Preoperative Carbohydrate Loading in Patients Undergoing Thoracic Surgery: A Quality-Improvement Project.

PURPOSE: The purpose of this project was to implement carbohydrate loading in patients undergoing thoracic surgery in an effort to decrease postoperative pain, nausea, and length of stay as a part of an enhanced recovery after surgery protocol. DESIGN: This quality-improvement project used a preintervention and postintervention design. METHODS: Carbohydrate loading was given to 50 patients before undergoing thoracic surgery. Chart review was performed for 47 patients who received standard preoperative instructions in the preintervention group as historical control. FINDINGS: Patients who received carbohydrate loading had a decreased use of opioids in the first 4 hours after surgery (P = .028) and decreased use of antiemetic medication in the first 24 hours after surgery compared with the preintervention group (P = .066). Patients who were instructed to consume carbohydrate loading complied 87% of the time. CONCLUSIONS: Carbohydrate loading can decrease postoperative nausea and pain in patients undergoing thoracic surgery.

The Effects of a Take-Home Educational Video on Patient Knowledge Retention, Anxiety, Satisfaction, and Provider Time.

Patient anxiety related to prostate cancer surgery may lead to reduced patient satisfaction. Repeated reinforcement of pre-operative education to reduce anxiety greatly impacts provider time. Improved knowledge retention of what to expect postoperatively may reduce patient anxiety. This quality improvement project demonstrated that a take-home educational video supports patient knowledge retention, reduces patient anxiety, increases patient satisfaction, and saves postoperative provider time

Adherence to antiemetic guidelines in patients with malignant glioma: a quality improvement project to translate evidence into practice.

PURPOSE: A quality improvement project was implemented to improve adherence to evidence-based antiemetic guidelines for malignant glioma patients treated with moderately emetic chemotherapy (MEC). Poorly controlled chemotherapy-induced nausea and vomiting (CINV) reduce cancer treatment efficacy and significantly impair cancer patients' quality of life (QOL). A review of Duke University Preston Robert Tisch Brain Tumor Center (PRTBTC)'s usual practice demonstrates a high incidence (45%) of CINV, despite premedication with short-acting 5-HT3-serotonin-receptor antagonists (5-HT3-RAs). National Comprehensive Cancer Network (NCCN)'s evidence-based guidelines recommend the combination of the long-acting 5-HT3-RA palonosetron (PAL) and dexamethasone (DEX) for the prevention of acute and delayed CINV with MEC. Low adherence (58%) to antiemetic guidelines may have explained our high CINV incidence. METHODS: One-sample binomial test, quasi-experimental design, evaluated a combination intervention that included a provider education session; implementation of risk-assessment tool with computerized, standardized antiemetic guideline order sets; and a monthly audit-feedback strategy. Post-implementation adherence to evidence-based antiemetic order sets and patient outcomes were measured and compared to baseline and historical data. Primary outcome was the guideline order set adherence rate. Secondary outcomes included nausea/vomiting rates and QOL. RESULTS: Adherence to ordering MEC guideline antiemetics increased significantly, from 58% to a sustained 90%, with associated improvement in nausea/vomiting. In acute and delayed phases, 75 and 84% of patients, respectively, did not experience CINV. There was no significant change in QOL. CONCLUSION: Combination intervention and audit-feedback strategy to translate evidence into oncology practice improved and sustained adherence to antiemetic guidelines. Adherence corresponded with effective nausea/vomiting control and preserved QOL in patients with malignant gliomas.

The experience and self-management of fatigue in patients on hemodialysis.

Fatigue is a common and debilitating symptom for adult patients with end stage renal disease on hemodialysis, and has been associated with decreased survival and quality of life. Patients on hemodialysis must find ways to manage their fatigue and mitigate its effects on their lives. The purpose of this qualitative descriptive work was to describe the experience and self-management of fatigue in patients on incenter hemodialysis. Several themes were identified which included the nature of fatigue, management of fatigue, consequences of fatigue, and factors associated with fatigue. This information will be valuable to nephrology nurses as they continue to care for and educate patients on hemodialysis.

