[shalvoy.1]

Here are the May/June journal articles. Please respond to at least 3 out of 4 of the prompts soon so we can get a conversation started.

Don’t forget to also respond to at least two peers’ responses.

Management of skin adverse events associated with immune checkpoint inhibitors

 

Meeting the Challenge of Immune Related Adverse Events

 

 

• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.
• This topic was modified 5 years, 7 months ago by shalvoy.1.

[shalvoy.1]

Here is Courtney’s response, thanks Courtney for starting the discussion!

1. What was the knowledge gained from the article? Management of skin: A nursing perspective-I gained insight in CTLA-4 such as Ipilimumab and PD-1 such as nivolumab and pembrolizumab inhibitory receptors. Up until now I was familiar with their names, but did not have an understanding of how they work to limit T-cell activity and the side effects that they are known to cause. With the vast number of immunotherapies, it was nice to target in on a few with specific side effects and treatments for adverse effects. Hoffner and Rubin speak about clinics at Memorial Sloan Kettering Cancer Center and Penn Medicine Abramson Cancer Center that are open 24 hours a day 7 days a week to treat patients with adverse events from their chemotherapy. I am proud to say that the James is in that “expertise and benchmark” group with the ICC (Immediate Care Center) which has now been open 1 year. A relationship between the ICC and the ED, clinics, and triage aids in making sure patients are placed in the appropriate level of care. And ideally decrease hospital admissions.
2. Will the research/information in this article change or influence your practice? If so how? The information I gained from this article will be utilized at the bedside with patient education. Educating myself on these treatments will improve the care my patients receive. If we can teach the patient to recognize early adverse effects of the treatment and know who to contact with these symptoms, it can only improve their outcome. This education can also be shared with other nursing staff and/or providers.

3. What other questions does the article raise about current practice? The article by Hoffner and Rubin raises the question of education and knowledge in respect of adverse reactions as treatments of cytotoxic chemotherapy moves toward immunotherapy and/or a combination of both. They also bring attention to improvement in telephone triage. James triage does have grading systems in place depending on symptoms, but I do not know if they use aimwithimmunotherapy as part of their triage process if the patient is on immunotherapy. It seems like quite a useful tool.

4. Do you agree/disagree with the conclusions of the author, why? I do agree with the conclusions of the author M. Thebeau et al. Nursing plays a vital role in recognizing adverse effects of immunotherapy. A collaborative effort between patients, nurses, practitioners and physicians can improve patient outcomes who are undergoing treatment with immune checkpoint inhibitors.

[shalvoy.1]

Hi Courtney,
I am glad you mentioned the great work ICC is doing. I do not think all of our ambulatory nurses really know what your unit does. We got a little confused because when your unit first opened you took a lot of patients for treatments that you are no longer able to take because the volume of the cases the unit was designed to take has increased.
Am I describing this correctly?
I agree with you that Hoffner and Rubin raise great points about the importance of nurses really understanding the side effects associated with ICIs and using this knowledge to educate their patients. On page 14 they state,
“The patient action plans found on the IO Essentials site provide key education and anticipatory guid-ance that can be shared with patients so they know what to do and how to direct themselves should they experience symptoms associated with an irAE (Figure 3). Further patient education may also be accomplished during a telephone triage call (Hickey & Newton, 2012). Advanced practice providers often lead such patient education efforts”.
Part of this statement I do not agree with, the chairside oncology nurse is often the best person to educate the patients and their families. No one does this better and it is a responsibility that we should not abdicate to others.
Thanks for your great analysis Courtney!

[blackwell.72]

Thank you for participating – I really need these for clinical ladder so your all helping me out!
I chose these articles because we all do telephone triage and it seems that Melanoma isn’t the only cancer that is being treated with immunotherapy and we all could benefit from the article even though it only talks about Melanoma.

