At the recent 47th Oncology Nursing Society (ONS) Congress in Anaheim, California, Cynthia Huff, DNP, RN, MSN, OCN®, CRNI, CNL®, Manager of the Ambulatory Infusion Center at Long Beach Medical Center, presented two posters about the importance of safe oral chemotherapy administration and the need to ensure proper lab monitoring and follow-up for patients receiving chemotherapy. Afterwards, she spoke with Oncology Data Advisor to further expound on her work in these areas and her passion for guaranteeing the safety and optimal care of all patients receiving cancer treatment.
Oncology Data Advisor: Thank you for joining us, Dr. Huff. Would you like to give us an overview of your presentation at ONS about oral chemotherapy handling?
Cynthia Huff, DNP, RN, MSN, OCN®, CRNI, CNL: So, about three years ago, I recognized a need for nurses in the outpatient setting to have more information regarding chemotherapy administration at home. I was really alarmed when I went to a patient's home and they were crushing chemo pills and trying to push them down a percutaneous endoscopic gastrostomy (PEG) tube, so much so that I thought, "Gosh, I need to do something." I reached out to some colleagues and said, "I want to write an article about this and tell my story." The Clinical Journal of Oncology Nursing (CJON) grabbed it, and then they worked with me for a year so that I could get all that information put into the article.
Oncology Data Advisor: Thank you. So, what did you find because of this research?
Dr. Huff: Well, I found that many nurses weren't very familiar with oral chemotherapy—99% of them thought they didn't need to know about oral chemotherapy because they don't touch those drugs at all. But patients were coming into the infusion center where I worked who were on oral chemotherapy with symptoms and side effects, and nurses were telling them, "Maybe you could put it in applesauce? Maybe you could crush it? Maybe you could..." I'm not saying it's a bad thing, they just didn't know. That was a real wakeup call for me, so I did a literature search to find out what best practice was in handling these drugs, and I didn't find a whole lot.
I graduated from the University of San Francisco, and I'm kind of an environmentalist at heart. I don't want to see things going into our ocean or our landfills that are hazardous, especially when we wear PPE to give chemotherapy. These same drugs are coming out in pill form for the convenience of the patient, but patients are not being educated on how to protect themselves or the environment from hazardous drug exposure. When someone says, "Well, it's just a pill, you can put it in your mouth, it's no big deal," it's still hazardous, so we do need to wear gloves.
Oncology Data Advisor: What do you think nurses should take away from this? How should they implement it into their practice?
Dr. Huff: There are a couple of ways. One would just be to always ask a patient if they're on oral chemotherapy because many organizations are pharmacy-led, so we're not privy to that. Maybe they have a nurse navigator and that person is managing all of that, or maybe there's no one, it's just the doctor. I think what I would like for them to do is to always ask patients if they're taking any oral chemotherapy, if they're following up with their lab work, and whether they have any concerns about taking the drug and how to dispose of it. Those are the main things.
Then there's advocacy from the political level. The opportunity is really to talk to the drug companies who are giving out their medications and encourage them to include information in package inserts about the dangers of handling the drug for patients, their family members, their pets, and their home. Then the other thing is to figure out a way for the drug companies to get the drug back if the patient stops taking it, so that it's not just tossed away or left in their cupboard for five years. We need to know where the drug is and how much of it was used, and then we need to send it back.
If the drug companies can help us by changing their package inserts and by providing a way for the patients to send the drug back, then that would relieve my mind by knowing that we're doing the best that we can.
Oncology Data Advisor: Thank you for this advice. Would you also like to tell us about your other poster here about lab monitoring?
Dr. Huff: Yes, the other poster that I have is about lab monitoring and follow-up. As a Clinical Nurse Leader (CNL®), I'm kind of a gap follower. I look for things that fall through the cracks, and usually they're patient-related. I have a short story about a patient who had kidney problems, but he was getting chemotherapy in the infusion center and was admitted to the hospital. I was asking some routine questions about why he went to the hospital—did he have an infection? What was his white count? What I realized was that the patient had not been getting labs for his oral chemotherapy.
There's no blame to the doctors, but when I interviewed both doctors to ask how we missed this, one doctor said, "Well, I thought the oncologist was watching that." The oncologist said, "No, I thought you were watching that." It was kind of a "pass the buck." I don't know how to fix that other than to say that if you see something wrong and if you ordered it, you're responsible for that. Even if you're not, and it comes to you, you're still responsible for reporting the abnormal result. We did a study in our clinic at Long Beach Memorial, which is where I was working. I wanted to look at 100 charts and review them for one drug, just one.
