Palliative care outpatients and improved documentation-what matters most? Quality improvement project.

OBJECTIVE: Patients needs should be regularly assessed. We aimed to improve assessment and documentation of needs from baseline 25% in June 2022 to 75% in December 2022. METHODS: The A3, a structured problem-solving continuous-improvement methodology was used. Fish-bone analysis and pareto charts identified root causes; key drivers and interventions were developed. Interventions included (1) documentation templates, (2) a brochure about services, (3) extra team communication skills training, (4) repository in different languages to help patients identify needs, and (5) weekly review meetings. Reliability and sustainability were ensured through ownership and delegation to team members. RESULTS: Documentation of needs increased from baseline 25% to 75% within 3 months. This has been sustained at 83% in August 2023. The total number of patients assessed during the project was 1818. Maximum percentage of documentation was 91%. Mean additional time taken to ask and document needs was 2 min. CONCLUSIONS: Identification and documentation of patient needs and prioritisation are feasible in palliative medicine outpatient clinics. This project has directed the team to provide patient-led palliative care interventions.

Regular Low-Dose Oral Metronidazole Is Associated With Fewer Vesicovaginal and Rectovaginal Fistulae in Recurrent Cervical Cancer: Results From a 10-Year Retrospective Cohort.

PURPOSE: Anaerobic necrosis in cervical cancer can lead to malodor, fistulae, and treatment abandonment. In this retrospective cohort study, we examined the association between maintenance metronidazole and the incidence of malignant fistulae in recurrent cervical cancer. METHODS: We screened all cervical cancer records registered between 2007 and 2016 in the local palliative care database at Christian Medical College, Vellore, India. There were 208 eligible patients with post-treatment residual/recurrent pelvic disease. Among them, 76 had received oral maintenance metronidazole 200 mg once per day for 2 to 86 weeks (interquartile range, 4-16 weeks). RESULTS: Seventy-two patients developed at least one fistula. Forty-nine had vesicovaginal fistulae, 10 had rectovaginal fistuale, and 13 developed both types of fistulae. Patients on maintenance metronidazole had fewer fistulae (22.4% v 41.7%; P = .005), a longer median fistula-free survival (42.9 months v 14.1 months; P < .001), and a postrecurrence survival of 11.5 months versus 8.7 months (P = .112). We performed Cox multivariable proportional hazards regression analysis on the data from the subset of 146 patients observed until death. Bladder/rectal infiltration had a higher risk of fistula (HR, 5.24; P = .011), whereas distant metastases (HR, 2.46; P = .012) and Eastern Cooperative Oncology Group performance status greater than 1 (HR, 1.64; P = .008) were associated with a higher risk of death. Maintenance metronidazole was associated with a lower risk of fistula (hazard ratio [HR], 0.33; 95% CI, 0.16 to 0.67; P = .002) and a lower risk of death (HR, 0.56; 95% CI, 0.39 to 0.81; P = .002). CONCLUSION: Our data indicate that there is a significant inverse association between oral maintenance metronidazole and malignant fistulae in locally recurrent cervical cancer. The impact of this simple intervention on pelvic symptoms, fistulae, and survival should be evaluated in prospective studies.

Improving malodour management in advanced cancer: a 10-year retrospective study of topical, oral and maintenance metronidazole.

OBJECTIVES: To explore the relative effectiveness of topical or oral metronidazole used for malodour in necrotic cancers and to propose a protocol for metronidazole usage in managing malodour. METHODS: A retrospective case note review of the management of malodour over 10 years comparing outcomes with topical, intermittent and maintenance oral metronidazole. RESULTS: Among 179 patients treated for malodour, the commonest primaries were cervical (45%), and head and neck cancers (40%). Outcomes were poor during the period when only topical or intermittent oral metronidazole was used. Topical use gradually decreased (97% vs 55%) and the proportion of patients receiving maintenance oral metronidazole increased (0% in 2003-2004 vs 93% in 2011). Concurrently, there was reduction in documented malodour (12.5% of visits per patient in 2003-2004 vs 1.5% in 2011, p<0.01). CONCLUSIONS: Our data support formulary guidelines recommending maintenance metronidazole for recurrent malodour. Dimethyl trisulfide, a product of anaerobic necrosis causes malodour and can attract maggot-producing flies to decaying tissues. Therefore, to reduce anaerobic malodour in vulnerable settings, we propose a ladder for metronidazole titration. High-risk patients should start with 400 mg thrice daily ×7 days and continue 200 mg once daily. The SNIFFF severity (Smell-Nil, Faint, Foul or Forbidding) can guide follow-up dosage: 200 mg once daily to continue for nil or faint smell; breakthrough courses of 400 mg thrice daily ×1 week for foul smell and 2 weeks for forbidding smell, followed by 200 mg once daily.The effectiveness and limitations of maintenance metronidazole and the SNIFFF ladder should be prospectively evaluated.