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Happy August!
Patti Gabel has kindly offered to lead our discussion this month.
She chose the topic of remote symptom management.
This is a timely topic as we are starting to see it in some of our clinics.Here are the articles this month:
Feasibility of perioperative remote monitoring of patient-generated health data in complex surgical oncology.Thank you for your participation this month.
Renee
Hello, My name is Patti Gabel and I currently work on the Clinical Call Center team. My colleagues and I remotely monitor James patients. We monitor both biometric values (blood pressure, heart rate, temperature, oxygen saturation and weight) and patient reported symptoms. I choose this topic because it was relevant to my current practice.
Melstrom et al., (2022) focused on monitoring general and urologic oncology surgery patients. The need for monitoring surgical patients after discharge is more crucial now than in the past because the advancements of minimally invasive procedures has allowed for earlier discharges when compared to the more invasive surgical technique. Thus, the postoperative complications that would have occurred in the hospital during postoperative recovery are occurring in the home or outpatient setting. Much of the current evidence focuses on remote monitoring of patient reported symptoms not physiologic data (vital signs and daily steps). This small study looked at the feasibility of remote perioperative telemonitoring of patient-generated physiologic data and patient-reported symptoms. The adherence level for completing vital signs and electronic surveys decreased over time. The greatest atypical vital sign was observed on day 2 after discharge and was oxygenation. It was found patients are the most vulnerable on post op day 2 with taking the fewest steps per day and having lowest appetite. Post operative day 2 was identified as a critical time in care and the outpatient team should be ready to intervene if necessary.
Offodile et al.,(2023) focused on the remote monitoring of the gastrointestinal or thoracic cancer medical oncology population. Oncology patients receiving active treatment often have side effects from treatment and/or their cancer requiring frequent medical visits and even hospitalizations. It was stated that remote symptom monitoring, via electronic patient-reported outcomes (PROs), has been associated with significant improvements in health-related quality of life, health resource utilization, and clinical outcomes. Remote biometric data can provide supplementary information that enhances patient-provider communication and clinical decision-making regarding symptom management. As a triage nurse I’m often asking whether or not the patient is capable of taking their vitals to provide the medical team with more clinical information to make the safest treatment plan. I also ask patients to take pictures and send them through osu mychart. This is helpful to provide additional information when a patient is calling in with complaints of a rash or incision changes.
Will the research/information in this article change or influence your practice? If so how? Yes, this information has validated current practice. The article that focused on surgical patients did discuss having a time frame of utilizing this resource and after the patient is outside the time frame they could be off boarded. Since this practice is new, we don’t always off board patient at any given time frame.
What other questions does the article raise about current practice? how can we make this practice mainstream in the outpatient setting? It’s new to providers and not fully integrated into the epic system so providers forget it’s part of the patient’s care.
Do you agree/disagree with the conclusions of the author, why? I agree that remotely monitoring patients can be a helpful tool to caring patients.Hello! My name is Jeff and I work in the outpatient float pool. Thanks for hosting this journal club Patti! This is a relevant topic as every clinic has a telephone triage process and can be utilized for early symptom recognition and management.
1. What was the knowledge gained from the article?
The 1st article emphasizes what we all already know- more and more is being pushed to the Outpatient world and faster discharges from hospitals. I’ve heard that CAR-T therapy will now be an outpatient procedure (whether that is true or not but seems crazy to me if it’s actually true).
In the 2nd article I found it was interesting that an AI was used to help the screening process of the patient to determine eligibility. In reading the article it mentioned the symptoms they were tracking but I am surprised that shortness of breath was not included in the thoracic population. Having previously worked in the thoracic oncology clinic (and having my turn as phone triage), I am a little surprised that there isn’t a question or tracking cough or shortness of breath as a symptom!! The other symptoms listed are all good things to know but cough and SOB are important to know for thoracic. I know they are limited in the data they are monitoring and are covering a BIG portion of the common side effects from chemotherapy treatment.
2. Will the research/information in this article change or influence your practice? If so how? I feel that remote symptom monitoring will become even more prevalent in our society but there could be some hiccups along the way. Some of our patients just aren’t able to help themselves due to performance status or other concerns. These patients are going to be a high risk to actually follow through with monitoring themselves and early recognition could still be missed. I know AI is becoming more of a thing (Heck I was unknowingly taking to an AI assistant dealing with home repair project recently) but the AI interface is only as good as the programming that goes into it.
3. What other questions does the article raise about current practice? How many of these patients did not actually answer the questions but rather had a family member or caregiver answering for them? (This is relevant because sometimes family members always do the talking for patients and aren’t always 100% honest with the information). Are we able to customize the symptoms we are tracking based off disease line? In the data is there an option for other (or write-in) concerns? (something we may not even think about being a concern but to the patient they view it as a concern); or does the monitoring only trigger based off predetermined alerts? Both articles were mentioning that day 2 saw the biggest number of alerts- why is this the case?
