JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Documentation of chemotherapy administration by nursing staff in inpatient and outpatient oncology/hematology settings: a best practice implementation project Allison Turner
1
Matthew Stephenson
2
1. Chemotherapy Clinical Development Nurse, Cancer, Ambulatory and Community Health Service, Canberra Hospital and Health Services. Australia 2. The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Australia
Primary contact Allison Turner
[email protected] Key dates Commencement date: July 2014 Expected Completion date: December 2014
Executive summary Background Documentation of chemotherapy administration by nursing staff is undertaken in a written and electronic form at the Canberra Hospital and has been identified as requiring improvement in both inpatient and outpatient settings. Safe prescribing, dispensing, administration and documentation are essential to patient safety, outcomes and quality of care, and to staff safety. Due to the limited available research and evidence on this topic, recommended safety standards for the safe administration of chemotherapy formed the framework for audit criteria and documentation requirements. Objectives The aim of this evidence implementation project was to improve documentation of chemotherapy administration by nursing staff in inpatient and outpatient oncology/hematology units, thereby improving patient care and safety, as well as meeting the legal and educational responsibilities of the nursing staff.
doi: 10.11124/jbisrir-2015-2157
Page 316
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Methods This evidence implementation project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. A baseline audit was conducted to assess current practice and identify areas requiring improvement, followed by reflection on results and design, and implementation of strategies for documentation improvement. Lastly, a follow-up audit was conducted to assess compliance and practice improvement. Results The baseline audit results highlighted areas of good current practice, areas requiring improvement and barriers to data collection and practice improvement. Strategies based on raising awareness of best practice guidelines, education and useful tools were developed and implemented. It was evident that the electronic documentation prompts used in the outpatient setting, compared to paper-based documentation in the inpatient setting, contributed to better compliance to documentation guidelines. The follow-up audit demonstrated improved practices across both the inpatient and outpatient settings. Conclusions The aim of improving documentation after chemotherapy administration was achieved, yet there is still room for further improvement. Education will continue through training courses, communication at meetings and utilization of the tools developed. Future auditing is planned to ensure sustainability. Keywords audit; best practice; chemotherapy; documentation; evidence implementation; inpatient; outpatient
Background Chemotherapy and targeted therapies are used for the treatment of malignant and non-malignant diseases, and may be used with curative or palliative intent. Safe prescribing, dispensing, administration and documentation are essential to patient safety, outcomes and quality of care, and to staff safety.
1,2
Patients being treated for a cancer diagnosis require holistic, multifactorial care,
involving on-going physical and psychological assessment and care.
3
Timely, relevant and detailed documentation is vital from both medical and legal perspectives, and is 4
an essential nursing responsibility. Documentation enables communication of information relevant to the patient’s needs, condition, care and treatment, and is useful when investigating incidents 4
concerning chemotherapy administration.
Documentation may be completed in a written and electronic form and has been seen to require 4
improvement in both inpatient and outpatient settings. During routine clinical record reviews and investigation of chemotherapy related incidents at the Canberra Hospital by the author, it was found that some documentation lacked important information regarding chemotherapy protocol, blood results, intravenous access and patency, physical and psychosocial assessment of the patient,
doi: 10.11124/jbisrir-2015-2157
Page 317
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
administration of prescribed medications, post-administration requirements and care, and safe handling. This quality improvement project targeted two oncology/hematology units at the Canberra Hospital – one inpatient unit and one outpatient unit. Ward 14B is a 44-bed inpatient ward for any patient with a cancer diagnosis, with an average of five to ten patients a day requiring chemotherapy administration. 5
On Ward 14B, chemotherapy is prescribed using the CHARM™ electronic system , but with paperbased documentation of the prescription and a paper-based clinical record. CHARM™ is an oncology information management solution for cancer care clinical coordination and management enabling electronic prescribing of chemotherapy protocols by hematology and oncology consultants and advanced trainees. The system is backed by appropriate protocols located on eviQ (NSW Cancer 6
7,8
Institute) , and recent journal articles based on evidence-based practice and clinical trials.
