Currently, the Centers for Medicare and Medicaid Services (CMS) mandates 33 oncology-specific benchmark measures related to end-of-life care and hospice, unplanned hospital admissions (UHAs), pain, falls, medication, central venous catheter (CVC) line, pressure ulcers, tobacco cessation, catheter-associated urinary tract infections, sepsis, and function. Advanced practice nurses can play a role in achieving benchmarks and developing innovative strategies to accomplish these goals.
Patricia I. Geddie, PhD, CNS, AOCNS®, a clinical nurse specialist at Orlando Health, discussed the CMS standards and provided research related to the measures during a session at the 42nd Annual Congress in Denver, CO.
Predictors of EOL include stage IV solid tumor, poor prognosis, unplanned emergency department visits, and hospital admissions. Using a three-month retrospective chart review of UHA, mobility, nutrition, and symptoms, healthcare providers can predict 30-, 60-, and 90-day survival probabilities.
UHAs are a recurrent problem for older patients with cancer. Using a prospective, longitudinal design and retrospective chart review, healthcare providers can determine the presence of impaired function and side effects and can predict UHAs in older adults during treatment. Symptoms related to UHAs include anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, and sepsis.
Geddie presented a study published by Matthie et al. in the Clinical Journal of Oncology Nursing (CJON) that indicated that pain is usually evaluated improperly because it varies by patient and is difficult to control. The study indicated that an understanding of the total pain experience, including type of pain and pain location, is important for addressing pain in patients with cancer who are in hospice care, and more effective pain management strategies are needed.
She then presented a study published by Capone et al. in the Oncology Nursing Forum that assessed predictors of patient falls. The retrospective chart review of 145 patients indicated that while patients were hospitalized, predictors of a fall episode were low pain level, abnormal gait, cancer type, presence of metastasis, antidepressant and antipsychotic medication use, and blood product use (p < 0.02 for all; risk model c-statistic = 0.89).
During hospital discharge and ambulatory follow-up, patient confusion or misunderstanding of medication instructions can impact adherence and safety and efficacy of the treatment regimen. A study published by Berry et al. in CJON advised ensuring patient receipt of written discharge medication instructions and checking in with patients to maximize the safety of self-administered drugs. Another study published by Spoelstra et al. in CJON indicated that the Morisky Medication Adherence Scale and Adherence Estimator—which can predict risk of patient nonadherence—may be useful tools, and the Adherence Starts With Knowledge®-12 and the Brief Adherence Rating Scale may be useful for measuring rates of adherence.
Central line-associated bloodstream infections (CLABSIs) can occur with the use of CVC lines. Healthcare providers should evaluate the necessity of a standardized CVC line daily and audit for CLABSIs. A standardized CLABSI observational tool and unit chart reviews could decrease CVC line use and, thus, CLABSI incidence.
Geddie noted that sepsis screening is not done in the outpatient setting and is not oncology-sensitive. The prevalence of sepsis in the outpatient setting is unknown. With a descriptive, retrospective review, they found no significant difference in modified versus standard sepsis screening criteria.
Lastly, a study published by McLaughlin et al. in CJON assessed the effect of regularly supervised exercise programs led by nurses in an effort to maintain patient muscle strength to preventing falls and reduce pressure ulcers. In a cohort of 16 patients, 81% maintained or improved their muscle strength compared to their baseline.