Neuroinvasive Bacillus cereus Infection in Immunocompromised Hosts: Epidemiologic Investigation of 5 Patients With Acute Myeloid Leukemia.

Background: Bacillus cereus is a ubiquitous gram-positive rod-shaped bacterium that can cause sepsis and neuroinvasive disease in patients with acute leukemia or neutropenia. Methods: A single-center retrospective review was conducted to evaluate patients with acute leukemia, positive blood or cerebrospinal fluid test results for B cereus, and abnormal neuroradiographic findings between January 2018 and October 2022. Infection control practices were observed, environmental samples obtained, a dietary case-control study completed, and whole genome sequencing performed on environmental and clinical Bacillus isolates. Results: Five patients with B cereus neuroinvasive disease were identified. All patients had acute myeloid leukemia (AML), were receiving induction chemotherapy, and were neutropenic. Neurologic involvement included subarachnoid or intraparenchymal hemorrhage or brain abscess. All patients were treated with ciprofloxacin and survived with limited or no neurologic sequelae. B cereus was identified in 7 of 61 environmental samples and 1 of 19 dietary protein samples-these were unrelated to clinical isolates via sequencing. No point source was identified. Ciprofloxacin was added to the empiric antimicrobial regimen for patients with AML and prolonged or recurrent neutropenic fevers; no new cases were identified in the ensuing year. Conclusions: B cereus is ubiquitous in the hospital environment, at times leading to clusters with unrelated isolates. Fastidious infection control practices addressing a range of possible exposures are warranted, but their efficacy is unknown and they may not be sufficient to prevent all infections. Thus, including B cereus coverage in empiric regimens for patients with AML and persistent neutropenic fever may limit the morbidity of this pathogen.

Measuring Advanced Practice Provider Productivity at the National Comprehensive Cancer Network's Member Institutions.

Introduction: The utilization of advanced practice providers (APPs) in oncology has been growing over the last decade; however, there is no standard method for assessing an APP's contributions to oncology care. Methods: The NCCN Best Practices Committee (BPC) created an APP Workgroup to develop recommendations to support the roles of APPs at NCCN Member Institutions. The Workgroup conducted surveys to understand how NCCN centers measure productivity. This article will review the survey results and provide recommendations for measuring APP productivity. Results: Although 54% of responding centers indicated they utilize relative value units (RVU) targets for independent APP visits, 88% of APPs are either unsure or do not believe RVUs are an effective measurement of overall productivity. Relative value units do not reflect non-billable hours, and APPs perform a significant number of non-billable tasks that are important to oncology practices. Sixty-six percent of APPs believe that measuring disease-based team productivity is a more reasonable assessment of APP productivity than measuring productivity at the individual level. Conclusion: Our recommendation for cancer centers is to focus on the value that APPs provide to overall care delivery. Advanced practice provider productivity metrics should consider not only the number of patients seen by APPs, but also the high quality and thorough care delivered that contributes to the overall care of the patient and practice. Advanced practice providers can help improve access to care, deliver improved outcomes, and increase patient and provider satisfaction. Reducing the focus on RVUs, accounting for important non-RVU-generating activities, and incorporating quality and team metrics will provide a better overall picture of APP productivity.

Development and Implementation of an Oncology Clinical Research Nursing Residency Program for Newly Licensed Nurses.

ABSTRACT: A paucity of nurses trained in clinical research prompted the development and implementation of a newly licensed nurse residency program in oncology research. The components of the program, funding, curriculum development, preceptor model, and partnerships, are described. Formal evaluation to quantify success in creating a pipeline for the future, increasing retention, and reducing costs is underway and will be reported in a future publication.

Psychosocial distress is dynamic across the spectrum of cancer care and requires longitudinal screening for patient-centered care.