Level 4 of
the Canberra Region Cancer Centre is an outpatient oncology/hematology unit that currently treats approximately 60 patients a day, of which 90% receive chemotherapy. The chemotherapy prescription and all clinical (medical and nursing) documentation are done electronically on CHARM™, with a paper-based copy of the prescription signed and scanned onto the electronic clinical record. Documentation in the inpatient setting is individual staff member dependent, with an absence of guidelines available for paper-based documentation at the baseline audit. In the outpatient setting, all documentation is completed electronically on the CHARM™ system, where documentation guidelines according to best practice are partly supported by the drop-down “Notes” box containing the following prompts:
Cycle/Day
Bloods
Patient assessment
IVC inserted
CVAD
Treatment given
Issues/Complications
Appointments confirmed
Discharge medications provided.
Despite the different mechanisms for documentation in the two settings, the information should be the same. There is little research and evidence available on this topic; however a number of nursing groups and experts support safety standards for the safe administration of chemotherapy, including the Clinical 1
Oncological Society of Australia (COSA) and the American Society of Clinical Oncology/Oncology 2
Nursing Society (ASCO/ONS). The recommended standards form a framework for documentation requirements. Auditing took place across both inpatient and outpatient oncology/hematology units of the Canberra Hospital, using document review. The aim was to audit chemotherapy documentation on 100 occasions of service- 50 inpatients and 50 outpatients. The stakeholders of this project were identified
doi: 10.11124/jbisrir-2015-2157
Page 318
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
as the Director of Nursing and the Assistant Director of Nursing of Cancer, Ambulatory and Community Health Support (CACHS), and the Clinical Nurse Consultants of the inpatient and outpatient settings. The Project Leader performed all audits, collation, education and practice change, with support from managerial stakeholders.
Aims and objectives The aim of this evidence implementation project was to improve documentation of chemotherapy administration by nursing staff in inpatient and outpatient oncology/hematology units, thereby improving patient care and safety, as well as meeting the legal and educational responsibilities of the nursing staff. The specific objectives of the project were to:
Identify current practices in inpatient and outpatient oncology/hematology settings
Reflect on baseline audit results and design strategies to implement best practice underpinned by expert standards and recommendations
Devise an education program for chemotherapy nurses to address recommended documentation guidelines and areas of non-compliance
Undertake a follow-up audit to assess the extent and nature of increased compliance with recommended best practice
Identify strategies to sustain and enhance improved chemotherapy documentation by nursing staff.
Methods This evidence implementation project used the JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tool. The PACES and GRiP framework for promoting evidence-based health care involves three phases of activity: 1
Establishing a team for the project and undertaking a baseline audit based on criteria informed by the evidence.
2
Reflecting on the results of the baseline audit, and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework.
3
Conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identify future practice issues to be addressed in subsequent audits.
Audit criteria were developed based on a JBI Evidence Summary on chemotherapy documentation by nursing staff, including the best available evidence identified from a structured search of the literature 9
and selected evidence-based health care databases. Due to a lack of specific research evidence on chemotherapy documentation, audit criteria were formulated according to expert guidelines for 1
chemotherapy administration from the Clinical Oncological Society of Australia (COSA) and the American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS).
2
Low level ethics approval was sought due to the need to access clinical records; however the ACT Health Human Research Ethics Committee – Low Risk Sub-Committee deemed this work to be a quality assurance project, thereby not requiring ethics approval.