I agree – with everything Courtney said. With recent breakthroughs, immunotherapies are being used in almost every modality – not just melanoma so we are all having to manage these symptoms. The ICC has been invaluable in managing our patients’ side effects and symptoms. When I tell them that they need to go to ICC the response is so much more positive than if I have to send them to the ED.
1. What was the knowledge gained from the article?
The grading scale in table 3 is very helpful and provides continuity of care in assessing and treating patients and I would hope that it becomes something we refer to when triaging patients. Does anybody know if any tool like this for immunotherapy is currently used by anyone of our clinics’ phone triages?
As I was reading the articles and it keeps saying that to “better manage” we should have 24 hr oncology urgent cares etc,. We have ICC which my clinic utilizes all the time. I believe our telephone triage is on a higher level and we do keep patients out of the ED unless absolutely necessary. The ICC has been instrumental in making it possible to keep a lot of our patients from going to the ED.
2. Will the research/information in this article change or influence your practice?
I will definitely be sure to include this information in my immunotherapy teaching and will also refer to it as I am triaging patients w/ AE’s. I kinda feel like a lot of the things in the article were old news for us because we have been doing a lot of this already at The James but there is always room to improve and build on information. It was nice to have the articles validate that we are doing things right and appears we are one of the few already doing these things.
As I was reading the articles and it keeps saying that to “better manage” we should have 24 hr oncology urgent cares etc,. We have ICC which my clinic utilizes all the time. I believe The James telephone triage is on a higher level and we do keep patients out of the ED unless absolutely necessary. The ICC has been instrumental in making it possible to keep a lot of our patients from going to the ED. I will continue to evaluate sending patients to ICC vs ED.

Do you agree/disagree with the conclusions of the author, why? I do agree that the recommendations for managing AE’s should be standard of practice/care. It only makes sense that we are all using the same tools to evaluate so we have something concrete to measure interventions needed and then the outcomes. It is important to be able to recognize the symptoms as being caused by immunotherapy or otherwise since management is different. The article by Hoffner and Rubin talks about needing the support from management and well-trained nurses to do the phone triaging which I agree with 100%. However, I feel that the current call time spent is underestimated and often grossly underestimated. I am hopeful that with more research and articles supporting this that it will be estimated a little more accurately.

[shalvoy.1]

Hi Ladies,
The ONS Voice this month has another good article on managing the side effects of immunotherapies.
Manage Immunotherapy-Related Diarrhea and Colitis. You might find this article helpful.
Renee

[khabiri.5]

Hi,
This is Sherry from the ICC. I feel this article was so helpful in improving my understanding of skin AEs associated with immune checkpoint inhibitors. Coming from the ED, I had very little understanding of what I was looking for when I ask patients if they have a rash. This article was very informative because it discussed the grading system and had images of rashes. I agree with the above responses. I feel it is important that anyone who is working with patients who are receiving ICIs become aware of what to look for when evaluating patients. There are so many patients who are receiving these treatments and they receive care in different areas, not always with their primary team. Providing increased education to staff, especially areas that don’t routinely administer ICIs, is beneficial.

[smith.10494]

Hello,
This Holly Smith from the JCRU ambulatory float pool.
1. Knowledge gained? I have spent the last 5-6 years working with more specialized patients, many of which were not oncology patients, and I did not give these type of medications. For that reason, these articles were very helpful to me.
2. Will this influence my practice? Absolutely. I will be more aware of what I am looking at when patients present with potential side effects/reactions and hopefully identify before the patient requires hospitalization or has a complication that might derail treatment or cause them unnecessary pain.
Agree or disagree? I agree that standard telephone triage guidelines are imperative. I agree that patient education is also imperative. However, I do not think APPs are the only ones who can provide valuable education, as Renee mentioned.
Good articles!

[blackwell.72]

Welcome Holly! Thank you for participating. I agree, these articles have a lot of new/different information that what we have been referring to in our past practices. I am not sure if each clinic has any specific assessment/triage tools pertinent to their modality but that sure would be helpful when floating to all the different clinics.

[blackwell.72]

Thank you for responding Sherry –
Does the ICC have any specific assessment tools that give specific grades etc,. for symptoms? I am also wondering what the after hours phone triage uses. I often see they document used “xxx protocol” I am wondering what that protocol is and if anyone else uses it.
I had invited the phone triage nurses to this hoping to get some good information on what they do as a guideline but none have participated so I will contact that department and ask.