PURPOSE: Screening for cancer-related psychosocial distress is recommended for patients with cancer; however, data on the long-term prevalence of distress and its natural history in survivors are scarce, preventing recommendations for screening frequency and duration. We sought to evaluate longitudinal distress in cancer patients. METHODS: We evaluated longitudinal distress screening data for patients with cancer treated or surveilled at our institution from 2010 to 2018. Anxiety, depression, insurance/financial, family, memory, and strength-related distress were separately assessed and analyzed. Multivariable logistic regression was utilized to evaluate factors associated with distress subtypes. RESULTS: In 5660 patients, distress was the highest at diagnosis for anxiety, depression, financial, and overall distress. On multivariable analysis, factors independently associated with distress at diagnosis included younger age, female gender, disease site/stage, payor, and income, varying by subtype-specific analyses. Severe distress in at least one subtype persisted in over 30% of survivors surveyed through 10 years after diagnosis. Over half of patients with initially severe distress at diagnosis improved within 12 months; however, distress worsened in 20-30% of patients with moderate, low, and no initial distress, regardless of the distress subtype. CONCLUSION: Psychosocial distress in cancer survivors is a long-lasting burden with implications for quality of life and oncologic outcomes. Severe distress remains prevalent through 10 years after diagnosis in survivors receiving continued care at cancer centers and results from both persistent and new sources of distress in a variety of psychosocial domains. Longitudinal distress screening is an invaluable tool for providing comprehensive patient-centered cancer care and is recommended to detect new or recurrent distress in cancer survivors.

A Study of Advanced Practice Provider Staffing Models and Professional Development Opportunities at National Comprehensive Cancer Network Member Institutions.

INTRODUCTION: The National Comprehensive Cancer Network (NCCN) Best Practices Committee created an Advanced Practice Provider (APP) Workgroup to develop recommendations to support APP roles at NCCN Member Institutions. METHODS: The Workgroup conducted three surveys to understand APP program structure, staffing models, and professional development opportunities at NCCN Member Institutions. RESULTS: The total number of new and follow-up visits a 1.0 APP full-time equivalent conducts per week in shared and independent visits ranged from 11 to 97, with an average of 40 visits per week (n = 39). The type of visits APPs conduct include follow-up shared (47.2%), follow-up independent (46%), new shared (6.5%), and new independent visits (0.5%). Seventy-two percent of respondents utilize a mixed model visit type, with 15% utilizing only independent visits and 13% utilizing only shared visits (n = 39). Of the 95% of centers with APP leads, 100% indicated that leads carry administrative and clinical responsibilities (n = 20); however, results varied with respect to how this time is allocated. Professional development opportunities offered included posters, papers, and presentations (84%), leadership development (57%), research opportunities (52%), writing book chapters (19%), and other professional development activities (12%; n = 422). Twenty percent of APPs indicated that protected time to engage in development opportunities should be offered. CONCLUSION: As evidenced by the variability of the survey results, the field would benefit from developing standards for APPs. There is a lack of information regarding leadership structures to help support APPs, and additional research is needed. Additionally, centers should continuously assess the career-long opportunities needed to maximize the value of oncology APPs.

Fixed-dose combination of pertuzumab and trastuzumab for subcutaneous injection in patients with HER2-positive breast cancer: A multidisciplinary approach.