doi: 10.11124/jbisrir-2015-2157
Page 319
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Data was collected from patients’ paper clinical notes in the inpatient setting, and by accessing patients’ electronic clinical records in the outpatient setting. The audit criteria were pilot tested prior to commencement of the baseline audit to ensure their applicability to the inpatient and outpatient settings. Phase 1: Stakeholder engagement (or team establishment) and baseline audit The project leader and first author of this article is the Chemotherapy Clinical Development Nurse at the Canberra Hospital, and undertook this project in order to complete a Joanna Briggs Institute Evidence Based Clinical Fellowship Program. All data collection and data analysis were completed by the project leader. Support was provided by managerial stakeholders of the Canberra Hospital’s Division of Cancer, Ambulatory and Community Health Support: Gaynor Stevenson, Director of Nursing Denise Breust, Assistant Director of Nursing Wendy Spencer, Clinical Nurse Consultant, Outpatient Oncology/Immunology Kathlene Robson, Clinical Nurse Consultant, Outpatient Hematology Sue Langdon, Clinical Nurse Consultant, Inpatient Hematology/Oncology David Larkin PhD, Research Officer All registered nursing staff who administer chemotherapy were deemed to be stakeholders in this project. The baseline audit was conducted during September 2014. Table 1 below shows the evidence informed audit criteria used in the project (baseline and follow-up audit) together with a description of the sample and approach to measuring compliance with best practice for each audit criterion. The audit criteria used in the inpatient and the outpatient settings were identical. Audit criteria were assessed with Yes, No and Not Applicable (N/A) responses. Table 1: Audit criteria Audit criterion
Sample
Method used to measure % compliance with best practice
1. It is documented that the presence or absence of medication allergies has been checked
50 occasions of chemotherapy administration in each setting
Electronic medication chart checked for documentation of allergies
2. Assessment of access device required for administration is documented
50 occasions of chemotherapy administration in each setting
Type of access device and proof of patency documented
3. Pre-medication/prehydration is documented
50 occasions of chemotherapy administration in each setting
Could be documented either in the clinical notes or signed for on the CHARM™ chart
4. Chemotherapy administration according to the protocol is documented
50 occasions of chemotherapy administration in each setting
Could be documented either in the clinical notes or signed for on the CHARM™ chart
doi: 10.11124/jbisrir-2015-2157
Allergies could be documented by nursing staff if not completed by prescribing doctor
Page 320
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Audit criterion
Sample
Method used to measure % compliance with best practice
5. Post-medication/posthydration is documented
50 occasions of chemotherapy administration in each setting
Could be documented either in the clinical notes or signed for on the CHARM™ chart
6. Treatment related toxicities/side–effects are documented
50 occasions of chemotherapy administration in each setting
Toxicities/side-effects/reactions (or lack of same) documented in clinical notes
7. Self-care instructions for patient post administration are documented
50 occasions of chemotherapy administration in each setting
Any instructions (e.g. taking anti nausea medication, attending mouth care) documented in clinical notes
8. Duration of cytotoxic precautions is documented
50 occasions of chemotherapy administration in each setting
Documentation of how long cytotoxic precautions are to be observed
9. Follow-up appointment/next cycle is documented
50 occasions of chemotherapy administration in each setting
When and where next cycle or appointment is booked for
10. Referrals to services are documented
50 occasions of chemotherapy administration in each setting
Referral made to any multidisciplinary service documented in clinical record
11. Chemotherapy nurses have received education regarding appropriate documentation applicable to chemotherapy administration
10 Registered Nurses in the inpatient setting and 40 Registered Nurses in the outpatient setting
Verbal questioning of staff
12. The patient’s diagnosis is documented
50 occasions of chemotherapy administration in each setting
Automatically documented as part of prescription on CHARM™ chart
13. It is documented that recent blood tests have been checked and action taken as required
50 occasions of chemotherapy administration in each setting
Documented acknowledgement in the clinical notes that blood tests had been checked
14. Physical assessment of the patient is documented
50 occasions of chemotherapy administration in each setting
Specific issues or “nil known complaints” documented in clinical notes
15. Psychosocial assessment of the patient is documented
50 occasions of chemotherapy administration in each setting
Specific issues or “nil known complaints” documented in clinical notes
doi: 10.11124/jbisrir-2015-2157
Page 321
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Audit criterion
Sample
Method used to measure % compliance with best practice
16. Patient education is documented
50 occasions of chemotherapy administration in each setting
Documentation in the clinical notes confirming that patient education had been provided
17. Informed consent or approval to proceed is documented
50 occasions of chemotherapy administration in each setting
Documentation of patient’s verbal consent, or doctor’s approval to proceed
