by Wai Man Ling, Hong Kong East Cluster, Hong Kong, China. ISNCC Communications Committee Member.
A 51-year-old leukaemia patient died of post chemotherapy septicaemia after a 5-hour delay in antibiotics treatment in Hong Kong 4 years ago. The incident has drawn the attention in the public and the healthcare community again after the verdict of Coroner’s Court in November 2015 (Lo, 2015). The coroner attributed the tragedy to a series of unfortunate mistakes, especially the multiple delays in the antibiotics treatment when the patient attended the two Accident and Emergency Departments (AEDs) for fever. She continued to urge the Hospital Authority (HA) of Hong Kong to review the existing clinical practice. Emergency protocol should be in place and there should be adequate instructions to the patients and the family members prior to post chemotherapy discharge (Lau, 2015).
Neutropenic fever is a known oncological emergency. Its mortality can be largely reduced by prompt and appropriate responses from the attending healthcare professionals. I believe that this unfortunate but real case can once again illustrate the risk vividly and further boost our vigilance. In response to the incident, the HA is now co-ordinating a number of remedial actions in the local public hospitals. Management guidelines will be developed. Emergency antibiotics kit is being considered to install in all the Accident and Emergency, Oncology, and Haematology Departments to facilitate a timely initiation of antibiotics treatment.
Moreover, concerns from the external accreditation body have given extra momentum to the move. Just take my hospital as an example, the external surveyors scrutinized the policies and performance of my Department in this area during their visit last year. Thereafter, we had implemented a number of improvement measures. We conducted a retrospective baseline audit on the door-to-needle (DTN) time for antibiotics treatment for the period of 2013-14. Similar to the findings of other local audits, our performance fell short of the international recommendations in terms of the mean DTN time (Chan, Wong, & Wu, 2015). Then, we developed the new clinical management guidelines, and collaborated with our AED and Pharmacy to establish a new workflow. Currently, we are conducting a post audit to review the effectiveness of our new practice.
On the other hand, our experience has underlined some pivotal roles played by the oncology nurses in enhancing the service. Firstly, we help to design the emergency protocol and the Chemotherapy Alert Card, and incorporate this new information in the pre-chemotherapy education for patients. Secondly, we liaise with the various Departments to establish an agreed workflow. We have then briefed the staff members on this workflow, and also educated the doctors and nurses of our AED on the use of different types of central catheters for blood culture and antibiotics treatment. Thirdly, we help to collect patient data for the post clinical audit.
Through this sharing, I would like to restate the importance of the prompt management of post chemotherapy neutropenic fever, and the significant contributions that oncology nurses can make in this area.
The new Chemotherapy Alert Card for the patients in our Department
Chan, S. H. O., Wong, K. M. I., & Wu, Y. G. P. (2015). Clinical Audit on Initial Management of Neutropenic Fever Patients. Unpublished manuscript, Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong.
Lau, C. (2015, November 19). ‘A series of unfortunate events’: Hong Kong coroner rules cab driver whose hospital treatment was delayed died of natural cause. South China Morning Post. Retrieved from http://www.scmp.com/news/hong-kong/law-crime/article/1880148/series-unfortunate-events-hong-kong-coroner-rules-cab
Lo, K. (2015, November 19). Natural causes ruling after leukemia delays. The Standard. Retrieved from http://www.thestandard.com.hk/news_print.asp?art_id=163364&sid=45601959
by Sandra L. Spoelstra, Michigan State University College of Nursing, East Lansing, United States.
Patients with cancer miss as much as one third of the prescribed doses of oral anti-cancer agents required for treatment of their disease. Even more disconcerting is that within the next three years, 25% of cancer treatment will be delivered in pill form. This shift in the treatment paradigm will result in increased care in the home, placing greater responsibility on patients. Barriers to oral agent adherence for patients include no or limited coverage for the medication, complex dosing regimens, difficulty obtaining the prescription, running out of the prescription, forgetting to take the pills, skipping or stopping because they believed the medication was not working or because it created symptoms from side effects, and not seeking help from others. Often, the more adherent patients are to oral chemotherapy agents, the more likely they are to experience symptoms. Patients prescribed oral agents have indicated titrating doses as they were unable to tolerate symptoms occurring as a side effect of the cancer treatment. Thus, prompt and aggressive management of symptoms becomes vital to managing adherence at home. Furthermore, pharmacy literature suggests a narrow therapeutic index for cancer therapy, increasing the importance of oral agent adherence, as non-adherence may affect time to disease progression and mortality. The therapeutic outcome for patients taking oral agents depends heavily on the ability of patients to adhere to the prescribed regimen. Healthcare research has not conclusively identified effective interventions to promote medication adherence. Chemotherapy classes are a common part of care for patients receiving IV treatment. However, training for patients on oral agents is underdeveloped, and needs to include adherence, monitoring and reporting of symptoms from side effects and toxicities, coordination of changes in dosing if altered or stopped, and management of insurance coverage and drug delivery. Oncology nurses must take the lead in structuring care settings that promote patient behavior to attain optimal adherence. Oncology nurses can help patients and their families understand what they are responsible for in many ways. The number of cancer patients who receive oral agents in pill form is increasing, and oncology nurses can lead the way enabling patients to adhere to and complete their cancer treatment.