Pertuzumab plus trastuzumab, administered intravenously (IV) with chemotherapy, is standard treatment for HER2-positive metastatic or high-risk early breast cancer. Pertuzumab and trastuzumab are administered over 1-2.5 h traditionally; however, the need for IV infusions places a strain on medical centers with respect to scheduling, preparation, and administration. A novel fixed-dose combination of pertuzumab and trastuzumab for subcutaneous injection (PHESGO®, PH FDC SC) can be administered in approximately 5-8 min. PH FDC SC was non-inferior to IV pertuzumab plus trastuzumab in terms of pertuzumab and trastuzumab serum levels in the phase III FeDeriCa study, which enrolled 500 patients with HER2-positive early breast cancer. Total pathologic complete response rates were comparable after PH FDC SC (59.7%) or IV pertuzumab plus trastuzumab (59.5%), as was the incidence of grade ≥3 (48.8% vs 52.8%) and serious adverse events (16.1% vs 17.9%). The results of a phase II clinical trial (PHranceSCa) showed that a majority of patients (85%) preferred PH FDC SC treatment over IV pertuzumab plus trastuzumab. A US multicenter expanded access study (NCT04395508) is evaluating the safety of PH FDC SC administered at home by nurse providers in patients receiving maintenance HER2-targeted therapy every 3 weeks. This product takes much less time to administer than IV pertuzumab-trastuzumab and has the potential to alleviate time constraints for patients and busy clinics. In this review we provide an overview of PH FDC SC, and discuss our experience in preparing and administering this product to patients with HER2-positive breast cancer during clinical trials.

Intravenous haloperidol: A systematic review of side effects and recommendations for clinical use.

INTRODUCTION: Though not approved by the United States Food and Drug Administration, intravenous haloperidol (IVH) is widely used off-label to manage agitation and psychosis in patients with delirium in the hospital setting. Over the years, concerns have emerged regarding side effects of IVH, particularly its potential to cause QT prolongation, torsades de pointes (TdP), extrapyramidal symptoms and catatonia. METHODS: We conducted a systematic review of literature of published literature related to side effects of IVH in PubMed in accordance with PRISMA guidelines. RESULTS: 77 of 196 identified manuscripts met inclusion criteria, including 34 clinical trials and 34 case reports or series. DISCUSSION: Extrapyramidal symptoms, catatonia and neuroleptic malignant syndrome appears to be relatively rare with IVH. In most prospective studies, IVH did not cause greater QT prolongation than placebo, and rates of TdP with IVH appear to be low. There is not clear evidence to suggest that IVH carries greater risk for QT prolongation or TdP than other antipsychotics. CONCLUSIONS: Based on the available literature, we provide modified evidence-based monitoring recommendations for clinicians prescribing IVH in hospital settings. Specifically, we recommend electrocardiogram monitoring only when using doses >5 mg of IVH and telemetry only for high-risk patients receiving cumulative doses of at least 100 mg or with accurately corrected QTc >500 ms.

Components of an Effective Professional Development Strategy: The Professional Practice Model, Peer Feedback, Mentorship, Sponsorship, and Succession Planning.

OBJECTIVES: To review components of an effective professional development strategy in the oncology setting that includes mentorship, sponsorship, and succession planning. DATA SOURCES: OvidSP, practice standards, professional guidelines, and websites. CONCLUSIONS: There are compelling reasons why oncology nurses in all settings are required to remain current in their area of practice and use strategies that take advantage of available opportunities for professional development. Benefits include enhanced autonomy, strengthened individual competence, greater engagement, and enriched organizational cultures that can positively impact patient care. IMPLICATIONS FOR NURSING PRACTICE: Creating an environment that supports professional development is dependent on nurse leaders and the organizational commitment to the value of lifelong learning. Professional development can be enabled through many structures, including mentorship, sponsorship, and succession planning.

Teamwork and Electronic Health Record Implementation: A Case Study of Preserving Effective Communication and Mutual Trust in a Changing Environment.

This article describes how trust among team members and in the technology supporting them was eroded during implementation of an electronic health record (EHR) in an adult outpatient oncology practice at a comprehensive cancer center. Delays in care of a 38-year-old woman with high-risk breast cancer occurred because of ineffective team communication and are illustrated in a case study. The case explores how the patient's trust and mutual trust between team members were disrupted because of inaccurate assumptions about the functionality of the EHR's communication tool, resultant miscommunications between team members and the patient, and the eventual recognition that care was not being effectively coordinated, as it had been previously. Despite a well-established, team-based culture and significant preparation for the EHR implementation, the challenges that occurred point to underlying human and system failures from which other organizations going through a similar process may learn. Through an analysis and evaluation of events that transpired before and during the EHR rollout, suggested interventions for preventing this experience are offered, which include: a thorough crosswalk between old and new communication mechanisms before implementation; understanding and mitigation of gaps in the communication tool's functionality; more robust training for staff, clinicians, and patients; greater consideration given to the pace of change expected of individuals; and development of models of collaboration between EHR users and vendors in developing products that support high-quality, team-based care in the oncology setting. These interventions are transferable to any organizational or system change that threatens mutual trust and effective communication.