[karafa.4]

1.What was the knowledge gained from the article?
*Working in oncology infusion units and the CTU, for the last 10 years, I have seen many advancements in oncology treatment. Immunotherapy treatments have changed the way our patient’s are treated and have made treatment much more tolerable for many patients. However I have seen quite a few terrible AEs from the drugs discussed in these articles. I have seen patient’s treated through the skin reactions/rashes, and I have seen patients that have had to be taken off treatment due to severe skin reactions/rashes. I appreciated Figure 2- Recommendations for pruritus/rash management and Table 3 Grading system of skin adverse events according to Common Terminology Criteria for Adverse Events. It gave me a better understanding of how the reactions/rashes are graded and how the MDs/ NPs treat these reactions/ rashes.
I also found the article interesting and helpful with much discussion about the importance of comprehensive telephone triage and the importance of guidelines. This is a part of oncology nursing I do not have much experience with. I have always worked more of the bedside hands on nursing roll. I can imagine the hurtles and difficulty of trying to assess patient’s via telephone without being able to do a hands on assessment.

2.Will the research/information in this article change or influence your practice? If so how?
*The information gained in these articles will help to improve patient care and be used for staff and patient education, since most all disease lines are utilizing immunotherapy for treatment.

4.Do you agree/disagree with the conclusions of the author, why?
* I am passionate about patient education and as an oncology RN, I believe that it is our duty to educate patients on their treatment regimens and possible side effects, as we are the ones delivering the treatments. I do not agree that MDs and APRNs are the best people to deliver this information, as patient’s can be overwhelmed at or after their doctors appointments and may not be hearing everything that the providers are saying, especially if they have just received bad news.

[karafa.4]

Thanks for also including this article Renee. I feel that diarrhea is sometimes easily overlooked with our patients. I have seen a few patients have to be admitted for severe colitis from immunotherapy, if caught earlier may have been able to be treated and the patient could have avoided a hospital admission.

[karafa.4]

Hi Courtney!! Hope your well! Thanks for the update on the ICC, such an awesome resource for our James patients! I am sure you guys are seeing some patient’s that present with immunotherapy related side effects. These articles will be good to share with your co workers and APRNs 🙂

[goodman.100]

Hello! This is Greg Goodman- I recently switched from inpatient JCRU to outpatient- thanks to Renee for setting this up and letting me join!

1. What was the knowledge gained from the article?

I have found in my own experience that Immune Checkpoint Inhibitors (ICI’s) don’t share the side effect profile as traditional chemotherapy. The Hoffner & Rubin (2019) article is very useful in explaining these differences, especially with the variety of presentations. I was not aware that side effects and complications can present themselves as far as 55-60 months after treatment starts. I’m hoping clinical locations (especially infusion clinics) have information for patients and/or staff like “cheat sheets” that I can use to quickly remind myself of what to watch for with particular medications. I’m glad there are handouts available to patients such as the example provided about Keytruda side effects. My concern is how many patients get these handouts? How many remember them, with as much information we give them when they are diagnosed and throughout treatment? It also concerned me that symptoms can be vague and varied- will these patients find themselves chasing every little symptom during and after treatment?

For the article by Thebeau, M., Rubin, K., Hofmann, M., Grimm, J., Weinstein, A., & Choi, J.N. (2017), I had no idea that skin toxicities are the earliest and most common adverse events, but I would pay attention to skin assessment for patients with a primary skin cancer. The fact that skin AE’s most commonly occur 4-9 weeks after treatment begins seems quite different with many chemotherapy agents where the chance for reaction starts high then decreases with subsequent doses (with the exception of platinum-based medications). I also find it surprising that something as simple as daily moisturizer use may prevent pruritus. It is unfortunate that there is currently no treatment for vitiligo associated with ICI administration.