Implementing the Condensed Memorial Symptom Assessment Scale on an Inpatient Oncology Unit.

BACKGROUND: Symptom distress places a burden on patients and their families, but it is often not captured in nursing documentation. Using a symptom management tool, such as the Condensed Memorial Symptom Assessment Scale (CMSAS), can assist in this capture and link patients to resources. OBJECTIVES: The purpose of this quality improvement (QI) project was to implement the CMSAS and capture symptom burden to create a streamlined method of documentation. METHODS: A QI pilot was conducted on an inpatient oncology unit implementing the CMSAS. Then, surveys were provided to the patients to complete at admission and discharge. The most distressing symptoms patients reported were added into the electronic health record nursing care plan that automatically uploaded interventions based on ONS Guidelines™. FINDINGS: Patient (N = 73) symptom distress was quickly tracked, and there were no statistically significant changes in patient distress from admission to discharge, except for two symptoms.

ONS Guidelines™ to Support Patient Adherence to Oral Anticancer Medications.

PURPOSE: This evidence-based guideline intends to support patients, clinicians, and others regarding interventions and processes to support patient adherence to oral anticancer medications (OAMs). METHODOLOGIC APPROACH: A panel of healthcare professionals and patient representatives developed a clinical practice guideline to support patients taking OAMs. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and criteria for trustworthy guidelines were followed. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A quantitative or narrative synthesis of the evidence was completed. Certainty of the evidence was assessed using GRADE. FINDINGS: The panel agreed on recommendations and suggested an adherence risk assessment, education addressing adherence, ongoing assessment, proactive follow-up, coaching, and motivational interviewing in addition to usual care. The panel suggested the implementation of a structured OAM program. IMPLICATIONS FOR NURSING: As cancer treatment shifts from clinic to home settings, interventions and programs to support patients on OAMs are needed.

Effect of virtual reality on time perception in patients receiving chemotherapy.

PURPOSE: Virtual reality (VR) during chemotherapy has resulted in an elapsed time compression effect, validating the attention diversion capabilities of VR. Using the framework of the pacemaker-accumulator cognitive model of time perception, this study explored the influence of age, gender, state anxiety, fatigue, and cancer diagnosis in predicting the difference between actual time elapsed during receipt of intravenous chemotherapy while immersed in a VR environment versus patient's retrospective estimates of time elapsed during this treatment. MATERIALS AND METHODS: This secondary analysis from three studies yielded a pooled sample of N = 137 participants with breast, lung, or colon cancer. Each study employed a crossover design requiring two matched intravenous chemotherapy treatments, with participants randomly assigned to receive VR during one treatment. Regressions modeled the effect of demographic variables, diagnosis, and Piper Fatigue Scale and State Anxiety Inventory scores on the difference between actual and estimated time elapsed during chemotherapy with VR. RESULTS: In a forward regression model, three predictors (diagnosis, gender, and anxiety) explained a significant portion of the variability for altered time perception (F=5.06, p = 0.0008). Diagnosis was the strongest predictor; individuals with breast and colon cancer perceived time passed more quickly. CONCLUSIONS: VR is a noninvasive intervention that can make chemotherapy treatments more tolerable. Women with breast cancer are more likely and lung cancer patients less likely to experience altered time perception during VR (a possible indicator of effectiveness for this distraction intervention). Understanding factors that predict responses to interventions can help clinicians tailor coping strategies to meet each patient's needs.

Larotrectinib: A Targeted Therapy for Solid Tumors.

BACKGROUND: Although neurotrophic tyrosine receptor kinase (NTRK) gene fusions are not common in most cancers, they are present in more than 90% of some rare tumors. The U.S. Food and Drug Administration has approved larotrectinib for patients with NTRK gene fusion-positive cancers that meet certain criteria. With ongoing advancements in tumor sequencing, it is anticipated that cancer treatment will be determined by genetic variants rather than by cancer type in the future. OBJECTIVES: This article provides an overview of larotrectinib, a targeted therapy. METHODS: This article reviews clinical trial results and highlights implications for oncology nurses caring for patients taking larotrectinib. FINDINGS: Larotrectinib is an effective treatment option for some patients with NTRK gene fusion-positive cancers. Oncology nurses are key to educating patients on dosing, administration, side effects, and precautions.

