Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management

2016 ◽  
Vol 23 (8) ◽  
pp. 563-574 ◽  
Author(s):  
Anastasia Finn ◽  
Carolyn Bondarenka ◽  
Kathy Edwards ◽  
Rebekah Hartwell ◽  
Cathy Letton ◽  
...  
Keyword(s):  
Treatment Plan ◽  
Retrospective Chart Review ◽  
Outpatient Setting ◽  
Oral Chemotherapy ◽  
Pharmacist Interventions ◽  
Before And After ◽  
Treatment Plans ◽  
Implementation Time ◽  
Chemotherapy Agents ◽  
Beacon Period

Background With the ever growing arsenal of oral chemotherapy agents now available, cancer treatment is being increasingly managed in the outpatient setting. However, oral chemotherapy use is often associated with several potential obstacles and complications. In order to provide optimal patient safety and oral chemotherapy monitoring, our institution implemented an oral chemotherapy program managed by clinical pharmacists electronically through Epic Beacon. Objective To describe implementation of a novel pharmacist-managed oral chemotherapy program and evaluate pharmacist interventions before and after implementation of an oral chemotherapy program. Methods This was a single-center retrospective chart review of documented pharmacy interventions for oral chemotherapy prescriptions during three months prior to as well as three months following Epic Beacon implementation. Time periods for data inclusion were October–December 2013 (pre-Beacon) and October–December 2014 (post-Beacon). Patients included in the study had one or more oral chemotherapy orders during the pre-Beacon period, the post-Beacon period, or both pre- and post-Beacon. Our analysis did not include oral chemotherapy orders that were placed outside of a treatment plan in the post-Beacon period. Results A total of 240 patients with 450 total oral chemotherapy orders were assessed over the duration of the study. Beacon implementation allowed a greater number of oral chemotherapy orders to be reviewed, with 134 oral chemotherapy orders reviewed in the study period prior to Beacon implementation and 316 orders reviewed in the post-Beacon period. Additionally, there were 660% more pharmacist interventions (89 interventions pre-Beacon versus 681 interventions post-Beacon), with an increased focus on coordination of care, chemotherapy calendar coordination, and assistance with treatment plans. Furthermore, implementation of Epic Beacon allowed identification of over 500% more chemotherapy order errors (41 total errors identified pre-Beacon versus 250 total errors identified post-Beacon). Pharmacists were also able to identify more significant, serious, or potentially lethal errors following implementation. The time associated with oral chemotherapy review and intervention also increased accordingly with number of orders reviewed. Conclusion Implementation of an electronic workflow for oral chemotherapy dramatically increased pharmacist review of orders, resulting in improved documentation of interventions and errors, decreased need for clarification of orders, as well as increased volume of prescriptions at our on-site pharmacy. This study demonstrates a comprehensive approach to maximize safety when oral chemotherapy is utilized as a component of the treatment regimen.

Nasal Endoscopy: Its Role in Office Diagnosis

1997 ◽  
Vol 11 (2) ◽  
pp. 177-180 ◽  
Author(s):  
Michael S. Benninger
Keyword(s):  
Treatment Plan ◽  
Septal Deviation ◽  
Diagnosis And Treatment ◽  
Nasal Endoscopy ◽  
Nasal Sinus ◽  
Anterior Rhinoscopy ◽  
Choanal Polyp ◽  
Before And After ◽  
Treatment Plans

To clarify the role of nasal endoscopy in the diagnosis and treatment planning for patients with nasal or sinus complaints, 100 consecutive new patients were evaluated. Patients were excluded if their only complaint was obstruction and they had a septal deviation as the only clinical finding. Each patient underwent a thorough history and head and neck examination, including anterior rhinoscopy before and after decongestion, and the diagnosis and treatment plans were documented. Each then underwent nasal endoscopy, and the diagnosis and treatments were compared. The most common diagnoses after anterior rhinoscopy were allergic rhinitis (21), nonallergic rhinitis (12), chronic sinusitis with polyps (19) or without polyps (9), and nonsinus pain (13). Nasal endoscopy played a role in 11% of patients, although in no case did endoscopy change the diagnosis or treatment plan. Endoscopy allowed visualization past an enlarged turbinate or septal deviation in six patients, confirmed a suspected diagnosis in three by visualization of the middle meatus, and detected the site of a large choanal polyp in one. In one case, endoscopy identified a paradoxical turbinate on the side opposite the symptoms and radiological findings. Routine nasal endoscopy need not be part of the evaluation of all patients with nasal sinus disorders but is particularly valuable in confirming diagnoses, particularly in patients where anterior rhinoscopy is limited by anatomic vobstruction.

