NURSING RESEARCH IMPORTANT POINTS COMPONENTS COMPONENTS. Proposed timeline Consent/ protection of human

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1 NURSING RESEARCH Implementation of a Chemotherapy-Induced Nausea and Vomiting Clinical Pathway for Moderate-high to Highly Emetogenic Chemotherapies A Nursing Research Project 2/01/2014 3/31/2015 PURPOSE: INCREASE NURSING KNOWLEDGE IMPROVE PATIENT OUTCOMES NURSING RESEARCH Systematic inquiry designed to develop trustworthy evidence about issues of importance to the nursing profession, including nursing practice, education, administration, and informatics IMPORTANT POINTS All proposals reviewed for approval by NRRB One RN investigator prepared at a graduate level PI must provide documentation of NIH or comparable education Following NRRB approval goes to IRB COMPONENTS Question or Problem Literature Review Abstract Proposed research question/hypothesis Methodology COMPONENTS Proposed timeline Consent/ protection of human subjects Acquired costs approval from supervisor Dissemination 1

2 NEXT STEPS Complete NRRB Request for Research Proposal Form Application Conflict of interest Cost analysis form Meet with NRRB for approval Introduction New Cancer Diagnosis Fear Stress Increased anxiety Overwhelming Experience Altered Comprehension Introduction New Cancer Diagnosis Information Overload Decreased retention of education provided Nausea and Vomiting among the most distressing side effects of Chemotherapy Empirical evidence of effectiveness of pharmacologic Interventions for the prevention of CINV Introduction Adherence to clinical pathways can manage patient symptoms and side effects No published studies on clinical i l pathways for CINV Background Coborn Cancer Center: Medical Oncology Clinic, Radiation Oncology Clinic, Infusion Center Education provided by staff in all areas Nurses heard from patients that instructions varied in how to take their medications for nausea Background A formal survey completed by RNs indicated: Variation in how nurses were teaching patients to take their anti nausea medications Variation in level of confidence by RNs in their knowledge of anti emetic medications Variation in the nurses understanding of the indication for dexamethasone in take home meds 2

3 Chemotherapy induced Nausea and Vomiting (CINV) an important adverse effect of chemo 75% of patients report nausea at some point of treatment Delayed CINV is more common than acute symptoms Nausea is more common then emesis CINV can complicate or prevent administration of planned therapy thus decreased quality of life and increased healthcare costs Prevention of CINV Optimizes outcomes of cancer therapy Maximizes i quality of life Prevention during initial cycles is crucial prevents anticipatory nausea and vomiting Appropriate antiemetic therapy when combined with patient education and clear communication results in optimal emetogenic control. Oncology nurses play a critical role to positively impact the prevention and management of CINV The art of oncology nursing: Effective communication Important role in education on what to expect and how to handle chemo treatment symptoms Nurses provide clear instructions Nurses collaborate with medical staff and pharmacy to provide individualized plans of care Clinical Pathways Tools for tracking patients progress to achieve positive outcomes Include key events (diagnostic tests, treatments, activities, medications, education) Occur within a specific time frame to achieve desired outcomes Promote organized and efficient patient care based on evidence based practice Optimize outcomes in the acute care and home care settings No published specific pathways for CINV National Comprehensive Cancer Network (NCCN) publishes guidelines for Antiemesis Humphrey Cancer Center at North Memorial Hospital developed a CINV pathway based on NCCN Guidelines for Take Home Medications that has been effective for patient education 3

4 Research Questions 1. Will the implementation of a CINV clinical pathway increase patients knowledge and understanding of how to take home medications? 2. Has the implementation of a CINV clinical pathway decreased the incidence of CINV? Definition of Terms Emetogenicity: Prediction of the risk of emesis following antineoplastic chemotherapy NCCN Levels of Emetogenicity: ii Level 5 High Emetic Risk: 90% frequency of emesis Level 3/4 Moderate Emetic Risk: 30 90% frequency of emesis Level 2 Low Emetic Risk: 10 30% frequency of emesis Level 1 Minimal Emetic Risk: <10% frequency Methodology Setting: Coborn Cancer Center, St. Cloud Hospital Implementation: Subjects receiving initial cancer treatment determined to be of moderately high or highly emetogenic nature 50 patients pre implementation of creation of CINV pathway asked to complete a survey at the one week toxicity review by an oncology nurse practitioner Approx 175 CINV pathways developed by Cancer Center CNS on moderately high to highly emetogenic chemo protocols Methodology Implementation continued After the survey of pre implementation patients, formal education was provided to oncology staff on the CINV pathways by members of the research project CINV pathways were initiated on newly diagnosed cancer patients who were prescribed moderate highly and highly emetogenic chemo 50 patients post implementation of creation of CINV pathway asked to complete a survey at the one week toxicity review by an oncology nurse practitioner AC (ADRIAMYCIN, CYTOXAN) Name: DOB: Take Home Medications Date Medication Reason Day before Day of Day after Day 3 Day 4 Day 5 Chemo Chemo Chemo Dexamethasone (Decadron) 8 mg orally Take 8 daily for 2 days. Start the day Prevention of In the In the STOP: Then repeat after chemo. Take with food. chemo side morning: morning: dexamethasone with effects 8 mg 8 mg each cycle of chemo *****Drink at least six to eight 8 ounce glasses of noncaffeinated beverages a day throughout your treatment***** Prochlorperazine (Compazine) Nausea Start with this medication. May take every six hours as needed for 10 mg tablets nausea. Start as soon as you feel nauseated at any time during your Take one tablet every 6 hours as needed. treatment cycles. Acknowledgement: Pathways adapted from: Jeremy Whalen PharmD North Memorial Medical Center Ondansetron (Zofran) 8 mg tablets Take one tablet every 8 hours as needed. Lorazepam (Ativan) 0.5mg tablets Take one to two tablets every six hours as needed. *May make you sleepy* Nausea Nausea, Anxiety, or Sleep Starting Day 4 If nausea continues after taking Prochlorperazine, you may take Ondansetron every eight hours as needed for nausea. You may alternate the two drugs or take both at the same time if needed. If Prochlorperazine and Ondansetron are not controlling nausea, you may take Lorazepam every six hours as needed for sleep, anxiety, or nausea. You will need a prescription from your oncology provider. Call if the above medications are not effective to control your symptoms. If you need refills call your pharmacy. 4