Music Intervention: Nonpharmacologic Method to Reduce Pain and Anxiety in Adult Patients Undergoing Bone Marrow Procedures.

BACKGROUND: Bone marrow procedures cause anxiety and pain in adult patients with cancer. Music is a safe, inexpensive, noninvasive intervention that is easy to implement and is well received by patients and providers. OBJECTIVES: The purpose of this quality improvement project was to develop, implement, evaluate, and sustain a music protocol during bone marrow biopsy and aspiration procedures for adult patients with hematologic malignancies. In addition, this project sought to decrease pain, anxiety, heart rate, and blood pressure in patients undergoing bone marrow procedures. METHODS: The project coordinator collected baseline data regarding toleration of bone marrow procedures and then implemented a music protocol during the procedures during a six-month intervention phase. Comparison variables included pain, anxiety, heart rate, blood pressure, and subjective impressions. FINDINGS: The music protocol resulted in improved patient anxiety, decreased procedure time, and decreased medication use during bone marrow procedures. All patients who used the music intervention indicated they would use it again.

Low-Dose Computed Tomography: Effects of Oncology Nurse Navigation on Lung Cancer Screening.

BACKGROUND: Low-dose computed tomography (LDCT) lung cancer screening is an evidence-based and reimbursable strategy to decrease lung cancer and all-cause mortality in qualifying patients, but there remains low use and variation in providers' LDCT screening, ordering, and referring knowledge. OBJECTIVES: The purpose of this quality improvement project was to examine the effects of oncology nurse navigation on assisting patients and ensuring optimal LDCT lung cancer screening. METHODS: Oncology nurse navigators conducted LDCT provider education and navigated 133 eligible patients to LDCT during a five-month intervention time period. FINDINGS: Provider education resulted in improved documented tobacco cessation discussions and increased LDCT screening ordering fidelity. Mean days from LDCT to provider notification and mean days from LDCT to patient notification improved significantly.

Implementation of Survivorship Care Plans in Patients With Glioblastoma.

Background: The outcomes and survival of patients diagnosed with glioblastoma are improving due to advancements in therapy and better symptom management. Focusing on survivorship is an important initiative for these patients. A quality improvement project performed by an advanced practitioner in adults with glioblastoma evaluated the efficacy and utility of survivorship care plans (SCP). Providing patients and their families with SCPs gives them important information about their cancer, treatment, and follow-up management and care. Methods: Survivors of a glioblastoma who were receiving an oral alkylating agent and/or bevacizumab, as well as those who had completed these therapies within the past year were included. Patients had received surgery and radiation. The National Comprehensive Cancer Network (NCCN) Distress Thermometer and a pre- and postintervention survey evaluated knowledge, distress, and rate of follow-up care. Results: Over 2 months, 18 eligible participants received the SCP with a long-term care coaching appointment with an advanced practitioner. Knowledge pertaining to long-term effects of therapy and chemotherapy regimen improved. Ratings of overall distress and patient-reported primary care follow-up remained the same. Conclusion: Providing patients with glioblastoma with an SCP and an educational visit can improve knowledge pertaining to their chemotherapy regimens and long-term effects of therapy. This can result in more effective long-term management and care.

Cancer Survivorship Program: Implementation for Individuals With Recurrent Breast Cancer.

BACKGROUND: Patients are living longer with recurrent breast cancer, but survivorship programs for these individuals are lacking. OBJECTIVES: The aims were to implement a survivorship program for individuals with recurrent breast cancer, increase their quality of life (QOL), and evaluate patient satisfaction with the program. METHODS: Survivors were referred for a one-hour coaching intervention tailored to their needs based on results of the Functional Assessment of Cancer Therapy-Breast (FACT-B) survey. Satisfaction was assessed immediately and two weeks postintervention. A paired t test was used to evaluate QOL scores before and two weeks following participation. FINDINGS: Statistically significant (p = 0.000) improvements were observed overall and in each subscale of the FACT-B survey. Patient satisfaction was high immediately postintervention and remained high at the two-week assessment.