4. Do you agree/disagree with the conclusions of the author, why? I agree with the authors- I believe more insight is needed before being able to determine the effectiveness of remote symptom monitoring. I think we will be seeing more of remote symptom monitoring but the hardship will be compliance from patients and also how do we decipher the data to make it relevant. FitBits or other smart devices are useful for gathering data but how to interpret it is the hard thing. I have heard of patients wearing a smart watch but the VS were no where close to what a reading with a live person was and could lead to false diagnosis or interventions.Hello everyone. Interesting topic’s. I work with Patti in the Clinical Call Center. Thank you for hosting this month Patti.
1. What was the knowledge gained from the article? First of all we all know that AI is the up and coming thing. Now where it belongs in healthcare is still debatable. Remote monitoring of patient generated health data is valuable in helping identify issues early and potentially improving outcomes. But it can be variable as patients are ultimately the deciding factor in how effectively remote monitoring works. Their ability to understand and use the equipment depends on the individual factors like health literacy, comfort with technology, and compliance. But overall these studies show how remote tools can support/personalize care for oncology patients.
3. What other questions does the article raise about current practice? How prepared is healthcare teams to manage and respond to remote data in real time, given how busy healthcare already is and the shortage we already have. Are patients being adequately educated and supported to use remote monitoring tools effectively by the company or is this also all put on the RN? How do we ensure data privacy and compliance with HIPAA in home monitoring? What are the cost implications and reimbursement models for using remote technologies in routine cancer care? There is a need for updated protocols, interdisciplinary coordination, and system level changes to fully integrate remote care into oncology nursing practice. We are trialing this now and it has it’s issues.
4. Do you agree/disagree with the conclusions of the author, why? The studies show that remote monitoring is both feasible and beneficial in cancer care. As a nurse, I’ve seen how early symptom detections and patient engagement are crucial. Remote tools can empower patients, reduce hospital visits, and catch complications early. HOWEVER, successful implementations depends on proper education, support, and infrastructure. The articles suggest we need more standardized systems and clear workflows for nurses and care teams to act on the data efficiently.
The conclusion here is this is realistic and forward thinking aligning with trends toward patient centered, tech-enabled care that nursing practice should continue to embrace. Whether we like it or not.Jeff thanks for your input. You bring up a good question “Are we able to customize the symptoms we are tracking based off disease line?” The James covers hundreds of specialties. Can we generalize triage questions or symptom management questions to capture every medical risk for all of these areas of medicine? or should each area have their own specific assessment tools?
Thanks, Patti, for leading this discussion in a subject that is very relevant to my current nursing practice as an After-Hour Triage nurse and remote monitoring nurse at the James Clinical Call Center. Since joining the Clinical Call Center as an After-hour triage nurse in 2016 with a small group of hematology and oncology teams to covering all services (hem/onc, surg onc, interventional radiology, Rad/Onc & the diagnostic center) at the James, the addition and expansion of ICC services, the James observation unit and last year the pilot study and implementation of James Remote Patient monitoring program. All of these services have been with the intention of early detection of manageable symptoms and complications for the cancer patient to provide early intervention and reduce any complications associated with cancer treatment all while reducing ED visits, exposure to neutropenic patients and hospitalizations.
1. What was the knowledge gained from the article?
The first article focused on post-op patients revealing that post-op day 2 was the most critical day in the home recovery as far as reported pain, decrease in physical activity and low oxygen saturation. The second article focused more
on oncology patients, which is more what I have experienced in my role. Both articles discussed the monitoring of vital signs, pain and symptom management with a nurse led triage practice. The compliance on both studies shows a gradual dwindling over time which is also consistent with what I see in my practice. Currently, the PRM at the James is not integrated with the IHIS electronic records so even the James providers do not have any access to the monitoring program unless the remote monitoring nurse escalates the information to the on-call provider or the outpatient team. We all recognize as nurses, that inpatient cancer treatments and surgical patients are discharged sooner and sooner and lose the benefit of trained medical staff watching for subtle signs of complications while inpatient. We also recognize that insurance encourages the early discharge of all patients in healthcare to reduce costs which sometimes lead to readmission or ED visits. Remote patient monitoring in cancer patients may be the only way to bridge the gap and to provide a watchful eye on the patients that are at home with chemotherapy pumps or surgical drains that would have been monitored in the hospital for complications a decade ago. Both articles show that PRM does have a benefit of catching subtle complications for the post-op and cancer patients.
