Inpatient versus outpatient vincristine, dactinomycin, and cyclophosphamide for pediatric cancers: Quality and cost implications.

BACKGROUND: Approximately 18% of the United States' gross domestic product is attributed to healthcare expenditures. Several studies have illustrated that shifting healthcare from the inpatient to the outpatient setting is more cost effective, in addition to improving patient satisfaction. Vincristine, dactinomycin, and cyclophosphamide (VAC) are used together to treat children with solid tumors. Our traditional treatment approach included a two day inpatient admission. The purpose of this project was to establish a process for the administration of VAC in the outpatient setting to improve satisfaction, and reduce costs. PROCEDURE: We aimed to benchmark practice standards with other institutions, revised our treatment approach to permit outpatient administration, and implemented the new protocol in a stepwise manner. We collected caregiver satisfaction metrics through the use of surveys. Costs of encounters were obtained from administrative data. Total costs and costs by service type were compared using descriptive and mean comparisons. RESULTS: Seven patients received a total of 31 cycles of VAC in the outpatient setting. The time to achieve an appropriate pre-chemotherapy specific gravity was reduced by a median of 120 min. In addition, time spent in the hospital setting was reduced by a mean of 27.2 hr. Adverse effects were minimal and all caregivers reported greater satisfaction with the outpatient regimen. Outpatient administration of VAC was $3,300 less on average compared to the inpatient administration. CONCLUSION: Outpatient VAC provides a safe alternative for administration that reduces healthcare costs, reduces healthcare utilization, and improves patient satisfaction.

Palliative Care Services within a Pediatric Hematology-Oncology Program in a Low-Resource Setting.

CONTEXT: Outcomes for children with cancer in sub-Saharan Africa (SAA) are dismal due to delayed diagnosis and limited access to curative therapy. When establishing a pediatric hematology-oncology (PHO) program in low-resource settings, early integration of palliative care services becomes essential. While palliative care is a human right, equitable distribution is lacking. OBJECTIVES: We aim to describe our experience establishing a palliative care program, the services offered, and the distribution of patients served. METHODS: This is a brief description of our PHO palliative care program in Lilongwe, Malawi at a tertiary care center and a three-year retrospective review of activities (2017-2020). Services offered include inpatient, outpatient, home visits, end of life care, and strengthening of referral systems. RESULTS: Over the three-year period, 315 patients were enrolled. 57% (n=179) were male. The median age was seven years (5 months-22 years). Patients served were from 17 of 28 districts within Malawi. Diagnoses of patients included 43% solid tumors (n=135), 22% lymphoma (n=68), 15% leukemia (n=47), and 21% hematologic disease (n=65). 40% of patients have died (n=125), with 53% of deaths occurring at home (n=66), 22% in the hospital (n=28), and 25% at unknown locations (n=31). CONCLUSION: Palliative care is a critical component of PHO programs worldwide. Programs must leverage existing networks to ensure optimal care to children and families. We demonstrate the feasibility of integrating palliative care services within a PHO program in a low-resource setting, which could serve as a model for other countries in SSA.

Delphi Method to Develop a Palliative Care Tool for Children and Families in Sub-Saharan Africa.

CONTEXT: In sub-Saharan Africa, there is no standardized approach to pediatric palliative care assessment. Because of this, there is a critical demand for evidence-based assessment tools that identify the specialized needs of children and their families requiring palliative care in developing countries. OBJECTIVES: To develop a standardized approach to pediatric palliative care (PPC) assessment that includes an individualized plan of care for use in sub-Saharan Africa. METHODS: A Delphi method approach used five rounds to explore core elements that define the essential assessment attributes mandatory for providing excellence in PPC. Using the Delphi method, the consensus from 11 PPC experts was obtained during four Delphi rounds regarding the most important questions to include in a PPC assessment tool and plan of care. During the final Delphi round 5, the expert consensus was confirmed in a separate group of 36 childhood cancer/palliative care clinical providers. RESULTS: Five core elements were developed as the foundation for a PPC assessment. A symptom assessment tool was developed that includes 15 symptoms that PPC experts agreed occurred more than 65% of the time in their patients. CONCLUSION: The Delphi method was an effective tool to develop a consensus on a PPC assessment tool to use with children and their families in sub-Saharan Africa. This standardized approach will enable the collection of data to drive outcomes and research.

Using Quality Improvement Science to Create a Navigator in the Electronic Health Record for the Consolidation of Patient Information Surrounding Pediatric End-of-Life Care.

BACKGROUND: It is important to document the domains surrounding end-of-life (EOL) care in the electronic health record (EHR). No pediatric navigator exists for these purposes. MEASURES: Medical charts were reviewed for documentation surrounding code status and care at the time of death from January 2017 to June 2019. INTERVENTION: Creation of a navigator in the EHR to consolidate advance care planning documents, code status orders and notes and EOL flowsheets. OUTCOMES: After implementing the navigator, 96% code status changes had supporting documentation, an increase of 35%. The percentage of deaths supported by a psychosocial team (social worker, chaplain and certified child life specialist) increased by 25%. Post-mortem documentation became electronic. Patient level metrics began to be electronically collected. CONCLUSIONS/LESSONS LEARNED: Little has been published regarding use of the EHR to consolidate EOL documentation in pediatrics. Development of a systematic approach to documentation is critical to providing EOL care and standardizing care delivered.

Using improvement science to promote evidence-based practice in a childhood cancer and hematology center.

