Exceeding the Benchmark: Nursing Sensitive Indicators

Oncology Nursing Society 42nd Annual CongressMay 4–7, 2017 • Denver, CO 1Clinical Practice

David Rice, PhD, RN, NPDirector, Professional Practice and EducationCity of Hope National Medical [email protected]

Key Session Takeaways1. YOU impact the care quality and safety of oncology

patients in measurable ways.2. YOU impact the care quality and safety of oncology

patients in ways that can’t be measured.3. YOU impact the care quality and safety of oncology

patients in immeasurable ways.

Be compassionate. Be self, patient, and population aware. Be data driven.

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Exceeding the BenchmarkNursing Sensitive Indicators

David Rice, PhD, RN, NPDirector, Professional Practice and Education

City of Hope National Medical Center

Disclosures

I have no financial disclosures.



Exceeding the Benchmark: Nursing Sensitive Indicators

Oncology Nursing Society 42nd Annual CongressMay 4–7, 2017 • Denver, CO2 Clinical Practice

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Exceeding the BenchmarkNursing Sensitive Indicators



Takeaways• YOU impact the care quality and safety of

oncology patients in measurable ways• YOU impact the care quality and safety of

oncology patients in ways that can’t be measured

• YOU impact the care quality and safety of oncology patients in immeasurable ways– Be compassionate– Be self, patient, and population aware– Be data driven

Objectives

• Define benchmark• Understand nurses’ key role in delivering safe, quality

cancer care• Understand how quality, financial, resource utilization

data impact care delivery• Appreciate transparency in healthcare• Appreciate underserved populations and nurses’

impact on providing equitable cancer care access• Take the message from the Extravasation Benchmark

measure that RNs help to set benchmarks


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

ANA Nursing’s Social Policy Statement (2010)

Four Essential Components of Nursing Practice

• Attention to the full range of the human experience

• Integration of objective and subjective phenomena

• Application of scientific knowledge• Provision of care that reinforces nursing’s intent

Improving performance• Continually identifying, understanding, and

adapting outstanding practices and processes found inside and outside the organization– Company– Public sector or private organization– University / college (e.g. nursing curricula)– Healthcare– Government

Benchmarking

What is a Benchmark?

Standard, or a set of standards, used as a point of reference for evaluating performance or level of quality. Benchmarks may be drawn from a firm's own experience, from the experience of other firms in the industry, or from legal requirements such as environmental regulations.

http://www.businessdictionary.com/definition/benchmark.html


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Quality – Why Quality Indicators• Quality “the degree to which health services for individuals

and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” (Lohr, 1990)

• To “use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.” (Cronenwett et al., 2007)

• Why Nurse Sensitive Quality Indicators? "Because nursing absorbs at least 50% of most hospitals’ expense budgets, and nursing also bears the continual risk of being targeted as a potential source of cost savings in response to economic and market pressures." (Le, 2014)

Agency for Healthcare Research and Quality (AHRQ)Six domains of Health Care Quality

• Safe– Avoiding harm to patients from the care that is intended to help them

• Effective– Providing services based on scientific knowledge to all who could benefit

and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).

• Patient-centered– Providing care that is respectful of and responsive to individual patient

preferences, needs, and values and ensuring that patient values guide all clinical decisions.

• Timely– Reducing waits and sometimes harmful delays for both those who receive

and those who give care• Efficient

– Avoiding waste, including waste of equipment, supplies, ideas, and energy• Equitable

– Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html

Public facing web pages - Transparencywww.csqi.on.ca

http://www.cancercenter.com/lung-cancer/statistics/tab/lung-cancer-NSCLC-survival-statistics/

https://moffitt.org/for-healthcare-providers/outcomes/rectal-cancer/

https://moffitt.org/for-healthcare-providers/outcomes/patient-satisfaction/


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

EQUALITY VS EQUITY

Used with permission from Liz Margolies, Executive Director, National LGBT Cancer Network

History


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

W. Edwards Deming

• Father of Total Quality Management (TQM), Continuous Quality Improvement (CQI), Performance Improvement (PI)

