Rinke, M. L., Chen, A. R., Bundy, D. G., Colantuoni, E., Fratino, L., Drucis, K. M., . . . Miller, M. R. (2012). Implementation of a central line maintenance care bundle in hospitalized pediatric oncology patients. Pediatrics, 130, e996–e1004.
To investigate whether a multidisciplinary, best practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population.
The organization joined an effort to improve quality, focusing on CLABSI elimination through the implementation of best practice central line care bundles. The care bundle used was based on relevant Centers for Disease Control and Prevention (CDC) guidelines, including daily site assessment and dressings based on CDC recommendations; procedures for cap, tubing, dressing, and needle changes; catheter site care; and catheter hub, cap, and tubing care. Education on the Children’s Hospital Association (CHA) central line care bundle of reduction of line entries, aseptic entries into the line, and aseptic procedures when changing line components was performed. Nursing self-practice audits were performed prospectively, with a one day per week random nursing shift sampling for all patients with central lines. Targeted interventions were performed to improve compliance, including staff feedback of CLABSI rates, discussion in daily rounds, and mini root cause analysis in cases of CLABSI development. Ongoing individual and group education was performed based on the findings.
This study was a prospective, interupted time series.
The unit experienced a 20% decrease in CLABSI rates after the implementation of the intervention (p = 0.58). Secondary analyses indicated that the second year of the intervention had a 64% decline in CLABSI rates below baseline (p = 0.091), suggesting that a long ramp-up period may be necessary to achieve effective change. At the end of 24 months of continuous improvement efforts, 35% of patients were not receiving all bundle elements.
Although the implementation of best practices for central line care to decrease CLABSIs is a viable intervention, the long time to significant results should be seriously considered ongoing education, and monitoring would be required, potentially increasing costs and decreasing staff interest in the intervention.
CLABSI prevention efforts focusing on central line maintenance are difficult, rely directly on front-line staff participation, and require patience for culture change but also have a profound effect on each nurse who has worked to prevent an infection from occurring. Nurses need to be aware of the evidence regarding effective approaches to improve guideline adherence and performance of evidence-based practice and use known effective strategies. Causes of nonadherence to guidelines need to be identified in order for ongoing improvement. With bundle approaches, it might be useful to analyze which bundle items are truly critical to the outcome.
Ring, A., Marx, G., Steer, C., & Harper, P. (2002). Influenza vaccination and chemotherapy: A shot in the dark? Supportive Care in Cancer, 10, 462–465.
To evaluate influenza vaccination in patients with cancer
DATABASES USED: PubMed from 1992–2002, using influenza, vaccination, immunization, cancer, and malignancy as search terms; no restrictions were placed on the language of the publications. Additional data were acquired by direct communication with vaccine manufacturers.
FINAL NUMBER STUDIES INCLUDED = 11 studies measuring seroconversion after influenza vaccination
KEY SAMPLE CHARACTERISTICS: No comments existed regarding the research design of the studies, but five studies included a control group.
Seroconversion rates following influenza vaccination ranged from 10%–78% in patients with cancer as compared with 56%–94% in healthy controls. Seroconversion rates following influenza vaccination ranged from 37%–52% in patients with cancer on chemotherapy as compared with 76%–92% of patients with cancer not receiving chemotherapy. One study of 42 adult patients with hematologic or oncologic disorders found that the seroconversion rate following influenza vaccination was 50% if the vaccine was given at the time of chemotherapy, compared with 93% if the vaccine was given between cycles.
Riley, P., Glenny, A.M., Worthington, H.V., Littlewood, A., Clarkson, J.E., & McCabe, M.G. (2015). Interventions for preventing oral mucositis in patients with cancer receiving treatment: Oral cryotherapy. Cochrane Database of Systematic Reviews, 12, CD011552.
STUDY PURPOSE: To evaluate the evidence to assess the effects of oral cryotherapy for the prevention of oral mucositis (OM)
PHASE OF CARE: Active antitumor treatment
Insufficient evidence exists to evaluate the effect of cryotherapy in patients receiving radiation therapy alone for head and neck cancer. Five studies in which 5-fluorouracil (5-FU) was administered showed that oral cryotherapy reduced the risk of OM development (RR = 0.61; 95% CI [0.52, 0.72]; p < 0.00001). Five studies involving treatment with high-dose melphalan risk of OM was also reduced (RR = 0.59; 95% CI [0.35, 1.01]; p = 0.05). OM risk was reduced in mild, moderate, and severe OM cases. Insufficient evidence existed to determine whether 30 minutes or 60 minutes of cryotherapy was more effective. One study with a high risk of bias showed no difference between oral cryotherapy and the use of prophylactic chlorhexidine.
