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Navigator-specific Interventions and Multidisciplinary Care Team Collaboration Improves Care and Outcomes for Patients with GI Cancers
ORLANDO, Fla.—The role of the oncology nurse navigator (ONN) is unique in that it allows for assessment and evaluation of systems of care as well as patterns of occurrences within a respective patient population, explained Teresa Labovich, MSN, RN, OCN, of Penrose Cancer Center, Colorado Springs, Colorado, in a presentation at the 2nd annual Oncology Nurse Advisor Navigation Summit.
Although navigation was conceived in 1990, the gastrointestinal (GI) ONN is a relatively new position whose role is not only to remove barriers to care, but also to facilitate timely, comprehensive, and evidence-based care for patients with GI cancers.
The GI ONN and the multidisciplinary care (MDC) team reviewed quality of care indicators based on evidence and national standards and took targeted action to improve the timeliness and quality of care for the GI oncology patients at our hospital-based community cancer center.
Colon cancer National Comprehensive Cancer Network (NCCN) guidelines for colon cancer recommend initiating adjuvant chemotherapy within 30 days of surgery. NCCN reports a reduction of 14% in overall survival for each 30-day delay.
Our goal is to initiate chemotherapy in 90% of patients undergoing treatment for colon cancer within 30 days of surgical resection, accounting for delays due to postoperative complications.
Rectal cancer NCCN guidelines for rectal cancer recommend initiating treatment within 180 days of diagnosis. Extrapolating from the data on colon cancer, our MDC team set target initiation for neoadjuvant chemoradiotherapy at within 30 days of diagnosis for patients with stage II-III rectal cancer.
Lynch syndrome NCCN guidelines recommend screening all patients younger than 70 years for Lynch syndrome. After careful review of the literature, as well as screening rates at our center, we opted to implement universal screening in all patients with colorectal cancer, regardless of age. In addition to communication with health care team members and receiving pathology reports, the GI ONN tracks data, ensuring adherence to monitoring and follow-up tests, including referrals to the genetic counselor.
The GI ONN also observed additional risks for select patients that warranted interventions.
Pancreatic cancer Patients with pancreatic cancer experienced significant morbidity and diminished quality of life due to symptoms of malabsorption. Pancreatic exocrine insufficiency affects 79% to 90% of patients with pancreatic cancer and leads to maldigestion, fat malabsorption, and steatorrhea. A short Yes or No questionnaire helped us identify patients’ symptoms and document weight loss.
Ileostomy Patients with rectal cancer who underwent ileostomy at the time of surgical resection were at increased risk for complications and readmissions due to dehydration, electrolyte abnormalities, and renal damage from high-output ileostomies.
GI ONN interventions were directed at identifying patients with high-output stoma (HOS), identifying and correcting the underlying cause of HOS, correcting fluid and electrolyte disturbances, and optimizing nutritional status of these patients.
To achieve these goals, the GI ONN manages communications with physicians and other stakeholders in the patient’s care, tracks pathology reports, and coordinates follow-up care and tests. Data are reviewed quarterly at GI multidisciplinary committee meetings.
Data collected over 3 years demonstrate improved patient outcomes and increased adherence to the NCCN guidelines and National Benchmark recommendations for timeliness of care for our GI oncology population.
Universal screening for Lynch Syndrome achieved a 94% screening rate over 7 quarters. Targeted education assessment, and interventions resulted in a 13% reduction in postoperative readmissions and emergency department (ED) visits among patients with ileostomies.
Working with the outpatient oncology dietitian, the GI ONN created a process for consistent assessment, documentation, and implementation of pancreatic enzyme replacement therapy for patients experiencing pancreatic enzyme insufficiency.
Successful implementation of our navigation process was achieved using targeted GI ONN interventions facilitated by collaboration with the other members of the MDC team.
1. Labovich T. Gastrointestinal oncology nurse navigation program development: improving outcomes through implementation of best practices. Oral presentation at: Oncology Nurse Advisor Navigation Summit; April 7-9, 2016; Orlando, FL.