A major children's cancer and hematology center established a Quality Transformation (QT) Core to develop and monitor empirical outcomes that demonstrate excellence in clinical care. The QT Core, based on the Institute of Medicine's domains of quality health care, aims to ensure that care is safe, effective, patient centered, timely, efficient, and equitable. Specific goals for the first year of the QT Core were to develop a team of improvement science experts, engage faculty and staff in QT initiatives, promote accountability for excellence in clinical care, and establish specific metrics to evaluate process, structure, and outcomes for QT Core projects. The purpose of this article is to discuss the successful development of a quality transformation core within a pediatric subspecialty and demonstrate the principles of improvement science through an actual quality transformation project designed to implement an evidence-based guideline for procedural sedation for children with cancer. The QT Core within this subspecialty was founded on principles of successful transformation of patient care that includes motivation to change, leaders committed to quality, active engagement of staff in meaningful problem-solving initiatives, alignment with organization goals with resource allocation, and integration to bridge boundaries throughout an organization. These key principles are demonstrated through the discussion of the development of the QT Core and implementation of an evidence-based procedure sedation guideline. Pediatric and pediatric subspecialty groups can be on the forefront of national initiatives that promote quality health care, exemplified by the QT Core developed within the cancer and hematology center.

Children's coping strategies for chemotherapy-induced nausea and vomiting.

PURPOSE/OBJECTIVES: To identify anticipatory, acute, and delayed chemotherapy-induced nausea and vomiting (CINV) frequency and coping strategies used among pediatric patients with cancer. DESIGN: Prospective, cohort design. SETTING: A pediatric teaching hospital in the southern United States. SAMPLE: A convenience sample of 40 children aged 7-12 years scheduled to receive either moderately emetic chemotherapy or highly emetic chemotherapy for cancer treatment. METHODS: Children completed the Adapted Rhodes Index of Nausea and Vomiting for Pediatrics and the Kidcope-Younger Version. MAIN RESEARCH VARIABLES: CINV and coping strategies. FINDINGS: CINV occurred during the anticipatory, acute, and delayed times, with the highest frequency occurring during the delayed time. The most frequently used coping strategies were distraction and wishful thinking, whereas the most effective strategies were social support and distraction. No statistically significant differences were observed in the frequency or efficacy of coping strategies over time. CONCLUSIONS: CINV occurs throughout chemotherapy treatment. The most efficacious coping strategies included active and passive coping, with active coping strategies being more effective. IMPLICATIONS FOR NURSING: Nurses should recognize that CINV occurs at all points of chemotherapy treatment. Nurses can assist children in developing active coping strategies to manage their CINV.

Improving care for children with sickle cell disease/acute chest syndrome.

BACKGROUND: Acute chest syndrome (ACS) is a leading cause of hospitalization and death of children with sickle cell disease (SCD). An evidence-based ACS/SCD guideline was established to standardize care throughout the institution in February 2008. However, by the summer of 2009 use of the guideline was inconsistent, and did not seem to have an impact on length of stay. As a result, an implementation program was developed. OBJECTIVE: This quality-improvement project evaluated the influence of the development and implementation of a clinical practice guideline for children with SCD with ACS or at risk for ACS on clinical outcomes. METHODS: Clinical outcomes of 139 patients with SCD were evaluated before and after the development of the implementation program. Outcomes included average length of stay, number of exchange transfusions, average cost per SCD admission, and documentation of the clinical respiratory score and pulmonary interventions. RESULTS: Average length of stay decreased from 5.8 days before implementation of the guideline to 4.1 days after implementation (P = .033). No patients required an exchange transfusion. Average cost per SCD admission decreased from $30 359 before guideline implementation to $22 368. Documentation of the clinical respiratory score increased from 31.0% before implementation to 75.5%, which is an improvement of 44.5% (P < .001). Documentation of incentive spirometry and positive expiratory pressure increased from 23.3% before implementation to 50.4%, which is an improvement of 27.1% (P < .001). CONCLUSIONS: Implementation of a guideline for children with SCD with ACS or at risk for ACS improved outcomes for patients with SCD.

On the front lines: lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals.

Venipuncture and intravenous cannulation are among the most common and widespread medical procedures performed on children today. Therefore, effective treatment of venous access pain can benefit from an integrated systems approach that enlists multiple players in the health care system. By using case studies that analyze this issue from the perspective of the nurse, the physician, the pharmacist, and the child life specialist, this article illustrates how multidisciplinary programs designed to manage needle pain have been developed successfully in several institutions. Common themes that arise from these case studies include the importance of a multidisciplinary evidence-based approach to advocate change; a system-wide protocol for the administration of local anesthetics; convenient access to topical local anesthetics; department and hospital-wide support for educational efforts, including training in nonpharmacologic techniques used by child life specialists; and ongoing quantification of the overall success of any program. Implementation of these strategies can result in significant improvements in the pediatric venous access experience.

Variations in pain, sleep, and activity during hospitalization in children with cancer.

This study examines the pain experiences of children with cancer during hospitalization. A descriptive design with repeated measures was used to describe the location, intensity, and quality of pain, pain medications, amount of pain relief, and perceptions of sleep and activity during hospitalization. Data were collected once daily from the day of admission for up to a maximum of 5 consecutive days during hospitalization. Results show that more than half of the patients (27 of 49 patients) indicated they were having pain. Eleven patients (22.4%) had mild pain (mean = 2.3 +/- 0.9 SD; range, 0.3-3.6), 10 (20.4%) had moderate pain (mean = 5.3 +/- 0.2 SD; range, 5.0-5.5), and 6 (12.2%) had severe pain (mean = 7.6 +/- 1.3 SD; range, 6.5-10.0). The highest pain intensity ratings occurred on day 1. Overall, most patients reported good relief after pain medications during hospitalization. Consistent assessment and implementation of pain interventions within the 24 hours of admission is recommended, with particular attention to persistent pain after painful procedures.