Transforming Oncology Care: Developing a Strategy and Measuring Success.

OBJECTIVES: To examine accountability and performance measurement in health care and present a case study that illustrates the link between goal setting and measurement and how a strategic plan can provide a framework for metric selection. DATA SOURCES: National reports, literature review and institutional experience. CONCLUSION: Nurse leaders and clinicians in oncology settings are challenged to anticipate future trends in oncology care and create a culture, infrastructure, and practice environment that supports innovation, advancement of oncology nursing practice and excellence in patient- and family-centered care. Performance metrics assessing key processes and outcomes of care are essential to meet this challenge. IMPLICATIONS FOR NURSING PRACTICE: With an increasing number of national organizations offering their version of key quality standards and metrics, it is critical for nurses to have a formal process in place to determine and implement the measures most useful in guiding change for a particular clinical setting.

Oral Chemotherapy Education: Using Innovation to Ensure Broad Access.

The purpose of this article is to share one institution's intervention to improve oral chemotherapy patient education. The overall aim was to provide clinicians with a single source of educational materials that would meet a diverse group of patients' educational needs and be consistent with published guidelines.
.

What matters to the patient is what really matters: quality in oncology nursing.

Reflecting on the 40th anniversary of the Oncology Nursing Society led me to recall my own 30-plus years in nursing and how, as a new graduate nurse, almost all oncology care was delivered in the inpatient setting. In my first few years of practice, I mixed my patients' chemotherapy in a medicine room without a ventilated hood and administered those medications without personal protective equipment or the independent RN double checks that have become standard to safe practice today. Through advances in science, tools are now in place to test and make changes, measure impact, and sustain improvements over time. Through advancements in nursing science and oncology research, the ability to treat and cure many cancers and to manage the symptoms and side effects of treatment has improved. Those improvements extend survival; enhance quality of life; and keep patients, staff, and practice environments safer than ever before. In addition, the human side of care has advanced with respect to the quality of interactions with patients and families. Some call this the art of nursing. I call it the essence of our practice. Increasingly, nurses are able to name specific interventions, measure impact, and document outcomes of this so-called art. It is to this human side of our practice that I dedicate this column.
.

Quality care: where we came from and where we must go.

The focus of this new column will be to showcase innovative work that has advanced quality in areas of practice and care delivery that are of interest to the practicing oncology nurse. Examples include, but are not limited to, practice environment innovation, patient outcomes and experiences of care, team effectiveness, and unit-based or institutionwide system changes.

Erythrocyte membrane phospholipid fatty acid concentrations and risk of colorectal adenomas: a case-control nested in the French E3N-EPIC cohort study.

