Oncology Nurse Develops Monitoring Document for Monoclonal Antibodies

June 22, 2018 by Chris Pirschel ONS Staff Writer/Producer

It’s a rote but important phrase: Necessity is the mother of invention. When a need presents itself, developing novel, inventive solutions can lead to important change. But inventive change doesn’t have to come on a massive scale: small inventions can still have a big impact.

When ONS member Nancy Ehmke, RN, MN, AOCN®, clinical nurse specialist at Parkview Health in Fort Wayne, IN, noticed a lack of information for monitoring frequency with monoclonal antibodies and certain chemotherapies with the potential for anaphylaxis and hypersensitivity reactions, she took the opportunity to create a quick reference sheet for practice. Ehmke’s invention included the medication, the necessary premedication for that drug, and the monitoring frequency used at her institution.

“It started back with the advent of drugs like rituximab. The question in my mind was, how do we ensure that nurses safely administer the medications and appropriately monitor patients,” Ehmke says. “Initially, I started out developing policies and procedures for safe administration of those drugs. But, I quickly realized that nurses needed that information in a concise, easy-to-read format. I thought about how I could get that to them in a fast and easy way that would make it available at their fingertips. That’s what led me to developing this quick reference sheet.””  

Oncology Nurse Develops Monitoring Document for Monoclonal Antibodies
Nancy Ehmke, RN, MN, AOCN®, clinical nurse specialist at Parkview Health in Fort Wayne, IN

Ehmke’s first step was identifying the necessary information for the reference sheet and developing it into a user-friendly document. Collaboration and research played a big role in the process as she began to assemble the sheet.

“I started with the nurses. I wanted to make sure it was something they needed and thought they would use,” Ehmke recalls. “I had some key concepts I wanted to include, but I checked with our nurses to see if they had any further suggestions. From there, I looked into the evidence-based references for the medications I was including. Some of the evidence I included was pulled from the prescribing information that came with the medication. Unfortunately, a lot of times that wasn’t very helpful. It would say things like, ‘monitor frequently,’ but what does that mean?

Working With the Medical Team

Circling back with her team of nurses and collaborating with medical oncologists, Ehmke discussed what they thought would be best for monitoring frequency when the prescribing information was vague or unhelpful. She and her colleagues worked to determine best practices and included that information accordingly.

“After we talked about what we thought would be an adequate monitoring frequency, we added that to the document. But we made sure to regularly revise it based on our own experiences with the drug,” Ehmke says. “It’s a living document that can change with our experiences and as new evidence emerges.”

Ehmke also pulled on the expertise of her pharmacy colleagues as she developed the reference sheet, seeking their advice to ensure she was getting the most up-to-date information possible.

“I wanted to hear from the pharmacists as well, especially considering we were developing a document about medications,” Ehmke says. “Pharmacists can be a wealth of information and a tremendous resource, and it’s important to have their experience with something like this.”

Keeping Up With New Information

As time went on, Ehmke’s reference sheet began to grow. With new information emerging, Ehmke’s team added new medications. Moreover, changes in practice were happening all the time and Ehmke’s sheet expanded to encompass the evolving treatment landscape.

“It started out as one side of one sheet of paper, and now it’s almost four and half pages,” Ehmke says. “It’s not just that we’ve added new medications. We’ve accounted for changes in practice based on our experiences, based on what the literature says, and based on how practice continues to change. The frequency changes through time. With a document like this, it’s important to keep it updated.”

Ehmke notes that she revisits and updates the reference sheet on a regular basis, often more than once a month, and she always notes what the new information is, what changed in practice and references for those changes.

Creating an Overwhelming Success

Ehmke’s entire institution embraced her quick reference sheet. It’s a staple on everyone’s clipboard in both inpatient and outpatient units, and it’s grown to include other drugs that require special monitoring of patients (I.e. Remicade, Gamma Globulin).

“The sheet is being used throughout our entire health system for nurses who are administering any medications on the list,” Ehmke says. “It’s been morphed into an oncology and non-oncology document.”

On the ONS Communities (http://communities.ons.org/home), a question about monitoring frequency was raised (http://communities.ons.org/communities/community-home/digestviewer/viewthread?MessageKey=a5bb8a6b-0341-4d53-8567-ccd062c2d4f4&CommunityKey=0b54ba80-79aa-446b-80ae-5434d67c4adf&tab=digestviewer#bma5bb8a6b-0341-4d53-8567-ccd062c2d4f4) and garnered a considerable amount of attention. Ehmke mentioned the reference sheet to her fellow ONS members and fielded more than 150 requests from nurses across the country looking to see a copy of the document. The need was clearly there, and Ehmke was happy to provide the reference sheet for her peers.

Addressing a Gap in Your Institution

No practice is perfect. Ehmke and her colleagues recognized a gap in practice and sought to fill it. Other oncology nurses are also in a unique position to identify issues and change practice for the better.

“I think the first thing to remember is that if you notice a need for something in your practice, chances are that others have noticed it too,” Ehmke says. “All it takes is one person to say, ‘You know what? I’m going to address that need.’ Get input from your peers, get input from the clinical nurse specialists, talk to your manager, and involve colleagues from whatever specialty is involved. Look at what evidence is out there and lean on organizations like ONS to understand what’s out there for this process.”

Perseverance, team work, and continued evaluation are the hallmarks for great change. Ehmke emphasizes the importance of evaluating change and improving it through time. In addition, Ehmke believes that her role as a Clinical Nurse Specialist is instrumental in implementing evidence-based changes that can impact all practices settings.

“Addressing a need and instituting change is an ongoing process. It requires continued evaluation and revision,” she says. “It’s team effort, it requires perseverance, and it’s important to remember that if there’s a need, then addressing that is always going to be effective. It starts with just one person.”

To view Ehmke’s quick reference sheet, visit the ONS Communities (http://communities.ons.org/communities/community-home/digestviewer/viewthread?MessageKey=a5bb8a6b-0341-4d53-8567-ccd062c2d4f4&CommunityKey=0b54ba80-79aa-446b-80ae-5434d67c4adf&tab=digestviewer#bma5bb8a6b-0341-4d53-8567-ccd062c2d4f4).

Copyright © 2018 by the Oncology Nursing Society. User has permission to print one copy for personal or unit-based educational use. Contact pubpermissions@ons.org for quantity reprints.