public area?
A. Drink more water
B. Handwashing
C. Wear surgical mask
D. Take Panadol
E. Unknown
9. Which of the following item should patients needed to pay particular attention to prevent
infection?
A. Hand hygiene
B. Take diet regularly
C. blood result
D. Body weight control
E. Unknown
10. If the oral temperature is higher than what degree Fareinheight should seek medical help?
A. 98°F
B. 99°F
C. 100.4°F
D. 102°F
E. Unknown
11. Which of the following measures should be taken if the patient has a fever?
A. Seek medical help from Emergency Room
B. Self-take Tylenol
C. Seek medical help from Clinical Oncology Clinic
D. Self-take old antibiotics
E. Unknown
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