BACKGROUND: Although dietary fatty acids may influence colorectal carcinogenesis, few studies have examined the association with adenoma risk. We assessed the association between biomarkers of dietary fatty acids or metabolism of fatty acids and the risk of colorectal adenomas in a nested case-control study from the French E3N-EPIC cohort. METHODS: Among 13,106 women without prevalent cancer who completed the diet history questionnaire and who provided blood samples, 328 cases of adenomatous polyp were identified during an average of 6.6-year follow-up and randomly matched to 619 polyp-free colonoscopy controls. Erythrocyte membrane phospholipid fatty acid concentrations were determined by gas chromatography. Adjusted ORs for risk of colorectal adenomas with increasing concentrations of fatty acids were calculated using conditional logistic regression, separately for advanced and nonadvanced adenomas. RESULTS: Associations were stronger with advanced than nonadvanced adenomas. High concentration of pentadecanoate plus heptadecanoate acids were inversely associated with the risk of advanced adenomas [highest vs. lowest tertile: OR(T3vsT1) = 0.40 (95% confidence interval (CI) 0.20-0.79); P(trend) = 0.009]. Oleic acid was associated with an increased risk of advanced adenomas [OR(T3vsT1) = 2.32 (1.16-4.64); P(trend) = 0.018]. Some polyunsaturated fatty acids were associated with the risk of advanced adenomas, either positively for di-homo-γ-linolenate [OR(T3vsT1) = 2.07 (1.15-3.72); P(trend) = 0.013], or negatively for eicosapentaenoic and docosahexaenoic acids [OR(T3vsT1) = 0.50 (0.27-0.93); P(trend) = 0.044 and OR(T3vsT1) = 0.50 (0.26-0.96); P(trend) = 0.028, respectively]. CONCLUSION: A specific erythrocyte membrane phospholipid fatty acid profile, presumably reflecting both a complex dietary pattern and altered fatty acid metabolism, is associated with advanced colorectal adenoma risk. IMPACT: Adenomas could be a target for primary prevention of colorectal cancer, using interventional strategy based on lipidomic profile of patients.

High performance teamwork training and systems redesign in outpatient oncology.

BACKGROUND: Oncology care is delivered largely in ambulatory settings by interdisciplinary teams. Treatments are often complex, extended in time, dispersed geographically and vulnerable to teamwork failures. To address this risk, we developed and piloted a team training initiative in the breast cancer programme at a comprehensive cancer centre. METHODS: Based on clinic observations, interviews with key staff and analyses of incident reports, we developed interventions to address four high-risk areas: (1) miscommunication of chemotherapy order changes on the day of treatment; (2) missing orders on treatment days without concurrent physician appointments; (3) poor follow-up with team members about active patient issues; and (4) conflict between providers and staff. The project team developed protocols and agreements to address team members' roles, responsibilities and behaviours. RESULTS: Using a train-the-trainer model, 92% of breast cancer staff completed training. The incidence of missing orders for unlinked visits decreased from 30% to 2% (p<0.001). Patient satisfaction scores regarding coordination of care improved from 93 to 97 (p=0.026). Providers, infusion nurses and support staff reported improvement in efficiency (75%, 86%, 90%), quality (82%, 93%, 93%) and safety (92%, 92%, 90%) of care, and more respectful behaviour (92%, 79%, 83%) and improved relationships among team members (91%, 85%, 92%). Although most clinicians reported a decrease in non-communicated changes, there was insufficient statistical power to detect a difference. CONCLUSIONS: Team training improved communication, task coordination and perceptions of efficiency, quality, safety and interactions among team members as well as patient perception of care coordination.

Hopelessness and complementary therapy use in patients with ovarian cancer.

BACKGROUND: Hopelessness negatively affects ovarian cancer patients' quality of life (QOL). Research validating the effects of complementary and alternative medicine (CAM) use on QOL and hope is scarce, even though QOL and hope are reasons that patients cite for using CAM therapy. Clinicians need effective, evidence-based interventions to improve QOL and reduce hopelessness. OBJECTIVE: The objectives of this study were to examine factors influencing hopelessness in patients with newly diagnosed disease, long-term survivors, and patients experiencing ovarian cancer recurrence and to examine the effects of CAM on hopelessness in the same population. METHODS: Surveys of ovarian cancer patients (N = 219) undergoing treatment at a comprehensive cancer center in the United States were analyzed. Descriptive, correlation, and multivariate analyses described variables and demonstrated the effects of sociodemographics, disease state, psychological distress, QOL, CAM use, and faith on hopelessness. RESULTS: Patients ages 65 years or older (-0.95, P = .03), with strong faith (-0.28, P = .00), and good QOL (0.11, P = .00) directly reduced hopelessness scores (mean, 3.37). Massage therapy substantially reduced hopelessness scores (-1.07, P = .02); holding age constant, employed patients were twice as likely to use massage (odds ratio, 2.09; P = .04). Patients who had newly diagnosed and recurrent ovarian cancer were more hopeless because of greater distress from symptoms and adverse effects of treatment. CONCLUSION: Patients who used massage therapy were significantly less hopeless, as were those with strong faith and well-controlled disease symptoms and treatment for adverse effects. IMPLICATIONS FOR PRACTICE: Support of spiritual needs and symptom management are important interventions to prevent and/or reduce hopelessness, especially for patients with newly diagnosed and recurrent ovarian cancer. Further research testing the positive effect of massage interventions on hopelessness is needed.

