2017 Review: NON-SMALL CELL LUNG CANCER (Analytic, 1st contact 1/2017)

Overview

Review of pulled Non-Small Cell Lung Cancer (NSCLC) cases in 2017 (n=38) was undertaken that included elements of diagnostic evaluation per NCCN guidelines. This review was also done to check that when applicable the appropriate molecular evaluation was undertaken, as this is relatively new in the last 3 years and results directs first-line therapy in advanced NSCLC. The components for review selected included the following: CT evaluation, PET/CT, brain imaging (CT or MRI) if Stage IIB or higher, histology, molecular testing (EGFR, ALK, ROS1, BRAF, PD-L1) and treatment concordance with NCCN. Of note, data was cross-checked with clinical notes from UCS where available.

Overall, treatment concordance with NCCN guidelines was high at 87%. Of the 5 cases which were not in line with guidelines, 2 had no records to be found, 1 died as an outpatient after diagnosis before any clinic visits, 1 declined systemic therapy and 1 declined surgery and then lost to follow up by records available. If we censor the 2 without available records and the one who died as an outpatient before any clinic visits, treatment concordance with NCCN guidelines would be 95%.

With regards to diagnostic evaluation/staging, all (100%) had a CT and/or PET/CT but only 61% had brain imaging with MRI or CT. Of the 9 cases where no brain imaging done when applicable, 4 had no documented reason, 2 received care at HCI & no records found, 1 declined all systemic therapy, 1 elected for hospice on diagnosis and no records were found for one case. If we censor all but the 4 where there was no documented reason why brain imaging not done, 83% underwent brain imaging. Molecular testing was done in 72% where applicable (advanced NSCLC). Of the 5 cases where it was not done, 2 chose hospice upon diagnosis, 1 had very poor KPS and no treatment possible and for one, unable to find any records. There was one case where PD-L1 staining should have been done but was not. Cenosring ghe 2 who chose hospice and the one with poor KPS, rate of appropriate molecular testing where applicable was 89%.

In summary, rate of treatment concordance with NCCN guidelines was high and so was the rate of appropriate molecular testing in advanced NSCLC, indicating that compliance with guidelines remains good even with changes and updates that can occur frequently now. It also helps that effective therapies are available based on results of molecular testing. Areas worth pursuing for improvement include increasing rates of brain imaging where applicable to 90% or higher and improving documentation of PFT testing prior to surgery. One limitation here is that is may be possible that PFT’s were done outside of the St Marks Campus with results not available via Epic. An appropriate plan of action would be to distribute letters from Cancer Committee to both hospitalists and Thoracic Surgery regarding guidelines for brain imaging with either MRI (preferred) or CT for stage IIB or higher, as well recommendations for more precise documentation of PFT results/testing. We will also plan to review indications for Brain imaging with Utah Cancer Specialists at one of their next monthly physicians' meeting.

Nitin Chandramouli, MD

Cancer Process Improvement Study #1

GOAL: Reduce readmission rate d/t dehydration, electrolyte imbalances or malnutrition for cancer patients with newly formed ileostomy. Overall readmission rate for ostomy and Ileostomy 14% and ileostomy alone 40%.

  • Approved by Cancer Committee via email vote on September 19, 2018
  • Implemented on September 20, 2018
  • Notified floor staff on August 30, 2018 a new process would be implemented the following month regarding reducing readmission rates by providing electrolyte supplement
  • Staff Education began on September 14, 2018 with ongoing education/reinforcement for each new ileostomy patient
  • Ileostomy/Ostomy Resource Guide provided to each nursing unit on September 20,2018
  • Ostomy Diet Handout implemented on September 20, 2018
  • A newly created I&O Log implemented on September 20, 2018. Patients were educated and expected to document their intake and output while in the hospital and at home after discharge
  • Beginning September 20, 2018, ileostomy patients supplied with an oral electrolyte supplement (Pedialyte), goal to consume 48-64oz per day.
  • 100% of all ostomy patients received dietary supplement education on either ensure or Glucerna
  • 100% of all ileostomy patients received oral electrolyte supplement education
  • 100% of all ileostomy/ostomy patients received ostomy diet education
  • A request was generated on August 27, 2018 for an order button for Pedialyte to be created in EMR. This remains in the development stage, we do have a working process in place until completed
  • On September 12, 2018, weekly meetings were initiated with wound/ostomy nurses, dietician manager, nursing unit manager and director, quality personnel and cancer committee member to discuss patients, progress, and any concerns or barriers. Information relayed weekly to colorectal surgeons and CMO
  • Presented to Admin Council on 11/13/2018
  • Presented to MED on 11/20/2018
  • RESULTS: Unfortunately, we did not see a decrease in our readmission rate. Since implementation on September 20, 2018, 5 cancer patients were identified resulting in a 20% readmission for patients with an ostomy or an ileostomy and a 100% (1 patient) readmission for ileostomy patients alone. We had an overall decrease in the number of patients in the study primarily d/t time constraints. Our one ileostomy readmission patient had difficulties with ileostomy cares and hydration despite participating in monitoring I&Os, ileostomy cares, and return demonstration while in the hospital. She was also discharged with home health services.

Cancer Process Improvement Study #2

GOAL: Reduce LOS for newly formed ostomy/ileostomy cancer patients. Baseline LOS for ostomy/ileostomy patients 7.93 days.

  • Approved by Cancer Committee via email vote on September 19, 2018
  • Implemented on September 20, 2018
  • Notified floor staff on August 30, 2018 a new process would be implemented the following month regarding reducing the LOS by providing daily ostomy education to patients and/or family
  • Staff Education began on September 14, 2018 with continued ongoing education/reinforcement with each new ostomy/ileostomy patient
  • Daily Milestone implemented on September 20, 2018. Outlines what type of daily ostomy/ileostomy cares patients should be performing each day
  • New created Ostomy/Ileostomy Resource Guide created and provided to each nursing unit on September 20, 2018
  • On November 8, 2018 an overview of the Daily Milestone was added to the wound/ostomy nurse presentation at new employee orientation
  • Process change instituted on September 20, 2018 for patients with an ordered calorie count. Preliminary single day results are placed in EMR for physician to review. At the end of 3 days, a finalized report is also placed in EMR
  • Weekly meetings beginning September 12, 2018 with wound/ostomy nurses, dietician manager, nursing unit manager and director, quality personnel and cancer committee member to discuss patients, progress, and any concerns. Information relayed to colorectal surgeons and CMO
  • Documentation of patient specific ostomy/ileostomy education by nursing staff, including patient participating in own cares, increased from 0% to 75%
  • Presented to Admin Council on 11/13/2018
  • Presented to MED on 11/20/2018
  • RESULTS: 5 patients were identified from the above group with a LOS of 5.98 days from 7.93 days.

Community Outreach Summary

Skin Cancer Prevention Education - 4/18. Educational event hosted wtih 73 individuals in attendance.

Skin Cancer Screening Event - 10/17/18 - 73 patients in attendance, 9 patients identified at risk and scheduled for follow-up appointments.