18. Verification of the treatment plan (protocol), chemotherapy order and patient identification by two qualified staff is documented
50 occasions of chemotherapy administration in each setting
Each page of CHARM™ chart (prescription) signed by the qualified nurse who will administer the chemotherapy and the checker with CCC (CHARM™ Chart Check)
Phase 2: Design and implementation of strategies to improve practice (GRiP) At the inception of this project, chemotherapy administration documentation was placed on agendas of ward/area meetings, Nursing Governance meetings and Clinical Development Nurse meetings within the cancer service, and as an integral part of chemotherapy training. These forums enabled regular communication, information and result sharing, as well as identification of barriers to effective documentation after chemotherapy administration. Best practice guidelines were identified and used both as audit criteria and documentation topics. Using PACES, the baseline audit identified areas of good and excellent practice and areas of reduced or no compliance. Education was the primary strategy to improve compliance, with a number of tools and communication techniques required to target staff across the two areas. Phase 3: Follow-up audit post implementation of change strategy The objective of the follow-up audit was to measure improvement of documentation, in line with best practice guidelines. The follow-up audit was conducted in the same manner as the baseline audit, using the same audit criteria and sample sizes.
doi: 10.11124/jbisrir-2015-2157
Page 322
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Results Phase 1: Baseline audit The results of the baseline audits are shown in Figure 1 (a) for the inpatient setting, and 1 (b) for the outpatient setting.
Figure 1 (a): Compliance with best practice audit criteria in baseline audit (%) in the inpatient hematology/oncology setting
Figure 1 (b): Compliance with best practice audit criteria in baseline audit (%) in the outpatient hematology/oncology setting
doi: 10.11124/jbisrir-2015-2157
Page 323
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Criterion 1 (it is documented that the presence or absence of medication allergies has been checked) achieved results of only 44% compliance in the inpatient setting and 58% in the outpatient setting. While the prescribing doctor should document the presence or absence of medication allergies on the CHARM™ Chart prescription, it is the administering nurse’s responsibility to check for allergies and document them accordingly. This is an area that must be improved and sustained. Criterion 2 (assessment of access device required for administration is documented) achieved 100% compliance across both areas as it is such a vital component of chemotherapy administration. Documentation of premedication/pre-hydration (criterion 3) showed 83% compliance in the inpatient setting and 98% in the outpatient setting, with documentation of chemotherapy administration according to protocol (criterion 4) showing 88% compliance in the inpatient setting and 98% in the outpatient setting. Post medication/post hydration (criterion 5) was only documented in the inpatient setting on 42% of occasions, but may have been overlooked due to the orders being prescribed on the CHARM™ chart. The outpatient compliance was 95%. Toxicities/side effects/reactions (criterion 6) were only documented in the inpatient setting on 44% of occasions, and on 50% of occasions in the outpatient setting, primarily when they had occurred rather than when they were absent. Self-care instruction documentation (criterion 7) showed poor compliance in the inpatient setting, but may be explained by the fact that instructions are documented on a chart that does not form part of the patient’s clinical record. Documentation of self-care instructions in the outpatient setting showed compliance of only 16% on occasions of service, but should be noted that self-care instructions are explained at the initial education session and verbal reminders are given at each visit. Duration of cytotoxic precautions is documented (criterion 8) also achieved poor results of 18% in the inpatient setting, where observance of cytotoxic precautions was documented in the clinical record, but the duration of precautions was only documented on a sign that did not form part of the clinical record. Cytotoxic precautions in the outpatient setting were not documented at all, thereby achieving a 0% result. However, cytotoxic precautions are addressed in the pre-treatment education session. Follow-up appointments and treatment cycles (criterion 9) were only documented in the inpatient setting on 18% of occasions, which is understandable considering patients receiving chemotherapy in an inpatient setting tend to be more unwell, endure longer protocols and take longer to recover from treatment, therefore follow-up appointments are more difficult to book. Compliance in the outpatient setting was 98%. Referrals to other services (criterion 10) were documented in the inpatient setting on 40% of occasions, but are often already in place in the inpatient setting. Referrals to services from the outpatient setting (such as Community Nursing, Cancer Nurse Care coordinators, allied health and support networks) were made on 88% of occasions of service. Criterion 11 (chemotherapy nurses have received education regarding appropriate documentation applicable to chemotherapy administration) also achieved 100% compliance in that, on questioning, staff had received some form of education, but not necessarily according to all the best practice guidelines.