• Focus on statistics, systems, decreasing variation– 14 points for management

• Cease dependence on inspection to achieve quality• Institute a vigorous program of education and self-

improvement for everyone• Put everyone in the company to work accomplishing the

transformation

Ways nurses use data to deliver quality, safe care and improve performance

• Improve clinical pathways– Standardization (reduce variation)– Bundles – evidence-based – improve outcomes

• TJC National Patient Safety Goals• LEAN efforts

– Maximize value for customers and minimize waste• Root cause analysis

– Review event for underlying causes• Failure Mode Effects Analysis (FMEA)

– Improve the quality, reliability, and safety of a process

Avedis Donabedian, MD, MPH• University of Michigan

– Evaluating the quality of medical care (1966)– Models for organizing the delivery of health services

and criteria for evaluating them (1972)– The Quality of Care: How Can it be Assessed? (1988)

STRUCTURE PROCESS OUTCOMES

“Ultimately, the secret of quality is love. ….. If you have love, you can then work backward to monitor and improve the system.”


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Don Berwick, MD, MPP• Management of healthcare systems

– Scientific methods– Evidence-based medicine– Comparative effectiveness research

• President and CEO of Institute for Healthcare Improvement (IHI)– Independent not-for-profit to lead improvement of

healthcare by building the will to change, cultivating promising concepts for improving patient care, and helping healthcare system put ideas into action

• 2010 – President Obama appointed Berwick to service as the administrator of CMS.

“20-30% of health spending is ‘waste’ with no benefit to patients, because of overtreatment, failure to coordinate care, administrative complexity and fraud, and that part of this problem was because of CMS regulations.” "Health Official Takes Parting Shot at 'Waste'" Robert Pear, The New York Times, December 3, 2011

Seminal Institute of Medicine Reports

• To Err is Human (2000)• Crossing the Quality Chasm (2001)• Building a Better Delivery System: A New

Engineering / Health Care Partnership (2005)• The Future of Nursing (2010)• Delivering High Quality Cancer Care – A System in

Crisis (2013)• Assessing Progress on the Institute of Medicine

Report The Future of Nursing (2015)


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Visible / Public Identities

AgeSex

Gender expressionPhysical appearance

RaceClass

Health / ability

Invisible Identities

Ethnicity / national originGender Identity

PoliticsReligion

Relationship statusEmployment status

Personal habitsCommunication style

Educational backgroundWork experience

Socioeconomic status

The National Institutes of Health (NIH) defines diversity as “the range of human differences, including but not limited to race, ethnicity, gender, sexual orientation, age, social class, physical ability or attributes, religious or ethical value system, national origin, and political beliefs.”


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Underserved PopulationsCancer Access Healthcare Disparities


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Impact of Sexual Orientation and Gender Identity on Cancer Care

• Of the nearly 10 million lesbian, gay, bisexual, and transgender people in the United States– Tobacco use higher– Alcohol use 3X higher– Risk of sexually transmitted disease higher– Eating disorders / obesity– Elevated risk depression, anxiety, psychological distress,

suicidality– Higher cancer risks and lower cancer screening rates– Increased challenges in survivorship

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

POVERTY AND ITS IMPACT ON LGBT HEALTH

• 1/3 of LGBT people are uninsured– 34% of gay men – 31% of lesbians– 29% of bisexual people

• 2/3 of the uninsured had been without coverage for more than 2 years

• Nearly 40% of uninsured respondents carry medical debt

• 44% of the insured put off medical care because they couldn’t afford it


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

The highest-, lowest-ranked states for health carehttps://www.advisory.com/daily-briefing/2017/03/06/state-health-

rankings?WT.mc_id=Email|DailyBriefing+Headline|DBA|DB|2017Mar06|SurveyDB2017Mar06||||&elq_cid=1515155&x_id=003C000001gGXtJIAW

• Access to care (33%)– Six metrics, including health insurance enrollment,

adult and child wellness visits, and health care affordability

• Health care quality (33%)– Three metrics: Medicare quality, CMS nursing home

citations, and hospital readmission rates• Public health (33%)