That drug was capecitabine, which is very common and has a lot of side effects. There are FDA guidelines for lab monitoring and follow-up, as well as for documentation of treatment regimens and that type of thing. It does require a lot of monitoring upfront and then over time, because people take it for a while. In my poster, I show that 89% of the time, lab follow-up was great at baseline but then immediately dropped off at 30 days and then was literally about 30% after that. There's a great need to figure out a method, maybe even an app, that reminds patients to get their labs and make sure that the provider who ordered it knows about that, so we can intervene.
Some places are not big organizations, and that's one of the concerns that I have. Kaiser, for instance, has a great system for monitoring all that; they see all the labs and are proactive about them. But if you come to a community hospital or a community clinic where there are maybe six doctors, they don't always have a structure built for that. Or sometimes there are 50 different pharmacies that are sending the drugs directly to the patients, so we don't even know if they get the drug for maybe two to three weeks. So, who's following these people?
The literature search supported the fact that the rates of hospital readmissions related to chemotherapy treatments are high, and the cost is very expensive when people don't have their labs monitored. There are adverse side effects and may lead to poor outcomes. If you're supposed to be taking your chemo three weeks on/two weeks off/ three weeks on, and you don't get your lab work done, you can over- or underdose. Either way, you're not going to get optimal outcomes, and you could die. That was the whole purpose of the study, to look at whether it really is important for us as nurses to worry about lab work. And it really is, 100%.
When patients come in to see me, I always look at the labs for IV chemo, but I don't relate it to the oral chemo taken at home. We just check in terms of their treatment for that day. But why don't we? We just don't, and we should. How are their liver enzymes? Are they really taking the drug? If somebody's very neutropenic and we're going to give them another chemo treatment another day, what happened? I think nurses will have to step up, and as we always do, nurses will take the reins. They're really pushing pharmacy-led oral chemotherapy management. The pharmacists don't see patients; nurses see them. We need to focus on not being in a silo, but working as a team: a pharmacist, nurses, doctors, navigators, and even the manufacturers, to figure out how to put a safety net around these patients to whom we're giving highly toxic medications to, with lots of holes in the net.
I created a Failure Mode and Effects Analysis (FMEA) tool that's with the editor right now and is going to be published soon. When creating that tool, I went to the providers and nurse practitioners and said, "Give me all the steps, starting at the time you order an oral drug for a patient. I want to know, step one, what is the drug? If you order the drug, what could happen if the patient doesn't get it? Give me 10 reasons why this patient's not going to get the drug on time." So, we went through the steps and did that. Then we said, "What is the likelihood of that happening? And if it happened, how severe would that be? If they didn't get their labs done, would you be too worried about it? How severe would it be if they didn't get their labs?"
All the NPs in my group rated these questions on a severity scale. They all had a score, and then we did a mean score. So, if we just take one little thing that could go wrong, and we plug the hole in 30 days, what would our risk priority number (RPN) be? Would we see that go down? Sure enough, it's going down because we're plugging just little holes. If we just take one little bit at a time, by the end, our goal is to reduce the patient risk by 50%. Unfortunately, I'm no longer at the organization, but it's clearly on my mind to do this at City of Hope—to work with the team there and see what we can do.
I'm the manager for the clinics and the infusion center outside campus. I'm in Corona, and our population is mostly very, very low income, even poverty level. We have two elementary schools that rely on the community just for food and security and clothes for kids, and people in the community help them get what they need. Patients from this area are going to need a lot more help than the patients who may be in the majority areas, and that's what I'm interested in. I'm interested in the community where I live and taking care of the people who I see at the store, who come to church, who I see on a regular basis. I want them to come to me any time and say, "You know what? I don't know what to do with this medication. I didn't get my lab journal right." I don't want them to feel bad; there could have been issues with transportation or other things that prevented them from coming for treatment.
This is where we're at with lab monitoring and follow-up; you need to look at all social determinants of health to see if patients can do those things. If they're not, we need to figure out a way for them to know it's important and then help them get the best possible outcomes.
About Dr. Huff
Cynthia Huff, DNP, RN, MSN, OCN®, CRNI, CNL, is a Nursing Professor in the University of San Francisco's Nursing Program and Manager of the Ambulatory Infusion Center at Long Beach Medical Center's Todd Cancer Institute. Dr. Huff has 40 years of experience in oncology and infusion. She is passionate about improving the safety of hazardous drug administration and ensuring that all patients receive equal access to cancer care and follow-up.
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Transcript edited for clarity. Any views expressed above the speaker's own and do not necessarily reflect those of Oncology Data Advisor.