doi: 10.11124/jbisrir-2015-2157
Page 324
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Criterion 12 (the patient’s diagnosis is documented) achieved 100% compliance across both areas as it forms part of the CHARM™ Chart prescription. Blood results checking (criterion 13) in the inpatient setting was only documented on 52% of occasions, but this may be due to subsequent days of a chemotherapy protocol, where blood tests may not have been repeated or treatment would proceed regardless of results. Outpatient compliance was 79%. In the inpatient setting, physical assessment of patients (criterion 14) was only documented on 40% of occasions, with psychosocial assessment (criterion 15) only mentioned in 10% of notes. It must be noted that as inpatients, these assessments are regularly attended and documented by medical staff and ward nurses, thereby forming part of the patient’s clinical record. In the outpatient setting, physical assessment was documented on 78% of occasions, with psychosocial assessment documented on 50% of occasions. Education of the patient (criterion 16) pertained to education being provided on that occasion of service, most often referring to the formal education session given prior to commencing treatment, which showed 74% compliance in the inpatient setting and 86% in the outpatient setting. There were 74 occasions deemed not applicable as they were subsequent days or cycles of treatment. Criterion 17 (informed consent or approval to proceed is documented) achieved poor results of 10% in the inpatient setting and 0% in the outpatient setting, as written consent for chemotherapy administration is not sought or given in the Division of Cancer, Ambulatory and Community Health Support. Approval to proceed from the patient or medical officer will occasionally be documented by the chemotherapy nurse in the inpatient setting, while a patient arriving for a treatment appointment is deemed to be consenting in the outpatient setting. The baseline audit showed that chemotherapy nurses in the inpatient setting only documented verification of the treatment plan (protocol), chemotherapy order and patient identification by two qualified staff (criterion 18), seen in the signing by both staff with a CCC (CHARM™ Chart Check) on the paper based prescription, 70% of the time. In the outpatient setting, criterion 18 showed excellent compliance, as seen in the CCC (CHARM™ Chart Check), at 94% of occasions of service. The baseline results clearly showed areas of good compliance across both settings, and areas where improvement could be made. Explanations of other services and tools in place in the inpatient setting justified the results of some criteria. Phase 2: Strategies for Getting Research into Practice (GRiP) Careful consideration was given to developing strategies for GRiP, as they had to be introduced across the outpatient setting and the inpatient setting where staff worked rotating shifts. Communication was essential throughout the six months of this project, starting with areas requiring improvement according to best practice guidelines being acknowledged and accepted, what forms of communication, education and changes would be beneficial, and how best to feedback information and results. The decision was made to ensure chemotherapy documentation was a standing item on all meeting agendas, including ward/area meetings, chemotherapy staff meetings, Clinical Development Nurse meetings and Nursing Governance meetings (the latter allowing feedback, results and information to managers).