Oral cryotherapy is effective in reducing OM in patients receiving 5-FU and high-dose melphalan.
Studies were of moderate quality based on the risk of bias assessment.
Strong evidence existed in support of effectiveness of oral cryotherapy to reduce the OM risk in patients receiving 5-FU treatment and moderately strong evidence of efficacy in patients given high-dose melphalan. Very limited evidence existed in children. This intervention is very low risk, so nurses can advocate for the use of oral cryotherapy for patients receiving chemotherapeutic agents with a short half-life. Ice chips could create a potential choking hazard for children; therefore, the use of iced drinks or popsicles may be better approaches to use in this population. Future research of head and neck trials of cryotherapy versus other effective interventions would be useful to further inform clinical practice.
Rifkin, R., Spitzer, G., Orloff, G., Mandanas, R., McGaughey, D., Zhan, F., . . . Beveridge, R. (2010). Pegfilgrastim appears equivalent to daily dosing of filgrastim to treat neutropenia after autologous peripheral blood stem cell transplantation in patients with non-Hodgkin lymphoma. Clinical Lymphoma, Myeloma & Leukemia, 10, 186–191.
To compare time to absolute neutrophil count (ANC) recovery for patients treated with filgrastim versus pegfilgrastim.
Patients were randomized to Arm A, pegfilgrastim 6 mg subcutaneously on day 1 after autologous peripheral blood stem cell transplant (PBSCT), or Arm B, weight-based dose of filgrastim subcutaneously from day 1 until either the third consecutive day of ANC greater than 5,000/mm3 or one day of ANC greater than 10,000/mm3 after PBSCT. Duration of treatment was not to be more than 21 days.
Multi-site
Patients were undergoing the active treatment phase of care.
This was a randomized, phase II study.
In the posttransplant setting, pegfilgrastim is preferred over filgrastim based on faster neutrophil recovery, less patient discomfort, and comparable cost.
Small sample size
Pegfilgrastim is favored over filgrastim in patiens undergong NHL posttransplantation due to faster ANC recovery with less patient discomfort at cost that is comparable.
Rietjens, J.A., van Zuylen, L., van Veluw, H., van der Wijk, L., van der Heide, A., & van der Rijt, C.C. (2008). Palliative sedation in a specialized unit for acute palliative care in a cancer hospital: Comparing patients dying with and without palliative sedation. Journal of Pain and Symptom Management, 36(3), 228-234.
The primary aim of the study was to describe the practice of palliative sedation for patients with cancer and compare patients who were sedated prior to death with patients who were not sedated. The secondary aim was to explore clinical implications of palliative sedation for symptom management at the end of life.
The single-site study was conducted on an inpatient PCU in the Netherlands.
Patients were undergoing end-of-life and palliative care.
Retrospective, descriptive study
Checklist for data retrieval from medical records
Sixty-eight patients (43%) had received palliative sedation. Palliative sedation for the majority of patients (68%) started on the last day before death, with an average duration of 19 hours (range of 1–125 hours). No difference was seen between sedated and nonsedated patients with regards to sex or survival after admission to the acute PCU (mean of 8 and 7 days respectively, P = 0.12). Within 48–25 hours prior to death, sedation was initiated in 13 patients, while 45 patients received sedation 24–0 hours before death. The experience of pain, dyspnea, and delirium during the interval 48–25 hours before death in both sedated and nonsedated groups had decreased during the interval 24–0 hours before death (P = 0.54). Midazolam, sometimes combined with propofol, was the most commonly used sedating drug.
Ridner, S.H., Fu, M.R., Wanchai, A., Stewart, B.R., Armer, J.M., & Cormier, J.N. (2012). Self-management of lymphedema: A systematic review of the literature from 2004 to 2011. Nursing Research, 61(4), 291–299.
To evaluate evidence of lymphedema self-care through a systematic review
Databases searched were PubMed, CINAHL, Cochrane Collaboration, PapersFirst, ProceedingsFirst, Worldcat, PEDro, National Guidelines Clearing House, ACP Journal Club, and Database of Abstracts of Reviews of Effects. Best Practice for the Management of Lymphoedema (Lymphedema Framework, 2006) terms were used as well as additional terms that were not stated. Inclusion criteria were not specified. Qualitats, grey literature, dissertations, live studies, and case reports were excluded.