2. Will the research/information in this article change or influence your practice? If so how?
The PRM pilot at OSU was successful and is in the process of being developed into a larger service across the James patient population. So these articles are very relevant to my position as a current remote monitoring nurse in my everyday practice. Both studies validated the feasibility of PRM, our pilot study last year was for 50 Hem/Onc/BMT patients and 50 Gyn/ONC patients and at the tail end of the study, thoracic oncology patients on high-risk CRS immunotherapy patients were added. Our own study at the James showed similar results to the two articles in that patient compliance long-term was an issue but overall showed benefit in bridging the gap in health care from early discharge and home treatments to intervene earlier to prevent severe complications and readmissions.
3. What other questions does the article raise about current practice?
During the pilot study at OSU, the patient incurred no or very small charges after insurance submission. I am curious how insurance will pay for these
services in the future and what will be the patient’s cost burden for the nursing monitoring and for the equipment fees.
4. Do you agree/disagree with the conclusions of the author, why?
We currently use Remote monitoring for chemotherapy and immunotherapy for the highest risk patient s/p BMT and high risk for CRS immunotherapy patients. It does seem to show in the first study that it would be a very valuable service for post-op patients particularly in the first week (day 2 highest incidence of symptoms and low oxygenation for thoracic patients) pos-op. Sometimes, simple re-education on supportive care, i.e. pain medication use, incentive spirometry and activity can be beneficial to help with symptoms at home that otherwise may have resulted in a visit to accessHi Patti:
I agree with you that having the provider have access to the PRM information is extremely important to the overall care of the patients. I look forward to having IHIS integrated with our remote monitoring system as I feel that all the liability is currently on the remote monitoring nurses. The APP and physicians could use the information provided to have a better understanding of the Patient’s condition but currently, the providers have requested that only the information that requires urgent action be forwarded to them. I feel sometimes the subtle trends are missed under our current practice.
Hi Kathy:
I. too, am concerned about what costs the patient will incur with PRM equipment and nursing monitoring. During our PRM pilot, we entered billing information, but I think that was for tracking purposes only. Im not sure how much insurance is going to pay for and how much will be the patient’s responsibility. ED visits and re-admissions are expensive, but I wonder if insurance will see this program as a cost-saving or just an added expense.Hi, my name is Jennifer, I am a nurse in the Clinical Treatment Unit (ambulatory clinic). Thanks for hosting Patti. Both of these articles were interesting and timely.
1. What was the knowledge gained from the article? Both articles discussed very small sample studies where patients used blue-tooth medial equipment and tablets to self-report symptoms after either chemotherapy or surgery. I feel they did get some good data out of the studies, like post-op Day 2 generated the most symptom complains in the surgical patients, so education could be done regarding that.
2. Will the research/information in this article change or influence your practice? If so how? The CTU does not have after hours triage, we advise the patient to call their home clinic with issues after hours but we are available during operating hours to field any questions or concerns. We call new patients to educate them the day before their first treatment, and we have discussed if calling them 24-48 hours after D1 would be helpful in terms of managing any issues. I think providing patients with blue-tooth enabled equipment and tablets would be a reach in terms of cost, but a simple phone call would be a step in the right direction.
3. What other questions does the article raise about current practice? I feel that patients are more comfortable now with remote medicine in terms of office visits or follow-ups and the majority of our patients would be able to use the equipment and tablet to self-report. I did not work inpatient when they launched the Bedside MyChart but it is still a functional program – although the education of it landed squarely on the nurse. I do not know how feasible it would be to launch a program that included all the vital sign equipment and tablets.
4. Do you agree/disagree with the conclusions of the author, why? I do agree that more data needs collected in larger sample sizes and different populations. Both authors state that their study was feasible and an acceptable way to capture information and monitor symptoms. A cost analysis would need done and also consideration as to whom would monitor the alerts in real time.Jeff, welcome to crazytown because CAR-T is given outpatient. We are actually starting a trial next week with it. Like you mentioned in your post, more and more things are moving to outpatient clinics and even home administration. We have a trial right now that is gathering data comparing SQ Vidaza to oral Vidaza so patients spend less time in an Infusion chair.
Patti, how do you currently monitor the biometric values? Do we ask the patient if they have a home BP cuff or a pulse ox? Is any equipment provided to them currently?
Thank you, Patti, for these articles. My name is Michelle and I work with Jeff in the ambulatory JCRU.
What was the knowledge gained from the article? I truly am not sure if I gained any knowledge from the articles. Both articles had very few participants in their research, and I just don’t think those numbers are enough to say one way or another. I do know that there are a lot of inpatient treatments being pushed to the ambulatory world due to cost and making the bed available for other patients.
Will the research/information in this article change or influence your practice? If so how? No, I don’t think it will. Again, the number of patients in each trial really didn’t give me the feeling that the information was accurate. In the ambulatory infusion world, we call our patients (or the infusion clinic nurses) call the 1st time treatment patients about 24-48 hours post treatment to check on how they are feeling and to help with any symptom management issues.