The impact of multidisciplinary cancer conferences (MCC) on the treatment of metastatic rectal cancer (MRC) at the Ottawa Hospital Cancer Centre (TOHCC).

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e14686-e14686
Author(s):  
Tanya Di Valentin ◽  
Timothy R. Asmis ◽  
Rebecca Ann C. Auer
Keyword(s):  
Treatment Plan ◽  
Retrospective Chart Review ◽  
Multidisciplinary Care ◽  
Standard Of Care ◽  
Ottawa Hospital ◽  
Patient Demographics ◽  
Relative Risks ◽  
Included Patient ◽  
Treatment Plans ◽  
The Impact

e14686 Background: There is significant controversy surrounding the management of surgically resectable MRC. The use and timing of neoadjuvant chemotherapy, pelvic radiation, and relative risks and benefits of a combined surgical resection are areas of debate among surgeons, medical, and radiation oncologists. The TOHCC multidisciplinary Cancer Conferences (MCC) provide an opportunity to discuss these cases and propose treatment plans for these patients. Methods: We conducted a retrospective chart review of all the cases of MRC which were discussed at MCC at the TOHCC from November 2007 until October 2009. Information collected included patient demographics, site of metastases, the treatment they received prior to their case being discussed at MCC (past surgeries, chemotherapy, radiotherapy), the treatment plan discussed at MCC, treatment actually administered post MCC discussion, and patient outcome at 6 months. Results: Forty-two patients with MRC were reviewed. The most common sites of metastases were liver (45.2%) and lung (31%). Once diagnosed with metastatic disease, prior to the MCC, patients had received the following treatments alone or in combination: chemotherapy (33.3%), radiotherapy (21.4%), surgery (19.0%), no treatment (n=57.1%). After their case was presented, 38 patients (90.5%) received the treatment recommended at the MCC , while 4 (9.5%) did not. Treatment post MCC included: chemotherapy (neoadjuvant: 38.1%; adjuvant: 23.8%; palliative: 28.6%), radiotherapy (neoadjuvant: 14.3%; adjuvant: 7.1%; palliative: 7.1%) and surgery (31.0%). Conclusions: There is no standardized approach to the management of MRC. Given its complexity, many cases are reviewed at MCC, which allow coordination for multidisciplinary care of these patients. The results of this study suggest that in a majority of cases, the recommendations brought forth at MCC are indeed acted upon. Given that these meetings have a significant impact on the treatment plan and outcome of patients with MRC, they should represent the standard of care when treating this disease.

Building a new process: Nursing verification of pediatric oral chemotherapy.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 199-199 ◽  
Author(s):  
Jessica A. Zerillo ◽  
Erin Santacroce ◽  
Mary Ann Zimmerman ◽  
Melissa Freeman ◽  
Teresa Lau Greenberg ◽  
...  
Keyword(s):  
Pediatric Oncology ◽  
Treatment Plan ◽  
Drug Dose ◽  
Oral Chemotherapy ◽  
Near Miss ◽  
Patient Portal ◽  
Prescription Error ◽  
Vulnerable Patients ◽  
New Process ◽  
Treatment Plans

199 Background: While team-based safety checks ensure safe prescribing of parenteral chemotherapy, oral chemotherapy is usually prescribed by a single clinician. With the growing use of oral chemotherapy, processes are needed to protect these vulnerable patients from prescription errors. Methods: A team of nurses, clinicians, pharmacists and administrators developed a new process and checklist for nursing verification of oral chemotherapy prescriptions at Dana-Farber’s pediatric neuro-oncology program. Prescriptions are verified against the treatment plan by two pediatric oncology nurses. The verification checklist includes drug, dose with any modifications, height and weight, laboratory values and patient instructions. When available, the prescription bottle is also verified. Data was collected over a three-month pilot period. Results: From 6/18/15-9/16/15, 56 prescription verifications occurred. Verification rate of on-site retail pharmacy filled prescriptions was 47% (32/68 prescriptions). Median time for verification was 20 minutes (IQR 15, 40) per nurse. Nurses identified problems outside of prescription verification, including missing prior authorizations and unclear treatment plans. Medication bottles were not routinely available for verification. One identified near miss would have resulted in an 80% under-dose of everolimus. Conclusions: Prescription verification by nursing in a pediatric oncology clinic was feasible. While it was successful in identification of one medication error before it reached the patient, only 47% of prescriptions were verified. Since prescription bottles are usually obtained after a visit, verification of the actual bottles will require new workflows, such as additional clinic visits or uploading a picture via the patient portal. Involving the nurse in the review of oral chemotherapy not only identified a prescription error, but also highlighted issues within other aspects of patients’ care, including inconsistent documentation of the treatment plan. The inclusion of nursing in the review and management of oral chemotherapy has the potential to improve safety and outcomes for these patients.