The total references received was 47. Literature was evaluated and commented on using categories of PEP levels of evidence.
Reviewed findings related to self-care interventions. No interventions met criteria for Recommended for Practice. Interventions that were Likely to Be Effective included full-body exercise and phase 2 complete decongestive therapy (CDT). Pneumatic compression devices, compression garments, infection management, self-monitoring, skin care, simple manual decongestive therapy, and weight reduction were categorized as Effectiveness Not Established. Aromatherapy was categorized as Effectiveness Unlikely.
Strongest evidence for effect is found for exercise and phase 2 CDT.
There were relatively few studies in the area of self-care interventions.
Findings suggested that self-care using exercise and CDT are likely to be effective for lymphedema self-management. Further research in other potential self-care interventions are needed.
Ridner, S.H., Murphy, B., Deng, J., Kidd, N., Galford, E., Bonner, C., … Dietrich, M. S. (2011). A randomized clinical trial comparing advanced pneumatic truncal, chest, and arm treatment to arm treatment only in self-care of arm lymphedema. Breast Cancer Research and Treatment, 131, 147–158.
To compare advanced pneumatic truncal, chest, and arm treatment to arm only treatment to determine which therapy provides a larger reduction in lymphedema in post-operative patients with breast cancer
Participants were randomly assigned to receive truncal, chest, and arm compression or arm compression only. The compression was performed for one-hour, once per day for 30 days.
The study was conducted in Nashville, TN. The site and setting were not stated.
Patients were undergoing active lymphedema treatment.
This was a randomized control trial.
Demographic and medical data was collected via nurse interviews. The participants completed a Lymphedema Symptom Intensity and Distress Survey—Arm (LSIDS-A) and a functional assessment screening questionnaire (FASQ).
A statistically significant reduction was found in the number of symptoms and overall burden from the symptoms in both groups (p < 0.01). However, no statistical significance was found in the number of symptoms between groups (p = 0.145). No statistically significant change was found in functioning from baseline to the end of the study for either group, and no difference was found between the control and intervention group. The physical arm measurements indicated a significant reduction in bioelectrical impedance within both groups at the end of the study compared to baseline (p = 0.004 for arm only and p = 0.023 for truncal, chest, and arm). The combined groups were found to have a significant reduction at p = 0.018.
Both groups experienced a significant improvement but no difference was found based on treatment of arm alone or of truncal, chest, and arm. Some differences were noted between the intervention and control group that may have led to these conclusions. For example, the participants in the experimental group had more symptoms at baseline than the control group; whether these patients would have benefited equally from the arm-only treatment was not clear. Another variable that may have affected results is that the experimental group developed lymphedema more quickly after surgery and at a younger age. Researchers have hypothesized that opening truncal lymph channels is necessary to promote volume reduction, but this study suggested that the procedure may not play as a big of a role as originally thought. Repeating this study with a larger sample size, while holding these possible confounding variables constant, would be worthwhile.
This study suggested that truncal, chest, and arm pneumatic compression therapy is not significantly better than arm pneumatic compression alone. Differences between the control group and the experimental group could have contributed to these findings. Repeating the study with more rigorous inclusion and exclusion criteria is needed to ensure that these variables did not affect the results of the study.
Ridner, S.H., Poage-Hooper, E., Kanar, C., Doersam, J.K., Bond, S.M., & Dietrich, M.S. (2013). A pilot randomized trial evaluating low-level laser therapy as an alternative treatment to manual lymphatic drainage for breast cancer-related lymphedema. Oncology Nursing Forum, 40, 383–393.
To examine the impact of advanced practice nurse (APN)-administered low-level laser therapy (LLLT) as a stand-alone and complementary treatment for arm volume, symptoms, and quality of life (QOL) in women with breast cancer–related lymphedema
Three interventions were used, including LLLT alone, manual lympatic drainage (MLD) alone, and combined MLD and LLLT. LLLT alone used a RianCorp LTU 904, FAD-approved, class I laser. Grids for the areas to be treated were identified. The laser was applied, and exposure was limited to 20–30 seconds per point in each grid. Time for each session using this procedure was about 20 minutes. MLD alone included treatment that followed international standards. A standard number of strokes was used at each anatomical location. Each MLD session took about 40 minutes. Combined MLD and LLLT included participants receiving 20 minutes of LLLT, followed by 20 minutes of MLD. In addition, compression bandaging was applied after each treatment regardless of group assignment. Baseline and outcome data were collected pretreatment and on the last day of treatment after therapy was concluded.