– Six metrics, including infant mortality, overall mortality, smoking, suicide, and obesity rates

The highest-, lowest-ranked states for health carehttps://www.advisory.com/daily-briefing/2017/03/06/state-health-

rankings?WT.mc_id=Email|DailyBriefing+Headline|DBA|DB|2017Mar06|SurveyDB2017Mar06||||&elq_cid=1515155&x_id=003C000001gGXtJIAW

1. Hawaii 2. Massachusetts3. Minnesota4. New Hampshire5. Iowa6. Vermont7. Rhode Island8. New Jersey9. Washington10. California

41. Indiana42. Tennessee 43. Wyoming44. Kentucky45. Louisiana46. West Virginia47. Alabama48. Oklahoma49. Mississippi 50. Arkansas


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Information and Communications Systems:The Backbone of the Health Care Delivery System

• True?– EMRs – Help? Hinder? Hope?

• Financial systems versus clinical systems?

– Event reports• 50 – 70% of errors / events have some element of

communication failure– Handover– Transitions in care– Quality peer review

IN 1928, MAY AYRES BURGESS was commissioned and completed A Study of the Economics of Nursing Conducted by the Committee on the Grading of Nursing Schools. According to patients interviewed by Burgess, “the better the nursing, the less the ordinary patient thinks about it” (p. 203). Burgess pointed out the nurse moves the patient toward recovery in many ways imperceptible to the patient. Today, health care economic choices are made based on hard data yet nursing’s value remains imperceptible. Nursing struggles in communicating its value in a measureable way.

Rising health care costs and limited health care resources have created a call for data that documents the true value of nursing and these data are critical “to assure adequate investment in the nursing profession” (Rutherford, 2008, p. 347). Nursing is a costly yet essential resource and it is essential nursing leaders embrace those measures that chronicle its value.

Rutherford, Nursing Economics 2012

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Caring done well … Kristen Swanson

Theory of Caring and Healing “Doing for”


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Rutherford, 2012

Nursing care quality processes• Directly or indirectly influence patient outcomes

– Nursing Sensitive Indicators• CLABSI – Central Line Associated Blood Stream Infection• HAPI – Hospital Acquired Pressure Injury• Injury falls / falls prevalence• Use of Restraints• CAUTI – Catheter Associated Urinary Tract Infection• VAE – Ventilator Associated Events• Sepsis prevention and management• Pain management• Preventable hospital readmission• Vesicant Chemotherapy Extravasation

Ways to Display Data(Keep it simple – RN should be able to look at the

graphic and interpret the data easily)• Tools

– Bar graph– Histogram– Pareto diagram– Scatter charts– Run charts / control charts– Flowcharts– Cause and effect diagrams

– Pie charts– Gaussian curve

charts– PERT charts– Gant charts– Breakeven charts– Likert scales– Fishbone diagram

(“Ishikawa” diagram)


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Hospital Acquired Infections (HAIs)http://www.shea-online.org/priority-topics/compendium-of-strategies-to-prevent-hais

Medical Error

• The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors (in 2008) (Bos et al. 2011)– 10 types of errors accounts for more than 2/3 total costs– Leading error pressure ulcers, followed by post-op

infections– 6th on the list – infection due to central venous catheter

• Institute of Medicine (2000) estimates– 1.5 million patients harmed by medication errors annually– Increased hospital costs of $3.5 billion annually 2nd to

medication error complications• At least 25% are preventable

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

CLABSI – TJC Toolkit

https://www.jointcommission.org/topics/clabsi_toolkit.aspx

Annual education about CVADsBundles (insertion, maintenance, surveillance)2-person dressing changes (practitioner /

observer)CVAD dressing change validationAre you patients / families doing dressing

changes at home?