doi: 10.11124/jbisrir-2015-2157
Page 325
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
“Documentation guidelines around chemotherapy administration” (Appendix I) was developed according to best practice guidelines and made available to staff by email, and laminated and displayed at all work stations in the inpatient and outpatient settings. Staff in the outpatient setting also had the added advantage of electronic documentation and the drop down “Notes” box on CHARM™ which addresses eight of the criteria. Baseline audit results were also distributed to staff via email and presented at meetings. Chemotherapy documentation tags (Appendix II) for lanyards and ID tags were developed and laminated, then distributed to all nursing staff who administer chemotherapy, enabling guidelines to be available to staff at all times. The guidelines were also included in the Antineoplastic Drug Administration Course that was facilitated by the author in the Division of Cancer, Ambulatory and Community Health Support. Table 2 shows the key barriers to compliance with best practice that were identified, along with the strategies developed to overcome these barriers. The resources that were required for the implementation strategies are detailed as well as the outcomes achieved. Table 2: GRiP matrix Barrier
Strategy
Resources
Outcomes
Lack of staff knowledge regarding guidelines for documentation
Education sessions
Development of documentation guidelines
Agenda item for ward meetings, Nursing Governance meetings, chemotherapy meetings and Clinical Development Nurse meetings
Documentation guidelines around chemotherapy education tool developed (see Appendix I)
Staff have better understanding of specific guidelines for documentation after chemotherapy administration
Available time for thorough documentation
Inclusion in Antineoplastic Drug Administration Course
Ensure the guidelines are readily available for staff allowing rapid consultation
Laminated and placed at each work station Minuted at each meeting Guidelines emailed to all staff (Registered Nurses) who administer chemotherapy
Chemotherapy Documentation tag produced for inclusion on staff members’ lanyard ID (Appendix II)
More thorough documentation and increased efficiency with the guidelines readily available
Utilization of drop down box in Charm™ Encounters (clinical notes) in outpatient setting
doi: 10.11124/jbisrir-2015-2157
Page 326
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Phase 3: Follow-up audit(s) After six to eight weeks of implementing strategies of GRiP, follow-up audits were conducted using the same audit criteria and sample size of 100 occasions of service – 50 in the inpatient setting and 50 in the outpatient setting. The follow-up audit results, compared to the baseline audit results, for the inpatient setting are shown in Figure 2 (a) and those for the outpatient setting are shown in Figure 2 (b).
Figure 2 (a): Compliance with best practice audit criteria in follow-up audit compared to baseline audit (%) in the Inpatient Hematology/Oncology setting
doi: 10.11124/jbisrir-2015-2157
Page 327
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Figure 2 (b): Compliance with best practice audit criteria in follow-up audit compared to baseline audit (%) in the Outpatient Hematology/Oncology setting In Figures 2 (a) and 2 (b), criteria which showed a high compliance rate in the baseline audit remained largely unchanged in the follow-up audit across both settings. As can be seen from Figure 1 (b), criteria 2, 3, 4, 5, 9, 13 and 14 rated between 78% and 100% in documentation compliance in the outpatient setting, most likely due to the availability of drop down notes on the electronic CHARM™ system.
doi: 10.11124/jbisrir-2015-2157
Page 328
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
There was obvious improvement in varying degrees across many of the remaining criteria. However, poorer compliance to four criteria (criteria 1, 2, 7 and 10) in the inpatient setting and five (criteria 2, 5, 7, 13 and 16) in the outpatient setting were demonstrated in the follow-up audit.
