Oncology advanced practice RN (APRNs) are in an ideal position to put their leadership, clinical practice, critical thinking, and organization management expertise to use in new ways to advance and add value to cancer care. During her April 20, 2021, session at the 46th Annual ONS Congress™, Rosanne Casal, DNP, APN-BC, AOCNP®, from University Hospitals Seidman Cancer Center in Cleveland, OH, shared three examples: benign hematology, ambulatory acute care, and bone marrow biopsy.
Casal said that fellows tend to pursue oncology over hematology as the former is seen as having more earning potential, available jobs, and mentoring opportunities. Physicians also gravitate toward the academic setting and a focus on malignant rather than benign hematology. Advance practice providers are finding new roles that fill those gaps.
Although medicine calls them benign, hematology referrals can be devastating for patients and challenging for clinicians. The most common diagnoses for benign hematology referrals are:
- Anemia or polycythemia
- Thrombocytopenia or thrombocytosis
- Leukopenia or leukocytosis
- Bleeding and clotting disorders
- Clearance for surgery or procedures
Casal walked ONS Congress attendees through case studies, including a patient with iron deficiency anemia as a result of severe menorrhagia, another with metastatic breast cancer who experienced deep vein thrombosis, and a patient with an acquired blood factor deficiency uncovered during tooth extraction.
Factor deficiencies can also develop spontaneously and require extensive lab workups and symptom analysis to find the causes and develop solutions. APRNs’ training and knowledge are ideally suited to manage those conditions.
In addition to benign hematology diagnoses, ACCs may see patients with other benign but urgent conditions that require oncology nursing knowledge and experience. Casal used the example of a sickle cell disease ACC, where patients receiving chemotherapy and experiencing treatment-related side effects were frequently referred to the emergency department. The ACC’s APRNs already had expertise in acute symptom management, and all of the infusion nurse staff had experience in chemotherapy symptom management (80% were oncology nurse certified and all had completed the ONS/ONCC chemotherapy immunotherapy certificate course).
Because the skills were already in place, a task force of nursing leadership and APNs developed a standard operating procedure, supportive care order set, access guidelines, and patient card. The task force conducted a study from 2018–2020, which showed an increase in patients who were able to be treated and a reduction in those who were referred to the emergency department for care. By expanding the sickle cell ACC to include symptom management of patients receiving chemotherapy for solid tumors, the health system was able to accommodate many more patients in one location, which reduced costs and increased patients’ access to care.
Bone Marrow Biopsy
Patients with unexplained anemia, abnormal blood cell counts, iron deficiency, hematologic cancers, bone marrow metastases, or a need for chemotherapy evaluation (restaging) are referred to bone marrow biopsy clinics.
Although hematologists or oncologists typically perform a bone marrow exam, advanced practice providers can conduct them after special training, Casal said. The exam takes about 10–20 minutes, excluding preparation and postprocedure care, and some patients receive IV sedation. The procedure is well managed by APRNs and physician assistants, alleviating a time burden for the provider clinic.