What other questions does the article raise about current practice? Who filled out the questionnaire? Did they fill it out daily or wait until the end? Were they honest? I know several times, in clinic, a patient will deny symptoms when I check them in but as soon as the CNP or Doc walk in they have all kinds of symptoms. We also see patients wait until their next clinic appointments and then they will talk with the CNP or Doc about their symptoms. Some of our clinics have ERTs during their Monday clinics because of this issue.
Do you agree/disagree with the conclusions of the author, why? I do agree with the findings; there are people being discharged earlier and earlier and being managed via home equipment. I know this is the way of the future, I just think we need to make sure the data is correct, the technology is easy to understand and the follow through on the alerts is timely.
Jeff, I agree with you completely. We see more and more everyday of inpatient treatment coming to the ambulatory world. Agree with the issue of “who” is filling out the paperwork also. How many times are we in a clinic and the significant answers all the symptom questions or we do the telehealth check in and the spouse will answer the questions while the patient sits in the background. I think once this type of symptom management really takes place, we will have to make it more disease/symptom specific. I feel if we don’t and we ask several nonspecific questions we lose the effectiveness of the real questions.
Jenn, I have seen Sq Dara replace IV Dara. I have seen breast center take out premeds after so many cycles, this gets them out of the chair faster. HIDAC is outpatient too. Desensing use to be an inpatient thing too but now we just throw more medication and trudge on. It is crazy to see this but it is definitely the way of the future. I do like that infusion nurses call the patient within 48 hours for symptom management. Because I have noticed that when they talk to them, some patients just think they have to “deal” with the symptom and there is nothing they can do to make it better.
Patti, I am curious as well if you the patient is given specific equipment for biometric values. If they use their own equipment, do we ask how old it is? I know my home thermometer does not have the same values as the clinics. I just know when I have a fever off my thermometer.
Hello,
My name is Amy and I work in medical oncology at SSCBC. This is such an interesting topic, thank you for hosting Patti. I was happy to learn the positive results these studies showed with home monitoring. It was not surprising to me to see the declining participation as the studies went on. I think it can be very difficult to keep people engaged, and i wonder about our older patients who may struggle with technology and find it overwhelming. These studies bring to light how reactive our healthcare system is systemically. I think more proactive approaches like these would be extremely beneficial. I agree with Patti and kathy, i wonder what the costs implications may be, as recently there has been so much change in insurance coverage just for telehealth visits. I know this would be a deterrent to lots of patients. I also agree that so much more has been moved outpatient in healthcare, its extremely important to see the value in changing practices and implementing remote symptom management. As an outpatient oncology nurse, everyday i see the benefit of our patients who call in and are able to have their symptoms triaged in a timely manner.
I also wanted to comment on what Jeff and Patti said about tailoring symptom management to different specialties/disease lines; I think this is a great point, as we have struggled with tailoring our calls and assessments to the generalized protocols that we are to use now for telephone triage. They are very helpful, but since every cancer is so different and unique, especially with so many newer targeted treatments, it can be challenging to assess unless you know the patient or the specific side effects of each and every regimen, which is obviously difficult. I think it just brings up the challenges to telehealth, and also a lot of ownership on the patient to keep us updated and aware of changes in symptoms.
Sorry for the later response.
Patti, how do you currently monitor the biometric values? Do we ask the patient if they have a home BP cuff or a pulse ox? Is any equipment provided to them currently?
The James has partnered with a company called Veris. Currently Gyn/Onc, thoracic Med/onc and BMT are using the program. Patients are supplied with veris equipment a thermometer, blood pressure cuff scale, pulse ox and a scale. Patients are directed to take their vitals daily. They also have the ability to report symptoms through the veris platform. The providers give orders as far as parameters for each biometric measurement. If patient’s vitals are outside of parameters, the triage staff are alerted and then RN will call and assess the patient.
Personally, I feel like a lot of people have devices that obtain their vitals anymore. As a triage nurse I do include this information in our assessment. We already tell every patient to call with a fever of 100.4 or higher for the most part here at the James. We have to rely on whatever equipment they have to obtain this information. We don’t provide thermometers to all of our patients. I know when I worked on SSCBC we used some of our patient satisfaction money to buy thermometers from the dollar Tree. I wouldn’t have said they were the highest quality but for those patients that didn’t have a thermometer or means to buy one it was better than nothing.
apple watches now can track heart rate, ECGs, respiratory rate, and blood oxygen levels.Amy Mchale, I do agree patients struggle with using the equipment and I miss the days when I can just do it myself and recheck their vitals.
It would be nice if the triage protocols were completely targeted for the oncology patient. We have entire hospitals designated to caring for cancer patients (NCI). I’m not sure if a program exists but there is definitely a need. The James needs to use all of their brilliant specialists to make individual protocols for their patient population that everyone can use.
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