Discussion The aim of this implementation project was to improve nursing documentation of chemotherapy administration in the inpatient and outpatient settings of the Canberra Hospital. In the inpatient setting, the follow-up audit showed improvements in 12 of the 18 criteria, with another two criteria remaining unchanged at 100%. In the outpatient setting, there were improvements in 10 of the 18 criteria, with another three criteria remaining unchanged at 98-100%. The prompts available in the CHARM™ electronic documentation used in the outpatient setting contributed to better evidence based documentation. Feedback and results from both audits to nursing staff occurred at ward meetings and via email. Results were presented to managers at education meetings and nursing governance meetings. In both settings, the distribution of guidelines through posters, email, prompt cards for lanyards and inclusion of the guidelines in the chemotherapy training course raised awareness of recommended best practice for documentation around chemotherapy administration. In the inpatient setting, there was marked improvement in the documentation of post-medication and post-hydration (criterion 5), toxicities/side effects/reactions (criterion 6), follow-up appointments (criterion 9), blood results checking (criterion 13), physical assessment (criterion 14) and patient education (criterion 16). In the outpatient setting, there was noted improvement in the documentation of toxicities/side effects/reactions (criterion 6) and physical assessment (criterion 14), along with consistent compliance in many of the other criteria. The challenges of this project revolved around concentrating on two settings, the need for 18 criteria to address recommended guidelines and changing of staff’s documentation habits. The feedback from staff on the strategies implemented through GRiP was very positive, and further improvement in practice is expected. The wording of the criteria dictated the actual data collected, and different results would have been achieved if they had been worded slightly differently. For example, the duration of cytotoxic precautions documented in the inpatient setting resulted in the poor compliance of 8% in the follow-up audit, whereas there would have been 90-100% compliance had it just said “documentation of the need for cytotoxic precautions”. The results of documentation of referrals (criterion 10) in the inpatient setting did not allow acknowledgement of referrals by clinicians other than staff administering chemotherapy, so removal of this criteria for future auditing in the inpatient setting would be considered. Criterion 11 (chemotherapy nurses have received education regarding appropriate documentation applicable to chemotherapy administration) would need to be more specifically written in order to gain more accurate data. All nurses have had education about documentation, but it would be useful to know if they were aware of the specific guidelines recommended as best practice for chemotherapy administration. While criterion 18 (verification of the treatment plan [protocol], chemotherapy order and patient identification by two qualified staff is documented) improved from 70% to 78% with each page of the
doi: 10.11124/jbisrir-2015-2157
Page 329
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
CHARM™ chart being signed and dated in the inpatient setting, it is suspected that the task was in fact performed 100% of the time. Continued education will be required to ensure staff sign each page of the order. The relatively poor performance for documentation of presence or absence of medication allergies (criterion 1) will require education of the doctors who prescribe chemotherapy, as well as further education to nursing staff on their responsibility to check and document the presence or absence of allergies on the CHARM™ chart. The main area of non-compliance, and deemed to be impossible to rectify, is the gaining of consent for administration of chemotherapy. The Canberra Hospital does not require written consent for the administration of chemotherapy for either inpatients or outpatients. Consequently, improved results for this criteria are not expected. In order to continue to improve and sustain thorough documentation around chemotherapy administration, the plan is to continue to distribute the tools developed and include education in area/ward meetings and chemotherapy administration courses. The CHARM™ system is currently under review at the Canberra Hospital, and the possibility of expanding the drop down “Notes” box to include more criteria based on the guidelines is being explored. A second follow-up audit is planned in six to 12 months to maintain and sustain practice change.
Conclusion Documentation is an essential nursing responsibility from medical, legal and information-sharing perspectives. Thorough documentation after administration of chemotherapy is essential to patient safety, outcomes, quality of care and staff safety. Due to the limited available research and evidence on this topic, recommended safety standards for the safe administration of chemotherapy formed the framework for the audit criteria and documentation requirements. Different documentation techniques between the inpatient setting and the outpatient setting made standardized education and tools necessary, in order to cover all areas of practice based on the best practice guidelines, and not only the areas of poor compliance. The inpatient setting still uses paper based documentation, while the outpatient setting is fully electronic and includes the drop-down “Notes” box on CHARM™, which addresses eight of the recommended criteria, with the possibility of expansion being explored. There is also the possibility of the remaining criteria being added in the future. In conclusion, the aim of improving documentation after chemotherapy administration was certainly achieved, yet there is still room for further improvement. Education will continue through training courses, communication at meetings and utilization of the tools developed. It is clear that this project promoted understanding and raised awareness of the recommended guidelines to all staff administering chemotherapy in both inpatient and outpatient settings.
Conflict of interest The authors declare that there were no conflicts of interest.
doi: 10.11124/jbisrir-2015-2157
Page 330
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Acknowledgements
Alexa McArthur and the staff of the Joanna Briggs Institute
Research Centre for Nursing and Midwifery Practice, The Canberra Hospital
My fellow Clinical Fellows
David Larkin, Clinical Cancer Research Nurse, The Canberra Hospital
Director of Nursing and Assistant Director of Nursing, Cancer, Ambulatory and Community Health Support, The Canberra Hospital
doi: 10.11124/jbisrir-2015-2157
Page 331
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
References 1.
Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol. 2010;6(3): 220-37.
2.
Vioral AN, Kennihan HK. Implementation of the American Society of Clinical Oncology and Oncology Nursing Society chemotherapy safety standards. Clin J Oncol Nurs. 2012;16(6): E22630.
3.
Henry R, Hartley B, Simpson M, Doyle N. The development and evaluation of a holistic needs assessment and care planning learning package targeted at cancer nurses in the UK. ecancermedicalscience. 2014;8: 416.
4.
Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. J Adv Nurs. 2011;67(9): 1858-75.
5.
Charm Health. CHARM™. 2014. [Internet]. [Cited July 2014]. Available from: http://www.charmhealth.com.au/charm-products/charm/
6.
Cancer Institute NSW. eviQ, Cancer Treatments online. 2014. [Internet] [Cited July 2014]. Available from: https://www.eviq.org.au/
7.
Valle JW, Wasan H, Johnson P, Jones E, Dixon L, Swindell R, et al. Gemcitabine alone or in combination with Cisplatin in patients with advanced or metastatic cholangiocarcinomas or other biliary tract tumours: a multicentre randomized phase II study- The UK ABC-01 Study. Br J Cancer. 2009;101(4): 621-7
8.
Warnick RE, Prados MD, Mack EE, Chandler KL, Doz F, Rabbitt JE, Malec MK. A phase II study of intravenous Carboplatin for the treatment of recurrent glioma. J Neurooncol. 1994;19(1): 6974.
9.
Stephenson M. Chemotherapy: documentation by nursing staff (inpatient and outpatient settings). JBI COnNECT+ (Clinical Online Network of Evidence for Care and Therapeutics). Adelaide. 2014. [Internet]. [Cited July 2014]. Available from: http://connect.jbiconnectplus.org/ViewDocument.aspx?0=11042
doi: 10.11124/jbisrir-2015-2157
Page 332
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Appendix I: Documentation guidelines around chemotherapy administration The following guidelines are recommended by The Clinical Oncological Society of Australia (COSA) and The American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS):
Allergies - while this is initially the doctor’s responsibility, it becomes ours when checking the patient’s ID & allergies
Diagnosis - automatically on Charm chart
Blood results checked
Physical assessment - what is relevant, or document “nil complaints”
Psychosocial assessment - what is relevant, or document “nil complaints”
Patient education - when provided
Consent or approval to proceed
Verification of treatment plan (protocol), chemotherapy order and patient ID by 2 qualified staff (CCC) each day of treatment
Access device assessment
Pre-medication / pre-hydration
Chemotherapy administration according to protocol – signed and times filled in on Charm chart
Post-medication / post-hydration
Toxicities / Side effects – occurrence or absence
Self-care instructions (mouth care, skin care, anti-emetics, etc)
Duration of cytotoxic precautions – i.e. until when
Follow-up appointment / Next cycle
Referral to other services – if applicable
Remember, thorough documentation not only covers you legally, but informs your colleagues and the multidisciplinary team about the patient, ultimately assisting in the care of your patient.
doi: 10.11124/jbisrir-2015-2157
Page 333
JBI Database of Systematic Reviews & Implementation Reports
2015;13(10) 316 - 334
Appendix II: Chemotherapy documentation
Allergies
Diagnosis - automatically on Charm chart
Blood results checked
Physical assessment
Psychosocial assessment
Patient education
Consent or approval to proceed
CCC- signed x 2 each day
Access device assessment
Pre-medication / pre-hydration
Start & finish times completed-Charm chart
Post-medication / post-hydration
Toxicities / Side effects
Self-care instructions
Duration of cytotoxic precautions
Follow-up appointment / Next cycle
Referral to other services
doi: 10.11124/jbisrir-2015-2157
Page 334