An analysis of inpatient and ED admissions within 30 days of chemotherapy: An OP-35 review.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e19302-e19302
Author(s):  
Jay Carlson ◽  
Jiajing Chen ◽  
Michelle Smith ◽  
Jessica N. Snider ◽  
Mohan K. Tummala ◽  
...  
Keyword(s):  
Social Deprivation ◽  
P Value ◽  
Secondary Diagnosis ◽  
Clinical Variables ◽  
Outpatient Chemotherapy ◽  
Chemotherapy Agent ◽  
Chemotherapy Infusion ◽  
Study Interval ◽  
Enhance Patient Care ◽  
Deprivation Status

e19302 Background: To evaluate patients who were within 30 days of outpatient chemotherapy infusion for an admission or ED visit associated with a primary or secondary diagnosis of anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia or sepsis. Methods: A review of Epic was performed on all Mercy patients with cancer who received at least one outpatient chemotherapy between 1/1/16-12/31/18. Non leukemia patients ≥ 18 years of age with an inpatient admission(IPA) or ED visit (EDV) were further evaluated for either the primary or secondary diagnosis for referral with at least one of the following diagnoses: anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis. Univariate and multivariable analyses were performed to identify significant clinical variables associated with the risk of referral. Adjusted Odds Ratios were calculated for the significant variables with a p value < 0.05 being significant. Results: Of the 9,590 cancer patients who presented to an outpatient infusion center during the study interval, there were 8,319 eligible patients excluding those with leukemia or age < 18 (n = 503) or for a presentation in which a chemotherapy agent was not infused. There were 90,030 eligible chemotherapy encounters of which 16.8% of patients (n = 1400) had an IPA and 11.8% (n = 980) had an EDV within 30 days of infusion. Age, social deprivation status, NCI comorbidity index, Epic readmission score, ECOG performance score, smoking, and malnutrition were significantly associated with either an IPA or EDV in both settings. Sepsis, pneumonia, and anemia were the most common OP35 related diagnoses for an IPA at 47.2%, 26.9%, and 23.2%, respectively. Similarly, pain, dehydration and nausea were the most common OP35 related diagnosis for an EDV at 48.1%, 14.2%, and 14.1% respectively. Factors having the strongest association with an IPA were malnutrition (OR: 2.34 2.08-2.65; p < 0.00001) and an antibiotic type of chemotherapy (OR: 2.16 1.72-2.72; p < 0.0001). Factors having strongest association with an EDV were severe pain score (OR: 2.56 2.21-2.97; p < 0.0001) and moderate to most deprived social deprivation status (OR: 2.10 1.62-2.72; p < 0.0001). ER referrals for pain, dehydration, and anemia most commonly occurred during clinic hours. Conclusions: Many clinical variables were found to be significantly associated with an IPV or EDV. These variables are opportunities for outpatient interventional algorithms to enhance patient care.

Prognostic utility of the cell cycle progression (CCP) score generated from needle biopsy in men treated with prostatectomy.

2014 ◽  
Vol 32 (4_suppl) ◽  
pp. 17-17
Author(s):  
Jay T. Bishoff ◽  
Stephen J. Freedland ◽  
Leah Gerber ◽  
Pierre Tennstedt ◽  
William Welbourn ◽  
...  
Keyword(s):  
Cell Cycle ◽  
Metastatic Disease ◽  
Needle Biopsy ◽  
Cell Cycle Progression ◽  
Disease Diagnosis ◽  
P Value ◽  
Univariable Analysis ◽  
Cycle Progression ◽  
Clinical Variables ◽  
Prognostic Utility