2. Will the research/information in this article change or influence your practice? If so how? I will now pay more attention to patient’s medications to mentally assess and organize reported side effects and assist providers in managing those side effects to prevent worsening symptoms and outcomes. The IHIS ECOG assessment is a good start but it will help to be familiar with the side effects particular to a patient’s treatment regimen. This is where I will have the greatest challenge as a float nurse: I give all treatments in all clinics but rarely spend much time in the same clinic with the same treatments so I don’t have the opportunity to become familiar with each of them. Many clinics have Smartphrases in IHIS that go through symptom assessments for different treatments- these are very useful. On another hand, float nurses could be very useful to different clinics as many ICI’s expand their indications and usage each year. For example, pembrolizumab (Keytruda) is now FDA approved for 14 different cancers. A float RN might have experience administering this medication for lung cancer patients then float to the Gyn clinic and administer it for a cervical cancer patient with clinic staff that have never given it before.

Communication with clinicians is very important because I have had many experiences where patients will mention a symptom to one person then deny symptoms to another. Both of this month’s articles highlight the importance of care coordination with a multidisciplinary team- it surprises me how much of this coordination and communication falls on the nurses’ shoulders. A simple comment a patient makes during a clinic visit to a nurse could be very important and we must make certain that the necessary provider gets the information. There are so many different methods for clinic communication: Jabber, email, IHIS In Basket, phone calls, pagers, etc. It feels like there is too much opportunity for information to get lost or overlooked.

3. What other questions does the article raise about current practice?

Hoffner & Rubin (2019) lists best practices for managing side effects and avoiding negative outcomes and increased costs, including improved telephone triage, dedicated oncology acute care services (such as urgent care and emergency department). The James has already implemented these strategies yet faces challenges with them. In my experience these challenges have been: lack of space in the James ED and problems with communication between clinics/clinicians/departments. I would be interested to see how effective the James telephone triage line has been so far with items such as reducing severity of side effects and admission rates. The authors also list strategies to reduce acute care for patients with cancer and The James has almost all of the examples in place. They mention ED symptom management pathways: would these pathways need to be different for different medications? For example, diarrhea caused by Irinotecan vs. Ipilimumab?

4. Do you agree/disagree with the conclusions of the author, why? I agree with the authors and would be interested in seeing how these interventions have helped patient at the James Cancer Hospital- admission and re-admission rates, ED visit frequency, better management of/avoid Grade 3+ symptoms, etc.

Hoffner, B., & Rubin, K.M. (2019). Meeting the Challenge of Immune-Related Adverse Events With Optimized Telephone Triage and Dedicated Oncology Acute Care. Journal of the Advanced Practitioner in Oncology, 10(suppl 1), 9-20.

Thebeau, M., Rubin, K., Hofmann, M., Grimm, J., Weinstein, A., & Choi, J.N. (2017). Management of skin adverse events associated with immune checkpoint inhibitors in patients with melanoma: A nursing perspective. Journal of the American Association of Nurse Practitioners, 29, 294-303.

[blackwell.72]

Welcome Greg to the journal club and also to the ambulatory world! Thank you for participating. I would love for all clinics to have cheat sheets but I never encountered any when I floated. Maybe a project for you as you are getting acclimated with each individual clinic you could eventually create them from your notes?
I reached out to the after hours telephone triage to see if they used any specific tools to assess/grade symptoms but I have not heard back.
I agree- we often just don’t have enough room for everyone in the ED or ICC but it is so helpful when they are able to accommodate our patients. I really feel that when our patients (gyn/onc) are admitted it is because there were no other options and it is what is best for them.

[goodman.100]

Mindy- Thanks for the welcome! I should add that I didn’t mean to disparage the ED or ICC- they both provide a vital service to our patients with high quality care. I just think that their utilization was underestimated when they were planned. From floating to the James ED I know the patients felt so much better knowing that James RN’s were providing their care as opposed to a regular ED RN that is not as familiar with the needs of oncology patients. As far as notes, I am just finishing my training so I vaguely remember a couple of clinics having binders or file folders with education handouts for the things their clinic see patient about frequently.

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