All groups had clinically and statistically significant reduction in volume (p < 0.05); however, no statistically significant between-group differences were found in volume reduction. Treatment-related improvements were noted in symptom burden within all groups; however, no group differences were noted in psychological and physical symptoms or QOL. Skin improvement was noted in each group that received LLLT.
LLLT with compression bandaging may offer a time-saving therapeutic option to conventional MLD.
The study demonstrates that a trained APN could implement lymphedema therapy in clinical practice. LLLT with bandaging may offer a time-saving therapeutic option to conventional MLD. Studies with a larger sample size are needed to compare MLD and LLLT.
Ridner, S.H., Murphy, B., Deng, J., Kidd, N., Galford, E., & Dietrich, M.S. (2010). Advanced pneumatic therapy in self-care of chronic lymphedema of the trunk. Lymphatic Research and Biology, 8(4), 209–215.
To examine potential efficacy of the Flexitouch system (compression garment) for self-care home use in patients with breast cancer who had truncal lymphedema
The system examined includes compression garments for the trunk, chest, and arm and applies variable dynamic pressure to affected areas, controlled by software programming. It uses multi-chambered inflatable and stretchable fabric garments. Patients were fitted for the garments. Patients completed one-hour daily treatments for 10 days. Patient symptoms and cirumferential measurements were done at baseline, after the fifth treatment, and at the end of the study. Patients were trained in use and, after the initial treatment, were instructed in use for home treatment. Research staff observed the first home treatment, then patients completed the rest on their own at home.
The study took place in home settings in the United States.
The study has clinical applicability for late effects and survivorship.
The study used a quasi-experimental pre-post design.
There were significant reductions in symptoms of truncal heaviness (x2 = 15.07, p = 0.0001), swelling (x2=14.73, p = 0.0001), tightness (x2 = 12.63, p = 0.0002) and itchiness (x2= 12.0, p = 0.0002). There were no significant changes in truncal measurements; however, there was a general non-significant trend of reduced circumference in all areas measured. There was also significant reduction in difficulty sleeping (p = 0.008). All significant changes occurred after the fifth treatment and then remained stable at the end of the study. There was a general trend of increasing reports of skin conditions over the course of the study.
The system may be an effective device to relieve lymphedema symptoms with home self-care treatment.
The device may be helpful to reduce symptoms of lymphedema with an approach that patients can use at home for self-care. Larger controlled studies are warranted and longer term use should be evaluated.
Ridgway, D., Sopata, M., Burneckis, A., Jespersen, L., & Andersen, C. (2010). Clinical efficacy and safety of once-daily dosing of a novel, prolonged-release oral morphine tablet compared with twice-daily dosing of a standard controlled-release morphine tablet in patients with cancer pain: A randomized, double-blind, exploratory crossover study. Journal of Pain and Symptom Management, 39(4), 712–720.
To compare the safety and efficacy of a once-daily dose of a new formulation of morphine sulfate—abuse-deterrent, prolonged-release erodible-matrix (ADPREM) morphine sulfate—to the safety and efficacy of a twice-daily dose of standard controlled-release morphine
During a run-in period of three days, clinicians determined each patient's effective dose of the study drug. Throughout the study, immediate-release morphine was available for breakthrough pain. The study drug was titrated to provide a level of pain relief characterized by four or fewer episodes of breakthrough pain per day and a level of pain intensity that was acceptable (this level was undefined). Treatment periods were two weeks long. In a crossover trial, patients received either the study drug, once daily, or controlled-release morphine twice daily. In diaries patients recorded daily all medications used, number of breakthrough episodes, and pain ratings. Clinicians evaluated adverse events.
Randomized phase 2 double-blind crossover study
The pattern of treatment-related adverse events was the same for both treatments. The fixed dose determined during the run-in period was 30–210 mg/day. Authors noted no differences between treatments in regard to breakthrough pain episodes or use of rescue medication. Average pain intensity ratings were similar for both treatments.
The efficacy and side effects associated with a once-daily dose of ADPREM morphine sulfate were similar to those associated with twice-daily doses of controlled-release morphine. Studies that include larger samples are warranted.
For some patients, the ability to control pain by using fewer pills daily may be a significant consideration. This study provides evidence that supports the efficacy and safety of a once-daily ADPREM formulation of morphine.