17 Background: We developed a prognostic RNA signature that is strongly associated with prostate cancer outcomes. The cell cycle progression (CCP) score has proven to have prognostic utility in predicting disease progression in various clinical settings utilizing biopsy, transurethral resection of the prostate (TURP) and post-prostatectomy specimens. Previous studies evaluating post-surgical outcomes were conducted using CCP gene expression measured in the prostatectomy specimen. Here, we demonstrate the ability of the CCP score to predict cancer progression, as measured by both biochemical recurrence (BCR) and metastatic disease after radical prostatectomy, using needle biopsy tissue. Methods: We evaluated the CCP score in three patient cohorts. These included men from the Martini Clinic (MC, N=283), the Durham VA Medical Center (DVA, N=176), and Intermountain Healthcare (IHC, N=123). The CCP score was derived from a simulated biopsy (MC) or diagnostic biopsy (DVA and IHC), and evaluated for association with BCR and metastatic disease in univariable analysis and after adjusting for other clinical information. Results: In all three cohorts, the CCP score was associated with BCR and metastatic disease. The association with BCR remained significant after adjusting for other prognostic clinical variables. In a combined analysis of all three cohorts (N=582), the CCP score was a strong predictor of BCR in both univariable (HR per Interquartile Range [IQR] = 1.68 [95% CI: 1.41, 1.99), p value<10−6]) and multivariable analyses (HR per IQR = 1.53 [95%CI: 1.28, 1.84], p value < 10−4). CCP score was the strongest predictor of metastatic disease in both univariable analysis (HR per IQR = 6.32 [95% CI: 3.41, 11.71, p value<10−7]), and after adjusting for clinical variables (HR per IQR = 4.83 [95% CI: 2.40, 9.74, p value<10−5]). Conclusions: The CCP score derived from a needle biopsy sample was strongly associated with adverse outcome after surgery. It was the strongest predictor of eventual metastatic disease of the tested variables including Gleason and PSA. These results indicate that the CCP score can be used at disease diagnosis to better define patient prognosis and appropriate clinical care.

Prediction of treatment (tx)-induced fatigue in breast cancer (BC) patients (pts) using machine learning on genome-wide association (GWAS) data in the prospective CANTO cohort.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11515-11515
Author(s):  
Sangkyu Lee ◽  
Joseph O. Deasy ◽  
Jung Hun Oh ◽  
Antonio Di Meglio ◽  
Sandrine Boyault ◽  
...  
Keyword(s):  
Machine Learning ◽  
Cognitive Disorders ◽  
Enrichment Analysis ◽  
Gene Set Enrichment Analysis ◽  
Gwas Data ◽  
P Value ◽  
Cognitive Fatigue ◽  
Clinical Variables ◽  
Severe Fatigue ◽  
Zero Baseline

11515 Background: Many BC survivors report fatigue. The relevant genomic correlates of fatigue after BC are not well understood. We applied a previously validated machine learning methodology (Oh 2017) to GWAS data to identify biological correlates of fatigue induced after tx. Methods: We analyzed 3825 BC pts with GWAS data (Illumina InfiniumExome24 v 1.1) from the CANTO study (NCT01993498). The outcome of this study was post-tx fatigue 1 year after the end of primary chemotherapy/radiotherapy/surgery using the EORTC C30 fatigue subscale (overall fatigue) and the EORTC FA 12 fatigue domains (physical/emotional/cognitive). For each domain, we limited the study group to those with zero baseline fatigue and defined severe fatigue change as score increase above the third quartile. We tested univariate correlations between severe fatigue in each domain and 496539 SNPs as well as relevant clinical variables. The machine learning prediction model based on preconditioning random forest regression (PRFR) (Oh et al., 2017), was then built using the SNPs with ancestry adjusted univariate p-value < 0.001 and clinical variables with Bonferroni adjusted p-value < 0.05. The model was validated in a holdout subset of the cohort. Gene set enrichment analysis (GSEA) was performed using MetaCore to identify key biological correlates relevant to tx-induced fatigue. Results: Distinct results were found by fatigue domain (table). GSEA showed that the cognitive fatigue model SNPs included biomarkers for cognitive disorders (p = 1.6 x 10-12) and glutamatergic synaptic transmission (p = 1.6 x 10-8). Conclusions: A SNP based model had differential performance by fatigue domain, with a potential genetic role on risk and biology for tx induced cognitive fatigue. Further research to explore biomarkers of tx induced fatigue are needed. [Table: see text]