Bassan, F., Peter, F., Houbre, B., Brennstuhl, M. J., Costantini, M., Speyer, E., & Tarquinio, C. (2014). Adherence to oral antineoplastic agents by cancer patients: Definition and literature review. European Journal of Cancer Care, 23, 22–35. doi:10.1111/ecc.12124
Lichtman, S. M., & Boparai, M. K. (2008). Anticancer drug therapy in the older cancer patient: pharmacology and polypharmacy. Current Treatment Options in Oncology, 9, 191–203. doi:10.1007/s11864-008-0060-6
Soria, J. C., Blay, J. Y., Spano, J. P., Pivot, X., Coscas, Y., & Khayat, D. (2011). Added value of molecular targeted agents in oncology. Annals of Oncology, 22, 1703–1716. doi: 10.1093/annonc/mdq675
Spoelstra, S. L., Given, B. A., Given, C. W., Grant, M., Sikorskii, A., You, M., & Decker, V. (2013a). An intervention to improve adherence and management of symptoms for patients prescribed oral chemotherapy agents: An exploratory study. Cancer Nursing, 36, 18–28.
Spoelstra, S. L., Given, B. A., Given, C. W., Grant, M., Sikorskii, A., You, M., & Decker, V. (2013b). Issues related to overadherence to oral chemotherapy or targeted agents. Clinical Journal of Oncology Nursing, 17, 604–609. doi:10.1188/13.CJON.17-06AP
Spoelstra, S. L., & Given, C. W. (2011). Assessment and measurement of adherence to oral antineoplastic agents. Seminars in Oncology Nursing, 27, 116–132. doi:10.1016/j.soncn.2011.02.004
Weingart, S. N., Brown, E., Bach, P. B., Eng, K., Johnson, S. A., Kuzel, T. M., . . . Walters, R. S. (2008). NCCN Task Force Report: Oral chemotherapy. Journal of the National Comprehensive Cancer Network: JNCCN, 6, S1–S14.
by Catherine Johnson, Calvary Mater Newcastle, Newcastle, Australia. ISNCC Finance and Audit Committee Member, ISNCC Corporate and Philanthropic Committee Member, ISNCC Knowledge Development and Dissemination Committee Member, ISNCC Communications Committee Member, ISNCC Member Development Committee Member.
Globally non-communicable diseases (NCDs) which include cancer, cardiovascular diseases, diabetes and chronic respiratory diseases make the largest contribution to mortality; approximately 60% (35 million) of all deaths and have the greatest impact in low and middle income countries (28 million deaths) (1). Most of these deaths are from preventable causes: tobacco use, unhealthy diets, alcohol consumption and physical inactivity. In 2010 the International Council of Nurses (ICN) identified that nurses are well positioned to lead NCD prevention, care and treatment. The ICN have developed a website (www.growyourwellness.com) that has a variety of tool and resources to help nurses lead wellness including prevention and health promotion tools, health assessments, policy and advocacy and also a section on nurses’ own health.
The International Society of Nurses in Cancer Care (ISNCC) has strong leaders in the prevention and control of NCDs. Stella Bialous, current ISNCC president, with her colleague Linda Sarna have been advocates of tobacco cessation and the important role of nurses in helping smokers quit. They highlight tobacco cessation is incredibly important as it can lead to all four of the NCDs and have actively pursued capacity building of nurses in tobacco control. Of note, the ISNCC updated tobacco position statement was released in July 2014 and can be found at http://www.isncc.org/?page=Position_Statements. The ISNCC tobacco taskforce has been hosted in Eastern Europe (2012) and in China (2014) to increase nurses’ delivery of tobacco dependence treatment.
In 2014, at the World Cancer Leaders’ Summit, Sanchia Aranda, Past ISNCC president and current president of the Union for International Cancer Control, advocated for prevention strategies including higher tobacco taxes; implementation of prevention packages to improve diets and increase physical activity; development of effective workplace health promotion programs; and widespread vaccination programs, particularly in low-resource settings where routine screening and treatment services may not be available. Professor Aranda also spoke of the need for solutions that are accessible and affordable that deliver a return on investments for governments, particularly low and middle income countries where the burden of disease is greater and health services are not as well developed or resourced.
Nurses can play key roles in prevention and control of NCDs through key areas of policy, advocacy, research, education and clinical practice.
Do you feel prepared to contribute the prevention and control of NCDs?
Do you have the knowledge and skills to help patients, carers and their families modify their unhealthy behaviours to reduce their risk of developing one of the four key NCDs?
Will you be part of the solution?