Frequency of appropriate lab monitoring of oral chemotherapy in an outpatient setting

2019 ◽  
Vol 26 (5) ◽  
pp. 1097-1102
Author(s):  
Jessica N Heck ◽  
Aaron A Null
Keyword(s):  
Retrospective Chart Review ◽  
Outpatient Setting ◽  
Oral Chemotherapy ◽  
Laboratory Monitoring ◽  
Veterans Health ◽  
Health Administration ◽  
Provider Education ◽  
Chemotherapy Drugs ◽  
Effective Use

Purpose The aim of this study is to understand the frequency of appropriate laboratory monitoring of oral chemotherapy at the Eastern Colorado Health Care System (ECHCS) compared to recommendations set forth in the 2012 Veterans Health Administration (VHA) Guidance on Dispensing and Monitoring of Oral Chemotherapy. Methods This study is a retrospective chart review of patients who have received a subset of oral chemotherapy drugs at ECHCS. Patients 18 to 89 years of age with an active cancer diagnosis who initiated therapy at ECHCS between September 1, 2010 and August 31, 2014 were included in the study. Initial and subsequent prescription fill dates, appropriate labs as defined by VHA guidance and baseline and follow-up lab monitoring dates, and appropriate labs as defined by VHA guidance were collected for up to 12 cycles of chemotherapy per patient. Baseline labs were defined as within three months of the first prescription fill date, and follow-up labs were defined as within seven days of subsequent prescription fill dates. Results Results are presented as complete, partial, or incomplete and as attempt or no attempt at monitoring according to the VHA guidance recommendations. There was 100% attempt at laboratory monitoring at baseline; however, there was a decline in attempt and complete follow-up monitoring overall as well as for drugs that require special monitoring. Conclusion Based on recommendations from the 2012 VHA Guidance on Dispensing and Monitoring Oral Chemotherapy, data presented here demonstrate that ECHCS could benefit from improved lab monitoring in order to ensure safe and effective use of oral chemotherapies. These results provide a unique opportunity to consider the potential role of clinical pharmacists in monitoring and management of patients receiving oral chemotherapies as well as patient and provider education regarding the importance of appropriate lab monitoring.

scholarly journals 1170. A Quality Improvement Study to Assess the Effectiveness of a Meaningful Use Protocol in the Reduction of PICC Line Use and Complications

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S419-S419
Author(s):  
William P Dillon ◽  
Susan Szpunar ◽  
Mamta Sharma
Keyword(s):  
Retrospective Chart Review ◽  
Bloodstream Infections ◽  
Meaningful Use ◽  
Outpatient Setting ◽  
Vein Thrombosis ◽  
Relative Safety ◽  
Before And After ◽  
Chi Squared ◽  
Picc Line ◽  
Student’S T

Abstract Background The use of peripherally-inserted central catheters (PICC) has grown substantially over time because of their ease of insertion, cost-effectiveness and relative safety. With increased use; however, there are increased complications including catheter-related bloodstream infections (CLABSI) and PICC line-associated deep vein thrombosis (DVT). To help decrease complications a meaningful use protocol was implemented based on the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) to define appropriate indications for PICC line use. The objectives of this study were (1) to determine the rate of PICC line use at our hospital; (2) to determine rates of complications associated with PICC lines, including CLABSI and DVT; and (3) to compare the metrics listed above before and after implementation of the meaningful use protocol. Methods We performed a retrospective chart review of all inpatient admissions before (June 1, 2017 to September 1, 2017) and after the implementation of the meaningful use protocol (June 1, 2018 to September 1, 2018). Patients who had a PICC line inserted at another institution or in the outpatient setting were excluded. We compared the rate of insertion, patient demographics, characteristics of the use of PICC lines and complications from the two periods. Data were analyzed using the chi-squared test, Student’s t-test, the Mann–Whitney U test and the z test for proportions. Results We reviewed 281 patient charts, 166 before the implementation of the meaningful use protocol and 115 after implementation. Overall, the mean age was 55.8 ± 17.9 years, 58.7% male and 54.1% white. There were no significant differences between groups with respect to demographics, comorbidities, source of admission, or complications. Post-implementation there was a significant reduction in lines used for unknown reasons as well as lines used for multiple blood draws (P <0.0001). The overall rate of PICC line use decreased from 23 per 1,000 admissions to 17.2 per 1,000 admissions after the intervention (P = 0.007). Conclusion Implementation of a meaningful use protocol reduced the rate of PICC line use at our institution by 25%. The proportion of lines used for unknown reasons decreased as well. Widespread implementation could have a significant impact on the reduction of PICC line use. Disclosures All authors: No reported disclosures.