Immune-related adverse events in melanoma: A nationwide analysis 2016.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18253-e18253
Author(s):  
Manoj P. Rai ◽  
Prabhjot Singh Bedi ◽  
Rohanlal Vishwanth ◽  
Fawzi Abu Rous ◽  
Shiva Shrotriya ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Adverse Events ◽  
Adrenal Insufficiency ◽  
Cohort Analysis ◽  
Single Agent ◽  
Progression Free Survival ◽  
Common Side Effect ◽  
P Value ◽  
Secondary Diagnosis ◽  
High Index Of Suspicion

e18253 Background: Melanoma is an aggressive skin cancer. Immunotherapy is currently used as a first-line treatment for unresectable metastatic disease. Combination immunotherapy has been shown to improve overall response rate (ORR), progression-free survival (PFS) and overall survival (OS) compared to single-agent immunotherapy. However, immunotherapy related adverse events (irAE's) are being increasingly seen. This study analyses the incidence of irAE's and the variation in the length of stay, and mortality. Methods: This is a retrospective cohort analysis of the 2016 NIS database. We identified hospitalizations with either primary or secondary diagnosis of Melanoma. Logistic regression of irAE's such as pneumonitis, colitis, hypophysitis, adrenal insufficiency, encephalitis, myocarditis was performed. We evaluated the association between irAE's and various parameters. Results: We identified 13170 hospitalizations with primary or secondary diagnosis of melanoma. Univariate logistic regression showed pneumonitis (OR: 1.39; p value: < 0.01), hypophysitis (OR: 20.61; p value < 001), adrenal insufficiency (OR: 10.36, p value = < 0.01), colitis (OR 23.94, p value < 001), myocarditis (OR: 1; p value was n/a), encephalitis (OR 1.71; p value was 0.5). Univariate logistic regression for LOS showed colitis (OR 1.23; p value: 0.01), adrenal insufficiency (OR 0.20; p value: 0.748), hypophysitis (OR -2.50; p value: 0), myocarditis no admissions, encephalitis (OR -2.15; p value 0.01). Univariate logistic regression for mortality showed pneumonitis (OR 6.07; p value: < 0.01), colitis (OR 0.86 p value: 0.721), adrenal insufficiency (OR 1; p value: 0.996). Conclusions: The above results suggest that the incidence of colitis is the highest among irAE’s in melanoma patients likely due to immunotherapy. Hypophysitis is the next most common side effect, it’s followed by adrenal insufficiency which can be life-threatening. A high index of suspicion and anticipation of the above complications can lead to their timely detection and treatment.

Cardiotoxicity of 5-fluorouracil in patients with gastrointestinal cancer.

2012 ◽  
Vol 30 (4_suppl) ◽  
pp. 689-689
Author(s):  
Lourdes Lopez ◽  
Paola Catherine Montenegro
Keyword(s):  
Diabetes Mellitus ◽  
Gastrointestinal Cancer ◽  
Coronary Spasm ◽  
Cardiac Monitoring ◽  
Duration Of Symptoms ◽  
Chemotherapy Agent ◽  
Ventricular Extrasystoles ◽  
Cardiovascular Assessment ◽  
Chemotherapy Infusion ◽  
History Of

689 Background: 5-fluorouracil (5-FU) is a agent of chemotherapy that has been associated with cardiotoxicity infrequently. The reports shown incidence of clinically apparent 5-FU cardiotoxicity in 1.6% for patients receiving 5-FU alone or in combination with another agents. Methods: We investigated the clinical characteristics of 5-FU cardiotoxicity in patients with gastrointestinal cancer treated in instituto nacional de enfermedades neoplasicas (INEN) Lima - Peru between October 2009 and October 2010. Results: Between October 2009 and October 2010, were evaluated 240 cases with gastrointestinal cancer treated with 5-FU alone or plus combinations with another chemotherapy agent, 8 cases (3.3%) had cardiotoxicity. 37.5 % had history of cardiovascular disease, 3 patients had a history of hypertension and 1 patient diabetes mellitus plus hypertension. 50% (4 patients ) had normal EKG prior to treatment, 25% (2 patients) had no EKG, In 12.5% (1patient) had sinus tachycardia and another patient had ventricular extrasystoles were detected. After chemotherapy infusion 75% (6) had changes in the EKG. In 8 patients was observed as the main symptom chest pain with radiation to left arm or upper back, without elevated cardiac enzymes. 87.5% (7 patients ) had symptoms after 6 pm. And the duration of symptoms was 48 hours in 62.5% (5 patients), 12.5% (1patient ) in 24 hours and 6 hours in 12.5% (1 patient). One patient died of acute heart failure and had history of hypertension and diabetes mellitus and received the combination cisplatin - 5-FU. Conclusions: The eight cases reports confirm the potential cardiotoxicity of 5-FU and argues the need for cardiovascular assessment by a specialist before the start of treatment in addition to cardiac monitoring in patients during treatment, especially in patients with risk factors especially in the first cycle, women and at night. The mechanism of 5-FU cardiotoxicity is not fully elucidated. Coronary spasm is the most accepted hypothesis.

