Purpose: Provision of optimal care is an essential component of veteran-centered care. The objectives of this evaluation were to assess the existing process of supportive care management in patients who receive chemotherapy and to optimize current practices to improve the veteran experience.
Methods: This project was a quality improvement assessment and was reviewed and approved by oncology staff (providers and nurses), the chief of staff, the chief of pharmacy, and the Pharmacy and Therapeutics Committee. Current supportive care practices were assessed to identify chemotherapy treatment plans that defaulted to IV supportive care medications. Veterans receiving these regimens were then evaluated by a clinical pharmacist using National Comprehensive Cancer Network Antiemetic Guidelines to assess eligibility for a switch from IV to oral antiemetics. An automatic switch to oral products was made, if appropriate. Following conversion from IV to oral therapy, a chart review was completed to assess changes in supportive care medication use (ie, increased refills), identify patients who switched back to IV antiemetics with future cycles of chemotherapy, evaluate time saved when an oral product was used instead of IV, and determine if delayed emesis was assessed via a phone call by nursing staff within 7 days after chemotherapy using an adapted anti-emesis questionnaire. Pharmacy and nursing satisfaction of the conversion from IV to oral supportive care medications was assessed by survey. Cost and resource avoidance in nursing, pharmacy, and facility parameters was also monitored. Thirty-five unique veterans received 68 cycles of chemotherapy comprising 90 visits within the 10-week data collection period. The majority (59%) of the chemotherapy regimens contained a drug with high or medium emetogenicity risk. Fourteen of the cycles that previously used IV supportive care products were switched to oral products via protocol. There were 9 cycles where conversion from IV to oral products did not take place, mostly due to human oversight. The other cycles already used oral products. No veteran was switched back to the IV product as nausea was controlled with oral products. These patients saved an average of 60.3 minutes in clinic by using oral products instead of IV. Follow-up after chemotherapy by nurses occurred 81% of the time, and no instances of increased nausea or emesis were noted. In fact, an episode of pneumonia and an episode of severe neutropenia were discovered based on conversations between the nurse and the veteran.
Results: When surveyed, nurses and pharmacists involved agreed that the conversion to oral products helped improve their workflow and no major barriers to implementation of the protocol were identified. Conversion to oral products saved about $6 per chemotherapy visit per veteran.
Conclusions: This project improved facility workflow while maintaining equivalent clinical outcomes for veterans, saved veterans time in clinic, and provided a standard follow-up approach to assess outcomes. Limitations included a small sample size, oversights by stakeholders, and subjectivity of reported information. Areas for advancement include converting all chemotherapy templates to oral antiemetic products, expansion of conversion to other premedications, inclusion of an antiemetic medication review section in the pharmacist chemotherapy note documented in the electronic patient chart, and providing education to veterans about reporting concerns.