Evaluation of the prescribing patterns, adverse effects, and drug interactions of oral chemotherapy agents in an outpatient cancer center

2018 ◽  
Vol 25 (7) ◽  
pp. 1564-1569 ◽  
Author(s):  
Jenna M Solomon ◽  
Veronica B Ajewole ◽  
Amy M Schneider ◽  
Manvi Sharma ◽  
Eric H Bernicker
Keyword(s):  
Drug Interactions ◽  
Clinical Pharmacist ◽  
Financial Burden ◽  
Retrospective Chart Review ◽  
Oral Chemotherapy ◽  
Prescribing Patterns ◽  
Cancer Center ◽  
Medication Access ◽  
Secondary Endpoints ◽  
Chemotherapy Agents

Purpose Although oral chemotherapy offers advantages over intravenous chemotherapy, it creates a unique set of challenges. Potential barriers include treatment complexity, patient responsibility for medication adherence and monitoring, reduced healthcare contact, and increased financial burden. The purpose of this study is to estimate the prevalence of drug-related problems among a sample of patients treated with oral chemotherapy agents. Methods A single-center, retrospective chart review was conducted on patients prescribed oral chemotherapy at our institution between 1 January 2017 and 31 August 2017. The primary endpoint was the incidence of drug-related toxicities within 90 days of starting treatment. Secondary endpoints included incidence of drug–drug interactions, proportion of patients receiving medication education by a clinical pharmacist, and quantification of issues related to medication access. Results Charts of 100 patients were reviewed. Median time to oral chemotherapy receipt by the patient from the day the order was written was eight days. Prior to initiating therapy, 27% of patients received education by a clinical pharmacist. Toxicity checks were conducted by the provider at 30, 60, and 90 days for 80%, 65%, and 48% of patients, respectively. Treatment-related toxicities secondary to oral chemotherapy were reported by 79% of patients, with 55% classified as severe. Potential drug interactions were in 55% of the patients. Conclusion Data from this study have highlighted avenues for pharmacists to make an impact on patients newly started on oral chemotherapy. Opportunities exist to increase patient education, ensure appropriate follow-up, and assess adherence while preventing and managing treatment-related toxicities.

scholarly journals 1692. Retrospective Review on the Safety and Efficacy of Nitrofurantoin for the Treatment of Cystitis in the Veteran Population With or Without Renal Insufficiency

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S829-S830
Author(s):  
Elwyn W Welch ◽  
Shaila Sheth ◽  
Chester Ashong ◽  
Caroline Pham
Keyword(s):  
Renal Function ◽  
Renal Dysfunction ◽  
Clinical Cure ◽  
Clinical Cure Rate ◽  
Retrospective Chart Review ◽  
Outpatient Setting ◽  
Secondary Outcome ◽  
Cure Rate ◽  
Acute Cystitis ◽  
Significant Difference

Abstract Background Nitrofurantoin has been used to treat cystitis in women; however, data supporting its use in men is lacking. In addition, recent retrospective studies have challenged the manufacturer’s recommendation to avoid nitrofurantoin with creatinine clearances (CrCl) less than 60 mL/min. The purpose of this study is to compare the efficacy and safety of nitrofurantoin for the treatment of acute cystitis in male and female veterans with variable degrees of renal dysfunction. Methods A retrospective chart review was conducted in adult patients who received nitrofurantoin for acute cystitis in the outpatient setting between May 1, 2018 and May 1, 2019. The primary outcomes were rates of clinical cure as compared between males and females, and across various renal function groups (CrCl greater than 60 mL/min, 30 to 60 mL/min, and less than 30 mL/min) following treatment with nitrofurantoin. The secondary outcome was adverse event rates. Results A total of 446 patients were included with 278 females and 168 males. Overall clinical cure rate was 86.5% (n=386). Clinical cure rate did not vary between genders (p=0.0851) or CrCl ranges (p=1.0) as shown in the tables. Benign prostatic hyperplasia (BPH) was associated with decreased odds of clinical cure (OR 0.50 [95% CI 0.26-0.97], p=0.0404) in addition to cirrhosis (OR 0.22 [95% CI 0.06-0.91], p=0.0357). Adverse events occurred in 2% of patients and did not vary based on gender or renal function. RATES OF CLINICAL CURE Conclusion There was no statistically significant difference in clinical cure with nitrofurantoin between genders and various renal impairments. However, history of BPH and cirrhosis were associated with decreased efficacy. Subgroup analysis also revealed lower efficacy in males with CrCl greater than 60 mL/min versus females with similar renal function. This study adds to the growing body of literature suggesting that renal dysfunction with CrCl of 30 to 60 mL/min may not carry the risk of treatment failure and adverse effects previously associated with nitrofurantoin, but large randomized trials are needed to confirm these results. Disclosures All Authors: No reported disclosures