Evaluate Breathing Exercises on Improvement in Respiratory Status among Patients with Respiratory Diseases

2021 ◽  
pp. 495-498
Author(s):  
Gitima Kalita ◽  
Nabajani Dutta
Keyword(s):  
Respiratory Diseases ◽  
Structured Interview ◽  
P Value ◽  
Pulmonary Medicine ◽  
Deep Breathing ◽  
Breathing Exercise ◽  
Clinical Variables ◽  
Breathing Exercises ◽  
Respiratory Status ◽  
Post Test

Background: Respiratory diseases are typical issue of the airway that hampers the normal airflow and leads to airway inflammation. The impacts of breathing exercises on respiratory diseases have been concentrated to discover its role on improvement of respiratory status. Objective: To estimate breathing exercises on improvement in respiratory status among patients with respiratory diseases. Material and method: A pre experimental, one group pre-test post-test design was adopted on 50 samples with respiratory diseases selected by convenient sampling technique from Medicine (male and female), Pulmonary Medicine, CTVS ward of Guwahati Medical College and Hospital, Assam. Data collected through structured interview schedule for demographic and clinical variables and “modified respiratory status scale” for assessing respiratory status. The group received intervention for 3 minutes one time daily for 7 days. Post-test was done on 7th day. In this study, deep breathing exercise and pursed lip breathing exercise were used. Data were analyzed by using the software package SPSS 2.0 version. Results: the pre-test respiratory status mean was 7.6 and post-test respiratory status mean was 4.98 mean difference was 2.62. The difference in mean scores shows a significant improvement of Respiratory status among patients with Respiratory Diseases. The t’ value of the breathing capacity by using modified respiratory status scale (13.55) was much higher than the ‘p’ value at 0. 05 level of significance. So, Breathing Exercises (Deep Breathing Exercise and Pursed Lip Breathing Exercise) was effective which improve the respiratory status among Respiratory Disease patients. Respiratory status is associated with Gender, History of previous hospitalization and no association with clinical variables. Conclusion: The study concluded that breathing exercises is effective in improvement of respiratory status among patients with respiratory diseases.

Abstract 17063: Enhanced Prediction of Heart Failure 30-Day Readmission Risk With Four Readily-Available Clinical Variables

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Nicholas Wettersten ◽  
Machelle Wilson ◽  
Kathleen Tong ◽  
Javier E López
Keyword(s):  
Heart Failure ◽  
Standard Of Care ◽  
Categorical Variables ◽  
P Value ◽  
Continuous Variables ◽  
Clinical Predictors ◽  
Clinical Variables ◽  
Academic Center ◽  
Multivariate Prediction ◽  
Readmission Risk