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

4Q 15 1Q 16 2Q 16 3Q 16CLABSI Observed over Expected 0.60 4.57 1.10 1.80Benchmark NHSN Hem/Onc SIR 1.00 1.00 1.00 1.00

0.60

4.57

1.10

1.80

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

CLAB

SI M

ean

Nursing Sensitive Clinical IndicatorHematology Oncology Unit

CLABSI

Incidence = Observed / ExpectedSIR = Standardized Incidence Ratio

Implemented CHG bathing

CAUTI

• Nurse led catheter removal protocols• Bundle

– Evaluate need every day– Inserted by skilled, trained provider– Use smallest catheter available– Collection device secured and maintained below

level of bladder


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

4Q 15 1Q 16 2Q 16 3Q 16CAUTI rate (per 1,000 catheter days) 1.12 1.06 2.22 1.00Benchmark NDNQI Teaching Hospital Mean 1.46 1.27 1.26 1.37

1.12 1.06

2.22

1.00

0.00

0.50

1.00

1.50

2.00

2.50

CAU

TI M

ean

Nursing Sensitive Clinical IndicatorGeriatric Oncology Care Unit

CAUTI

Injury Falls

• Patients with a diagnosis of cancer are already at risk– Particularly with inpatient admission

• Risk scales (e.g. Morse, Hendrich II, etc.) not particularly sensitive but help to define risk elements

• Multiple interventions – can’t be studied separately

• Tai chi positive intervention in community dwelling elders

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

A Model of Care Delivery to Reduce Falls in a Major Cancer Center

Nancy E. Kline, PhD, RN, CPNP, FAAN; Bridgette Thom, MS; Wayne Quashie, MPH, RN; Patricia Brosnan, MPH, RN; Mary Dowling, MSN, RN

1. History of falls2. Help transferring (bed to chair; to commode; or

complete transfer)3. Sensory deficits (visual / auditory impairment

affecting mobility or peripheral neuropathy)4. Motor deficits (gait imbalance, R or L side

weakness, lower extremity weakness)5. Psychotropics (e.g., sleep medications, hypnotics,

sedatives, anxiolytics) or anticonvulsants


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

4Q 15 1Q 16 2Q 16 3Q 16 FALLS w/Injury rate (per 1,000 patient days) 0.15 0.16 0.13 0.22Benchmark NDNQI Teaching Hospital Mean 0.20 0.18 0.19 0.20

0.150.16

0.13

0.22

0.00

0.05

0.10

0.15

0.20

0.25

Falls

w/I

njur

y M

ean

Nursing Sensitive Clinical IndicatorMedical Surgical Oncology Unit

Falls with Injury

HAPI

• Patients with a diagnosis of cancer are already at risk• Frequency of Braden score

– Interrater reliability• Focus interventions on relevant subscale of Braden• RN staging of pressure injury

– Wound Treatment Associate (WTA®) program - WOCN• Turn and position – ambulate – early mobility• Caution with layers of linens and transfer devices on

bed• Specialty surfaces

4Q 15 1Q 16 2Q 16 3Q 16HAPU prevalence ≥ Stage 2 10% 6.25% 4.20% 3.00%Benchmark NDNQI Teaching Hospital (%) 4.46% 4.35% 4.30% 4%

10%

6.25%

4.20%

3.00%

0%

2%

4%

6%

8%

10%

12%

14%

% P

ts w

ith H

APU

≥ S

tage

2

Nursing Sensitive Clinical IndicatorOncology Progressive Care Unit

HAPU ≥ Stage 2


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Pain Management

• “Pain is whatever the experiencing person says it is, existing whenever the experiencing person say it does.” (McCaffery & Beebe)

• Pivotal and critical role of RN in cancer pain management– Assessment / Intervention / Reassessment– Educate, inform, validate, advocate

• Education / support may prevent avoidable readmission for pain

• Press Ganey perception of pain metric– Some pain will not be preventable (e.g. Grade III mucositis)

– so RN management and validation is critical

4Q 15 1Q 16 2Q 16 3Q 16Perception of Pain Mgmt Mean Score 94.00 95.00 96.77 97.01Press Ganey Benmark Mean 95.23 95.33 96.02 95.82

94.00

95.00

96.7797.01

92.00

92.50

93.00

93.50

94.00

94.50

95.00

95.50

96.00

96.50

97.00

97.50

Perc

ep o

f Pai

n M

gmt

Mea

n

Press Ganey ResultsSurgical Oncology

Perception of Pain Management

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

End of life metrics

• RN comfort level in caring for the dying patient– Measure of education such as End of Life Nursing

Education Consortium (ELNEC) training– Risk of provider burnout (“trauma”)

• Chemotherapy given within 14 days of death• Hospice referral utilization• Supportive Care Medicine utilization


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

• Acknowledge Suffering: We should acknowledge that our patients are suffering and show them that we understand.