Oncology nursing in Cuba: report of the delegation.

In December 2011, the first delegation of oncology nurses from the United States visited Havana, Cuba. The delegation included oncology nurses, educators, and leaders from across America and provided opportunities to learn about the healthcare system, cancer, and oncology nursing in Cuba. Delegation members attended lectures, toured facilities, and enjoyed Cuban culture. This exchange highlighted the similarities in cancer care and oncology nursing between countries and opened doors for future collaborations.

Perceptions and experiences of patients receiving oral chemotherapy.

Although many patients prefer orally administered cancer therapy (including oral chemotherapy) because of its convenience, the shift from hospital to home-based administration creates concerns. This article explores the perceptions and experiences of oral chemotherapy users and their caregivers to assess vulnerabilities and improvement opportunities at each stage of the medication process: choosing oral chemotherapy, prescribing, dispensing, administering, and monitoring. The authors recruited 15 current and former oral chemotherapy users, as well as caregivers who administered the medications to children, to participate in one of two focus group sessions at a comprehensive cancer center. Participants largely were satisfied with oral cancer therapy but raised concerns regarding their lack of preparedness for side effects and their unfamiliarity with the possible techniques to mitigate drug toxicity. Participants also described difficulties obtaining medications through retail pharmacies. Parents of pediatric patients with cancer indicated concerns regarding their children's emotional health and correct medication administration. Participants believed that the initial prescribing encounter should have included more education, and they also wanted more frequent follow-up by healthcare practitioners. As oral cancer therapy is used more widely, oncology healthcare providers will need to create robust mechanisms to support their safe use.

Medication errors involving oral chemotherapy.

BACKGROUND: Given the expanding use of oral chemotherapies, the authors set out to examine errors in the prescribing, dispensing, administration, and monitoring of these drugs. METHODS: Reports were collected of oral chemotherapy-associated medication errors from a medical literature and Internet search and review of reports to the Medication Errors Reporting Program and MEDMARX. The authors solicited incident reports from 14 comprehensive cancer centers, and also collected incident reports, pharmacy interventions, and prompted clinician reports from their own center. They classified the type of incident, severity, stage in the medication use process, and type of medication error. They examined the yield of the various reporting methods to identify oral chemotherapy-related medication errors. RESULTS: The authors identified 99 adverse drug events, 322 near misses, and 87 medical errors with low risk of harm. Of the 99 adverse drug events, 20 were serious or life-threatening, 52 were significant, and 25 were minor. The most common medication errors involved wrong dose (38.8%), wrong drug (13.6%), wrong number of days supplied (11.0%), and missed dose (10.0%). The majority of errors resulted in a near miss; however, 39.3% of reports involving the wrong number of days supplied resulted in adverse drug events. Incidents derived from the literature search and hospital incident reporting system included a larger percentage of adverse drug events (73.1% and 58.8%, respectively) compared with other sources. CONCLUSIONS: Ensuring oral chemotherapy safety requires improvements in the way these drugs are ordered, dispensed, administered, and monitored.