Introduction: Heart failure (HF) readmissions, with ~25% within 30 days of discharge, can be reduced with costly post-hospitalization interventions. Determining which patients will benefit from these interventions remains a critical challenge. Hypothesis: We aimed to devise a simple model to predict 30-day HF readmission risk. Methods: Patients ≥21 years of age admitted for HF to a single academic center from July 1st, 2008 to December 31st, 2009 were identified by billing codes for HF. Patients were excluded if they died within 90 days, were transferred, discharged to hospice or prison, or later admitted electively or for a surgical emergency not related to HF. Demographics, co-morbidities, laboratories, vitals, and discharge medications (27 variables) were tested as predictors for risk of 30 day readmission. First, independent univariate testing of categorical variables was performed utilizing a retention p-value of < 0.2. Next, continuous variables and retained categorical variables were tested in a multivariable model with retention of variables with p-value < 0.1. False discovery rate was controlled by the method of Benjamini and Hochberg. Statistical analyses were performed using SAS® software version 9.3. Results: Of 1253 HF admissions, 657 (55.8% men, age 60.9 ± 13.8 men, 66.8 ± 14.5 women) met criteria with complete data. Twenty percent were readmitted within 30 days. Odds for readmission increased 1.6% for every 100 pg/ml increase in BNP (p=0.082), 5.6% for each additional discharge medication (p=0.003), 200% if not discharged on an ACE-I/ARB (p=0.001), and 7% for every 10 mmHg increase in systolic blood pressure at discharge compared to admission (p=0.078). Conclusion: One laboratory value and 3 clinical variables were predictive of 30-day HF readmission risk in a multivariate prediction model. The 3 clinical predictors provoke the idea that “in hospital” care is a predictor and potential target for intervention to reduce 30-day readmission risk. Future validation studies should help define standard-of-care interventions that could still be improved to reduce readmission rates in HF patients as well as address the relative cost of more intense hospital interventions over outpatient interventions.

scholarly journals Performance of the Atherosclerotic Cardiovascular Disease Pooled Cohort Risk Equations by Social Deprivation Status

2017 ◽  
Vol 6 (3) ◽  
Author(s):  
Lisandro D. Colantonio ◽  
Joshua S. Richman ◽  
April P. Carson ◽  
Donald M. Lloyd‐Jones ◽  
George Howard ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Social Deprivation ◽  
Atherosclerotic Cardiovascular Disease ◽  
Deprivation Status

scholarly journals Validation of Modified Paediatric Triage Score in a Tertiary Care Hospital

2020 ◽  
Author(s):  
Bandya Sahoo ◽  
Reshmi Mishra ◽  
Mukesh Kumar Jain ◽  
Sibabratta Patnaik
Keyword(s):  
Intensive Care Unit ◽  
Emergency Department ◽  
Intensive Care ◽  
Scoring System ◽  
Tertiary Care ◽  
P Value ◽  
Care Hospital ◽  
Clinical Variables ◽  
Icu Admission ◽  
Physical Variables

Introduction: The global burden of paediatric mortality is high and majority of the deaths are preventable by providing timely access to specialised emergency care. An appropriate triage in a busy emergency department can identify the sickest patient for early intervention. Aim: To develop a simple score based on physical variables alone and assess its validation so as to predict Intensive Care Unit (ICU) admission. Materials and Methods: This prospective hospital based study included 936 children, aged 1 month to 18 years. Baseline demographic data along with clinical variables were noted in a pre-designed proforma at the time of admission. A scoring system was developed based on severity of various clinical variables i.e., heart rate, respiratory rate, respiratory effort, Oxygen Saturation (SpO2), Capillary Refill Time (CFT), temperature, level of consciousness and behaviour. The outcome i.e., admission to ward or Pediatric Intensive Care Unit (PICU) of the patient was correlated with the study variables and total score. An association of modified PETS with the PICU admission was done using Chi-square test. A p-value of <0.01 was considered as statistically significant. Results: The modified Paediatric Triage Score (PETS) which is developed based on eight physical variables, is reliable in discriminating the children with ward and ICU admission. A score of ≥6 leads to 14.8 times higher risk of getting admitted to ICU as compared to a child with score of <6. A cut-off of ≥6 for modified PETS score has a sensitivity of 79.6% and specificity of 79.2% in predicting ICU admission. Conclusion: This simple clinically developed scoring system based on physical variables alone with an optimal cut-off of ≥6 can predict severity of illness and need for PICU admission in Emergency Department with acceptable validity and can serve as a potentially excellent screening tool.