• Body Language Matters: Non-verbal communication skills are as important as the words we use.

• Anxiety is Suffering: Anxiety and uncertainty are negative outcomes that must be addressed.

• Coordinate Care: We should show patients that their care is coordinated and continuous, and that “we” are always there for them.

• Caring Transcends Diagnosis: Real caring goes beyond delivery of medical interventions to the patient.

• Autonomy Reduces Suffering: Autonomy helps preserve dignity for patients.

Federal, “Watch dog,” and Professional Organizations

• HCAHPS –– Hospital Consumer Assessment of Healthcare Providers

and Systems survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care

– Jointly developed 2002 by CMS (Centers for Medicare and Medicaid Services) and AHRQ (Agency for Healthcare Research and Quality)

• Both CMS and AHRQ are federal agencies in the Department of Health and Human Services

• Cancer care CAHPS

CAHPS Cancer Care Survey Measures

• Getting timely appointments, care, and information• How well the cancer care team communicates with patients• Cancer care team’s use of information to coordinate patient care• Helpful, Courteous, and Respective Office Staff• Cancer care team supports patients in managing the effects of their

cancer and treatment• Cancer care team is available to provide information when needed• Involvement of family members and friends• Availability of Interpreters• Patients’ ratings of cancer care team / overall cancer care


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________


• TJC– National Patient Safety Goals– ORYX Performance Reporting Requirements

• AMI - Primary Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of Hospital Arrival

• Median Time from ED Arrival to ED Departure for Admitted ED Patients

• Influenza Immunization • Tobacco screening


• Hospital Compare www.medicare.gov/hospitalcompare/search.html

• Leapfrog http://www.leapfroggroup.org/compare-hospitals

• Oncology Nursing Society• ASCO - American Society of Clinical Oncology

– ASCO - ONS – e.g. joint guidelines (standard for chemotherapy 2016 update)

– ASCO QOPI –Quality Oncology Practice Initiative– NCI – ASCO Teams Special Series – Journal of Oncology Practice

Vol. 12(11) November 2016• NQF National Quality Forum

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________


• C3NSI– Cancer Centers Consortium Nursing-Sensitive Indicators

• C4QI– Comprehensive Cancer Centers for Quality

Initiatives

• C3IC– Comprehensive Cancer Centers Infection Control


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

American Society of Clinical OncologyQOPI Quality Oncology Practice Initiative

Databases

• Vizient (formerly UHC) database• NDNQI – National Database of Nursing Quality

Indicators (now merged with Press-Ganey)• Press Ganey• ONS The Oncology Quality Clinical Data

Registry (in collaboration with CECity) https://www.ons.org/practice-resources/qualified-clinical-data-registry


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Vesicant Chemotherapy Extravasation

Establishing a National Benchmark

Cancer Center Consortium Nursing Sensitive Indicators

Cancer Centers Consortium Nursing Sensitive Indicators

Formed in 2010 to establish oncology-specific, ambulatory nurse sensitive metrics 19 centers have participated in the consortium 11 centers contributed data to the IRB approved study

Vesicant Chemotherapy AdministrationNo benchmark in the literature

“For the purposes of quality assurance, a tolerable frequency of chemotherapy extravasation should be significantly less than 1% of drug administration.” (Morris, Holland 2000)