Operant generalization of auditory tempo in quail neonates.

Operant generalization, a building block of cognition, has never been studied in neonates. We developed a preparation for newly hatched quail in order to investigate the form of the generalization gradient very early in development. For their first 4-5 days after hatching, northern bobwhite chicks pecked for brief heat presentations while hearing a high-pitched sound repeated at a constant rate (nondifferential training). Tempo generalization was then assessed in extinction. A significantly excitatory average gradient resulted despite minimal postnatal experience.

Optimizing Advanced Care Planning in Hospitalized Patients With Advanced Cancers: A Quality Improvement Initiative.

BACKGROUND: Advance care planning (ACP) that generates an advanced directive (AD) can ensure patient autonomy at end of life. ACP is challenging for healthcare providers. Delaying patient ACP may lead to poor quality end-of-life care. Facilitation of early ACP by bedside RNs and social workers (SWs) may improve end-of-life care. OBJECTIVE: To determine whether improved ACP by RNs and SWs impacts care transition times for patients with advanced cancers. METHODS: A pre-/post-educational intervention designed to reinforce the roles of RNs and SWs in facilitating early ACP and timely documentation of an AD on an inpatient oncology unit. RESULTS: AD documentation increased by 12% between pre- and post-intervention period. There was a nonsignificant trend toward longer lengths of stay for patients transitioning care without an AD compared to those patients with and AD. DISCUSSION: Bedside RNs and SWs are in a key position to facilitate early ACP which can positively impact care quality at end of life. However, ACP is a collaborative team effort, best initiated early by the primary oncology providers. CONCLUSION: Early ACP may improve quality end-of-life care. IMPLICATIONS FOR NURSING: Continuing education for RNs and SWs to enhance coordination with primary oncology teams to facilitate earlier ACP is recommended.

Improving Attitudes and Perceptions About End-of-Life Nursing on a Hospital-Based Palliative Care Unit.

Nurses play an integral role in high-quality patient care. Thus, their skills in providing end-of-life care should be assessed and continually enhanced. Education intended to improve end-of-life skills must address the affective/emotional component of nursing care. Evidence demonstrates that emotional engagement and resilience among health care providers are correlated with improved quality outcomes and, conversely, that burnout and stress negatively affect patient safety. Addressing the emotional needs of health care providers is critical to improving quality throughout the health care system. An evidence-based workshop was implemented among direct care staff on a hospital-based palliative care unit, with the goal of fostering emotional engagement to improve staff perceptions and attitudes about caring for patients at or near the end of life. Although perceptions about quality of death were not affected by this intervention, there was a significant improvement in attitudes about end-of-life nursing care. Qualitative feedback also reflected appreciation for small group discussions and opportunities to debrief with peers away from the unit. This intervention reflected the value of emotional engagement in educational efforts to improve end-of-life nursing care.

A two-stage model for concurrent sequences.

Schneider and Davison [Schneider, S.M., Davison, M., 2005. Demarcated response sequences and the generalised matching law. Behav. Proc. 70, 51-61] showed that the generalised matching law applied to concurrent free-operant two-response sequences. When sufficient temporal spacing is required between the responses, however, neither the response-level nor the sequence-level forms of the generalised matching law provide good fits. An alternative "two-stage sensitivity" model with fewer free parameters features two types of sensitivity to the reinforcement contingencies on sequences. When temporal spacing between the responses is long, the "response distribution sensitivity" parameter describes sensitivity only of the individual responses to the sequence-level contingencies. At a threshold level, this sensitivity reaches a maximum. When spacing is shorter than threshold, the "response order sensitivity" parameter reflects a new sensitivity to the order of the responses within sequences. As this sensitivity approaches its maximum, sequence matching is achieved. For both stages, a changeover parameter describes bias against sequences that require changeovers between the two responses. The model fit data ranging from near-response matching with long minimum inter-response times (IRTs) to sequence matching with no minimum IRTs, using two species and a variety of sequence reinforcer distributions. Rats differed from pigeons in achieving sequence matching only at a nonzero minimum IRT. In a comparison based on pigeon data with no minimum IRT, the two-stage sensitivity model was more efficient than the generalised matching law according to the Akaike criterion. The logic of the model suggests a new way of understanding the mechanisms underlying behavioural units.