The effect of Vitamin B6 on chemotherapy induced nausea and vomiting in pediatric cancer

2020 ◽  
Author(s):  
Morteza Mousavi-Hasanzadeh ◽  
Arefeh Adelnia ◽  
Golrokh Farokhmehr ◽  
Sarvenaz Mehrabi ◽  
Sima Zahedi ◽  
...  
Keyword(s):  
Vitamin B6 ◽  
Lymphocytic Leukemia ◽  
Nausea And Vomiting ◽  
Chemotherapy Cycle ◽  
P Value ◽  
Chemotherapy Agent ◽  
Pediatric Clinic ◽  
And Gender ◽  
Rare Malignancy ◽  
Tumor Types

Background: Nausea and vomiting are the common side-effects of chemotherapy in children with malignancy. In this study, the effectiveness of vitamin B6 in reducing the chemo-induced nausea and vomiting (CINV) in children was tested. Material and methods: A triple-blind clinical trials was performed on 100 children with malignancy referring to the pediatric clinic of Amir Kabir Hospital, Arak, Iran. Besides the infusion of granisetron (3mg/3ml) half an hour before each chemotherapy cycle, an intravenous dose of vitamin B6 (100 mg for children from 2 to 5 years old, 200 mg for children from 5 to 10 years old, and 300 mg for children older than 10) was given 6 hours before the first chemotherapy cycle and placebo was injected (2-5 years old: 100 mg, 5-10 years old: 200 mg, age≥ 10 years old: 300mg) 6 hours before the second cycle. Then the severity of nausea and the frequency of vomiting episodes in each cycle were recorded to be compared.  Results: The mean age of children was 7.98 ± 3.133 years old. The most common and rare malignancy were acute lymphocytic leukemia (ALL) (46%) and ependymoma (0.5%), respectively. Vincristin was the most commonly used chemotherapy agent (28%). A positive correlation between the severity of nausea(R=0.313, P-value=0.0016) and frequency of vomiting with age was found (R=0.319, P-value=0.0012). However, no noticeable association was observed between N/V and gender (P-value.0.05). There was a considerable correlation between the frequency of vomiting and different tumor types in this study (P-value=0.0006).In comparison with placebo, Vitamin B6 significantly reduced the severity of nausea (P = 0.0001) as well as the frequency of vomiting (P-value = 0.0005). It was also more effective in ALL compared to rhabdomyosarcoma (P-value=0.001). Conclusion: This study suggested that vitamin B6 can be considered as an appropriate alternative to treat CINV in children with malignancy.

Learning from near misses: Addressing nursing chemotherapy verification fatigue.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 70-70
Author(s):  
Meghan Shea ◽  
Aya Sato-DiLorenzo ◽  
Danielle Wright ◽  
Erika Coletti ◽  
Michael Carvalho ◽  
...  
Keyword(s):  
Processing Time ◽  
Near Miss ◽  
Near Misses ◽  
Outpatient Chemotherapy ◽  
Survey Response Rate ◽  
Chemotherapy Infusion ◽  
Pre Treatment ◽  
Verification Process ◽  
Recent Patient ◽  
Common Barriers

70 Background: Administration of chemotherapy is high-risk, requiring multiple safety checks, including pre-treatment laboratory value verification by nursing. A recent series of near misses in our event reporting system highlighted that nurses verified chemotherapy orders with pending pre-treatment or abnormal labs, such as grade 2 hyperbilirubinemia and grade 4 neutropenia. Such laboratory results would normally require holding or modifying planned treatment doses. Methods: Nurses treating patients in the outpatient chemotherapy infusion units were surveyed regarding barriers to pre-treatment lab verification. A team of clinicians, nurses, and pharmacists outlined a process map of the order verification process from acknowledging patient assignment and looking at patient oncologic history to sending the physician order to pharmacy. Pharmacists collected baseline data by tracking near-miss incidents. Results: The survey response rate of outpatient treatment nurses was 18 of 32 (56%). Nurses ranked inconsistent notation of treatment criteria in orders, long lab processing time, and patient frustration with a long wait as the most common barriers to lab verification. At baseline, in six non-consecutive weeks from August-October 2016, 31 of 947 (3%) orders were inappropriately verified by nursing in which pre-treatment lab results were pending or lab results did not meet parameters in the chemotherapy order. The team’s aim is by February 1, 2017, to reduce the number of chemotherapy orders sent to pharmacy without proper lab verification by 50%. Conclusions: Chemotherapy verification fatigue, specifically pre-treatment lab near misses, was identified as an area for improvement from recent patient safety reports. Barriers for nurses include inconsistent notation of treatment criteria in orders, long lab processing time, and patient frustration with a long wait. Interventions are underway to improve nursing adherence to pre-treatment lab verification.

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