5 Chemotherapy Patient Survey The purpose of this study is to assess effectiveness of nurse teaching related to chemotherapy-related nausea and vomiting. If you are willing to participate, please complete this brief (5 minute) survey. The survey will ask about your experience following chemotherapy. There are no foreseeable risks associated with this project, nor are there any direct benefits to you. All responses are confidential. Reporting will ensure that individuals are not identifiable. Your participation is voluntary. You may hand in the survey to the office nurse, place it on the desk in the office when you leave, or give it to the scheduler when you make your next appointment. If you have any questions, you can contact Mary Weis, RN, CNS, who can be reached at , extension This survey is to find out how satisfied you were with the information you received on your first day of chemotherapy related to how to prevent and manage nausea and vomiting. Did you receive any written information on nausea and vomiting? The nausea and vomiting medication information provided to you at the time of discharge from the first day at the Chemotherapy Infusion unit was How satisfied were you with the amount of nausea and vomiting information you received? How helpful has the nausea and vomiting information you received been? Yes Poor Fair Good Very Good No Excellent Not at All A Little Quite a Bit Very Much Since your chemotherapy began Have you felt nauseated? Have you vomited? Patient Survey Questions adapted from the EORTC Quality of Life Item Bank Used with permission from Dagmara Kulis. Statistical Analysis Incidence of nausea and vomiting lower than reported in literature Frequencies and grounded t tests by Statistical Consulting Center St. Cloud State University No significant relationship in any question Staff Survey: RNs felt tool useful and more effective in patient teaching Limitations Staff awareness and involvement in design of pathway may have increased quality and amount of patient education information Future Studies Redesign of research question measure knowledge and understanding Another study comparing similar populations from two different cancer centers 5

6 References References The Advisory Board Company. A Primer on Clinical Pathways for Cancer Care. (2013). Retrieved from: Colagiuri, B., Zachariae, R. (2010). Patient Expectancy and Post chemotherapy Nausea: A Meta analysis. Annals of Behavioral Medicine, 40, European Organisation for Research and Treatment of Cancer Treatment EORTC. Quality of Life Item Bank. Accessed Fabi, A., Barduagni, M., Lauro, S., Portalone, L., Mauri, M., Marinis, F., Narduzzi, C., Tonini, G., Giampaolo, M., Pacetti, U., Paoloni, F., Cognetti, F. (2003). Is Delayed Chemotherapy induced Emesis Well Managed in Oncological Clinical Practice? A. Support Care Cancer, 11, Fitch, M. I., McAndrew, A. (2011). A Performance Measurement Tool for Cancer Patient Information and Satisfaction. Journal of Cancer Education, 26, Hawkins, R., Grunberg, S. (2009). Chemotherapy Induced Nausea and Vomiting: Challenges abd Opportunities for Improved Patient Outcomes. Clinical Journal of Oncology Nursing. 13(1), Kinnane, N., Stuart, E., Thompson, L., Evans, K., Schneider Kolsky, M. (2007). Evaluation of the Addition of Video based Education for Patients Receiving Standard Pre chemotherapy Education. European Journal of Cancer Care. 17, National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. (2013). Antiemesis. Retrieved Noonan,K. Effective Prevention and Management of Chemotherapy Induced Nausea and Vomiting. The oncology Nurse APN/PA. 3(2), Schwartzberg, L. S. (2007). Chemotherapy Induced Nausea and Vomiting: Clinician and Patient Perspectives. Supportive Oncology. 3(2), 5 12 Thompson, N. (2012). Optimizing Treatment Outcomes in Patients at Risk for Chemotherapy Induced Nausea and Vomiting. Clinical Journal of Oncology Nursing 16(3), Thomas, R., Kaminski, E., Stanton, E., Williams, M. (2004). Measuring Information Strategies in Oncology Developing an Information Satisfaction Questionnaire. European Journal of Cancer Care. 13, References Tipton, J. M., McDaniel, R. W., Barbour, L., Johnston, M. P., Kayne, M., LeRoy, P., Ripple, M. L. (2007). Putting Evidence Into Practice: Evidence Based Interventions to Prevent, Manage, and Treat Chemotherapy Induced Nausea and Vomiting. Clinical Journal of Oncology Nursing. 11(1), Wood, J., Chapman, K., Eilers, J. (2011). Tools for Assessing Nausea, Vomiting, and Retching: A Literature Review. Cancer Nursing. 34(1),