scholarly journals The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Masayoshi Koike ◽  
Mie Yoshimura ◽  
Yasushi Mio ◽  
Shoichi Uezono
Keyword(s):  
Patient Safety ◽  
Retrospective Study ◽  
High Risk ◽  
Treatment Plan ◽  
Treatment Options ◽  
High Risk Patients ◽  
Appropriate Treatment ◽  
Risk Patients ◽  
Treatment Plans ◽  
Multidisciplinary Conference

Abstract Background Surgical options for patients vary with age and comorbidities, advances in medical technology and patients’ wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee. Methods In this retrospective study, we assessed the reasons for convening High-Risk Conferences, the final decisions made and treatment outcomes using conference records and patient medical records for conferences conducted at our institution from April 2010 to March 2018. Results A total of 410 High-Risk Conferences were conducted for 406 patients during the study period. The department with the most conferences was cardiovascular surgery (24%), and the reasons for convening conferences included the presence of severe comorbidities (51%), highly difficult surgeries (41%) and nonmedical/personal issues (8%). Treatment changes were made for 49 patients (12%), including surgical modifications for 20 patients and surgery cancellation for 29. The most common surgical modification was procedure reduction (16 patients); 4 deaths were reported. Follow-up was available for 21 patients for whom surgery was cancelled, with 11 deaths reported. Conclusions Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.

Use of Ophthalmic Sonography to Evaluate for Intraocular Foreign Body in Both Outpatient and Emergency Department/Urgent Care Patients

2021 ◽  
pp. 875647932110332
Author(s):  
Patrick J. Fish
Keyword(s):  
Emergency Department ◽  
Foreign Body ◽  
Foreign Bodies ◽  
Outpatient Setting ◽  
Intraocular Foreign Body ◽  
Urgent Care ◽  
Posterior Chamber ◽  
Emergency Department Setting ◽  
Before And After ◽  
Glass Metal

Intraocular foreign bodies (IOFB) present differently depending on the type of material (wood, glass, metal) for the IOFB, extent of the injury, and location of the injury. IOFB and the injury can cause a perforation or penetration of the globe which can require more extensive treatment including surgery. Proper evaluation of the IOFB and injury can help to determine extent of the injury, the prognosis of the vision, and health of the eye before and after treatment but may be difficult for the physician depending on the view of the posterior chamber being compromised by media or simply by patient sensitivity. The extent of the injury may also prevent proper evaluation due to swelling, lacerations on the lids, or pain. Proper ophthalmic sonography can provide a quick evaluation of the globe for any IOFB in both the outpatient setting as well as emergency department setting. Evaluation via sonography may allow the physician to accurately diagnose and properly treat the patient to help restore and prevent further loss of vision.

scholarly journals Multicriterial CNN based beam generation for robotic radiosurgery of the prostate

2020 ◽  
Vol 6 (1) ◽  
Author(s):  
Stefan Gerlach ◽  
Christoph Fürweger ◽  
Theresa Hofmann ◽  
Alexander Schlaefer
Keyword(s):  
Deep Learning ◽  
Treatment Planning ◽  
Treatment Plan ◽  
Plan Quality ◽  
New Approach ◽  
Beam Generation ◽  
Radiological Features ◽  
Improve Treatment ◽  
Robotic Radiosurgery ◽  
Treatment Plans

AbstractAlthough robotic radiosurgery offers a flexible arrangement of treatment beams, generating treatment plans is computationally challenging and a time consuming process for the planner. Furthermore, different clinical goals have to be considered during planning and generally different sets of beams correspond to different clinical goals. Typically, candidate beams sampled from a randomized heuristic form the basis for treatment planning. We propose a new approach to generate candidate beams based on deep learning using radiological features as well as the desired constraints. We demonstrate that candidate beams generated for specific clinical goals can improve treatment plan quality. Furthermore, we compare two approaches to include information about constraints in the prediction. Our results show that CNN generated beams can improve treatment plan quality for different clinical goals, increasing coverage from 91.2 to 96.8% for 3,000 candidate beams on average. When including the clinical goal in the training, coverage is improved by 1.1% points.

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