Overview of stereotactic body radiotherapy and the nursing role.

Stereotactic body radiotherapy (SBRT) is a rapidly emerging technology that enhances radiation therapy delivery. It allows for tightly conformed treatment fields and accurate delivery even with moving targets in the body. SBRT currently is used most commonly in treatment of medically inoperable stage I non-small cell lung cancers, as well as lung, liver, and spinal metastases. Studies to date are encouraging for increased local control with acceptable patient tolerance. This article familiarizes nurses with the use of this new technology and proposes the potential nursing role in maximizing patient preparation and follow-up care.

Radiation Dermatitis: A Prevention Protocol for Patients With Breast Cancer.

BACKGROUND: Patients with breast cancer undergoing radiation therapy can experience dermatologic adverse events. Oncology nurses can advocate for radiation dermatitis (RD) prophylaxis to minimize dermatologic adverse events. OBJECTIVES: This quality improvement project was conducted to evaluate the effect of implementing an RD prevention protocol. The objectives of this study were to (a) improve clinicians' knowledge of screening, assessment, and prevention of RD in patients with breast cancer and (b) decrease the incidence of RD by 10% at a tertiary care cancer center. METHODS: Center-wide standards of care were created and implemented. A retrospective chart analysis was performed before and after protocol implementation. An education session was used to analyze protocol effectiveness. FINDINGS: Surveys completed by nurses (N = 11) before and after the education session demonstrated a significant increase in overall confidence in assessing RD. Statistically significant increases were noted in using topical steroids for prophylaxis.

Pilot Study to Describe the Trajectory of Symptoms and Adaptive Strategies of Adults Living with Low-grade Glioma.

OBJECTIVES: To describe the adaptability to the patterns in symptoms and quality of life (QoL) during 6 months post low-grade glioma diagnosis by valid and reliable tools; to identify through qualitative interviews patient/provider adaptive techniques and strategies; and to assess associations among patient characteristics, symptoms and QoL, and adaptive techniques or strategies. DATA SOURCES: Demographic, clinical and pathologic data from medical records. Validated instruments that assess QoL, fatigue, depression, and distress were completed at 2, 4, and 6 months post diagnosis. Qualitative interviews identifying the symptoms, challenges, adaptive techniques and strategies were conducted at 4 and 6 months. CONCLUSION: The most frequently used adaptive strategies included: obtaining community support (87%), managing expectations (73%) and support systems (67%), and seeking out knowledge about physical (67%) and behavioral symptoms (53%). Seizures were reported with IDH1mut (11%) but not IDH1wildtype. Patients with either IDH1mut or TERTmut consistently reported lower QoL and higher distress, depression, and fatigue scores. IDH1/TERTmut may be related to lower QoL because of IDH1mut-related seizures. IMPLICATIONS FOR NURSING PRACTICE: Findings provide a list of adaptive strategies and characteristics to address the problems and symptoms that may improve overall QoL in patients with low-grade glioma.

Influenza Adherence Tool Kit: Implementation and Evaluation Among Allogeneic Hematopoietic Transplantation Recipients
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BACKGROUND: Allogeneic transplantation is associated with significant complications, such as influenza, a common virus in the post-transplantation setting that can be detrimental to patients. Therefore, patients should adhere to influenza vaccinations.
. OBJECTIVES: The objectives of this project were to improve influenza adherence rates from 2015-2016, to increase transplantation recipients' knowledge of the importance of vaccination, and to evaluate the barriers to and facilitators of adherence rates to influenza vaccinations.
. METHODS: A pre-/postscreening survey was used, as well as a tool kit with an education pamphlet and financial incentive, and a reminder letter. 
. FINDINGS: Forty-eight eligible patients participated in the study, and 32 completed the prescreening questionnaire. The adherence rate for the 2015-2016 influenza season improved compared to the baseline vaccination rate. The findings revealed a strong association between provider recommendation and vaccination adherence.