Siteman Cancer Center* City of Hope Dana Farber Cancer Institute

Duke Cancer Institute Fox Chase Cancer Center*

Dartmouth Hitchcock Norris Cotton Cancer

Center

Ohio State University The James Cancer

Center*

Karmanos Cancer Center M D Anderson Cancer Center

Moffitt Cancer Center

Roswell Park Cancer Institute*

Memorial Sloan Kettering Cancer Center*

Seattle Cancer Care Alliance*

University of Iowa Holden Cancer Center*

University of Virginia*

Sylvester Cancer Center Vanderbilt University Ingram Cancer Center*

Yale New Haven Hospital Smilow Cancer Center*

Emory HealthcareWinship Cancer Center*

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

• Extravasation: The inadvertent administration of a vesicant solution or medication into surrounding tissue – Tissue damage can progress from local pain and erythema to

sloughing, desquamation, ulceration and necrosis

• Incidence– Peripheral IV 0.07% to 7.0%– Central Vascular Access Device 0.01% to 4.7%

• Infiltration refers to fluids inadvertently leading out of the veins and into the tissues (such as IV fluid, IV medications, blood component products)

Extravasation

Jackson-Rose, DelMonte, Katania, et al. (2015)Ener et al. (2004)

Coyle (2014) Schulmeister (2010)

Payne, Savarese (2010)


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Damage potential / Classifications Vesicant Irritant Irritant with vesicant potential

Actual and suspected treated as events

Reported on 17 quarters of data between 2011 -2015

Continue to collect and report data under IRB

Centers use for ambulatory quality indicator

C3NSI (Cancer CenterConsortium Nursing Sensitive Indicators) Consensus for Extravasation Project (Jackson-Rose, Del Monte, Catania, et al 2015)1

Vesicant agents:DactinomycinDaunorubicinDoxorubicinEpirubicinIdarubicinMechlorethamineMitomycinVinblastineVincristineVinorelbine

Irritants / Irritants with Vesicant Potentialagents:

Albumin-bound paclitaxelBortezomibCarmustineCisplatinDocetaxelEtoposideGemcitabineLiposomal doxorubicinMelphalanMitoxantroneOxaliplatinPaclitaxelStreptozocin

Chemotherapy andBiotherapy Guidelines and Recommendations for Practice (Polovich, Olsen & LeFebvre, 2014)2

Vesicant agents:Albumin-bound PaclitaxelDactinomycinDaunorubicinDocetaxelDoxorubicinEpirubicinIdarubicinMechlorethamineMitomycinMitoxantronePaclitaxelVinblastineVincristineVinorelbine

Irritants / Irritants with Vesicant Potentialagents:

BleomycinCarboplatinCarmustineDacarbazineEtoposideFloxuridineGemcitabineIfosfamideLiposomal daunorubicinLiposomal doxorubicinOxaliplatinStreptozocinTopotecan

1 Used with permission by David Rice, 20162 Polovich, Lefebvre, & Olsen (2014)


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Category DosesAdministered

ExtravasationsCentral Venous

Access Device IV

Extravasations Peripheral IV

TotalExtravasations

ExtravasationRate

(95% CI)

Vesicants 123,993 11 79 90 0.07% (0.07%, 0.08%)

Irritants and Irritants with Vesicant Potential

615,819 19 564 583 0.09% (0.09%, 0.10%)

Totals 739,812 30 643 673 0.09% (0.09%, 0.09%)

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Observations• Significantly higher incidence of peripheral IV extravasations

compared to CVAD• Taxanes• Large volume drugs / long infusion times / movement during

infusion• Evaluation of drugs which irritate but don’t actually cause

tissue damage when extravasation occurs (e.g. gemcitabine)• Administration order of Cisplatin and Fosaprepitant (Emend

injection for delayed nausea)• Subgroup reviewed patient / family education from centers

and made a recommendation for standard• Manuscript – accepted for publication in CJON August 2017

Benchmarks – In Conclusion

• Nurses in all practice settings play key roles in designing, delivering, evaluating, managing safe, effective quality cancer care

• Nurses use data, measurement techniques, benchmarking, and analysis in their everyday practice

• The combination of nursing ethos, expert practice, application of data, interprofessional teamwork, and use of information technology, results in improved patient outcomes.

References and Resources


__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

References and Resources

Exceeding the Benchmark: Nursing Sensitive Indicators

Documents

Transcript of Exceeding the Benchmark: Nursing Sensitive Indicators