Taking a Practice-Based Immuno-Oncology Program to the Next Level

ACCC 2018 Innovator Award Winner Sidney Kimmel Cancer Center at Jefferson Health in Philadelphia, PA, has implemented new tools and processes to deliver a proactive, multidisciplinary team approach to caring for patients on cancer immunotherapies via continuous symptom monitoring and effective management of immune-related adverse events. Guest blogger Tracy Virgilio, RN, MSN, CCRC, OCN, describes the steps involved in taking their immunotherapy program to the next level.

Early triage and medical intervention are critical for managing symptoms in patients on immunotherapy. Because symptoms of side effects from immunotherapy present much differently than those resulting from chemotherapy and pose very different challenges—providers need point-of-care, fast access to resources that support early recognition and management of immune-related adverse event (irAEs). At Sidney Kimmel Cancer Center we have leveraged our electronic health record (EHR) platform so that all cancer patients receiving immunotherapy are identified immediately and the care team can rapidly access the appropriate triage algorithms.

Through our Epic EHR we can identify patients on immunotherapy treatments via banners in their patient chart and access the appropriate triage algorithm for managing a patient’s immune-related symptoms. These algorithms decrease the time from initial intake to office visit and allow for earlier medical intervention.

Developing Triage Algorithms
Our physician champion and the melanoma nursing team created two sets of immunotherapy triage algorithms: one for on-call physicians and one for nursing. The algorithms for the on-call physicians follow specific clinical guidelines that provide non-oncology clinicians with the tools to properly identify and treat any immunotherapy patient in a timely fashion and circumvent an Emergency Department (ED) visit.

Working with these clinical guidelines and the Clinical Journal of Oncology Nursing Melanoma Management supplement,¹ we developed nursing immunotherapy algorithms. These guide the nursing staff in assessing any patient on immunotherapy over the phone and empower the nurses to recognize any potential life-threatening reactions and intervene.

We have algorithms for many conditions, including but not limited to:

• Skin toxicity
• Gastrointestinal toxicity
• Hepatotoxicity
• Hypophysitis
• Mucocitis and xerostomia
• Type 1 diabetes
• Pneumonitis.

For our nursing algorithms, Sidney Kimmel Cancer Center has included a nursing assessment that encompasses chart review, patient feedback, patient education, and grading toxicity. Once the assessment is complete, the patient may be managed at home, seen in our same-day clinic, or admitted, depending on the symptom or symptoms present. All symptoms are recorded and tracked.

Our practice developed a “triage symptom note” in the EHR which is prepopulated with the most common immunotherapy symptoms, grading (mild, moderate, or severe), and the action taken (observation, clinic visit, ED visit, or admission). View video to learn more.

Sidney Kimmel Cancer Center is an Oncology Care Model (OCM) participant. As part of our practice transformation, the OCM project director, runs a weekly triage symptom and outcome report that includes the elements of the triage note. The report is reviewed by nursing leadership to determine if the management of the patient was appropriate, and then escalates any concerns to our physician champions for further review and action. All triage notes are reviewed weekly for nurse compliance, modification of algorithms, and continuing education.

The above initiatives, developed by our physician champion and the melanoma nursing team, have helped Sidney Kimmel Cancer Center transform our practice and improve outcomes and the overall quality of patient care. Some of the results we have seen include: prompt response to symptom management, empowerment of the nursing staff, the ability for nurses to work to the top of their license, and greater patient satisfaction. Our process is still in the infancy stage of reviewing the Emergency Department data to determine if the triage process has decreased ED visits. However, we do know that this process has been implemented on a much smaller scale at a sister site, where they have seen a 12 percent decrease in ED visits.

ACCC Cancer Program Member Sidney Kimmel Cancer Center at Jefferson Health will be sharing “how we did it” details on this initiative in an upcoming session at ACCC 35^th National Oncology Conference in October. 

Reference

1. McGettigan S, Rubin KM. PD-1 inhibitor therapy: Consensus statement from the faculty of the Melanoma Nursing Initiative on managing adverse events. Clin J Oncol Nurs. Aug 1;21(4 Suppl):42-51.
   
   Guest blogger Tracy Virgilio, RN, MSN, CCRC, OCN, is Nurse Manager Ambulatory Care at the Sidney Kimmel Cancer Center at the Thomas Jefferson University Health System in Philadelphia, Pa.