Radiology of Head And Neck Cancer Discussion Paper

Abstract

This DNP project proposal focuses on the implementation of an evidence-based high-risk patient management HEART (High ED/Admission Risk Therapy) team protocol at Mount Sinai West Hospital to reduce unplanned ED visits and hospital admissions of adult oncology patients receiving multimodal cancer therapy. It explores the extent to which Kotter’s 8 steps change model as the selected theoretical framework and the Plan-Do-Study-Act (PDSA) model as the selected methodology will be used to support the implementation of the proposed evidence-based intervention. The core findings of this project proposal shall create a better understanding of the impact of the HEART team protocol on the quality of care and support provided to cancer patients and survivors currently receiving multimodal therapy at Mount Sinai West Hospital. Focused on attaining a 20% reduction in potentially avoidable ED visits and hospital admissions, the project seeks to enhance nurses’ early detection and recognition of the risk factors and primary causes of ED visits and hospitalization of cancer patients after the initial oncology care, boost nurses’ knowledge of high-risk patient assessment and symptom management, and foster multidisciplinary team (MDT) collaboration in an attempt to prevent unplanned hospital admission and avoidable ED visits within 30-days of multimodal cancer therapy at the identified facility. As a quality improvement intervention, the proposed project is focused on meeting the OP-35 measure raised by the Centers for Medicare & Medicaid Services (CMS) and other clinical guidelines employed to ensure a significant reduction in the effects of treatment-related complications and emergencies amongst the growing population of cancer patients and survivors. Radiology of Head And Neck Cancer Discussion Paper

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1.0 Background and Significance

Cancer patients and survivors frequently utilize the Emergency Department (ED) for various diagnoses related and unrelated to their chronic medical condition. Nevertheless, ED outcomes for cancer patients receiving multimodal cancer therapy are not sufficiently documented in the United States and abroad. Findings from the reviewed literature indicate that a significant number of cancer patients receive care in the ED at some point after their diagnosis, with a projected 4.5 million visits to the emergency department reported each year (Young et al., 2020). Alsuhebany et al. (2022) established that cancer patients presenting in the emergency department units experience increased risk for hospital admissions and other detrimental outcomes (an increase in social and economic costs, a high number of comorbidities) compared to patients without cancer. Cancer patients and survivors represent a distinct patient population and may benefit from implementing evidence-based interventions to help manage treatment-related toxicity and specific cancer-related complications (Qian et al., 2021). Caterino et al. (2019) established that many cancer patients and their caregivers or families experience a lot of anxiety and stress, particularly when required to operate in a high-intensity ED setting. Other stressors that the patients often experience during the ED visits include lengthy waiting times; poor communication between patients, staff, and families; unexpected procedures; the occurrence of unexpected or acute onset concerns and lack of proper integration across the interface of cancer care between general practice, specialist cancer services and the emergency department (Biganzoli et al., 2021; Haugen, 2020). Enhanced comprehension of the distinct clinical and non-clinical needs of cancer patients presenting to emergency departments, and proper identification of areas for further improvements in the quality of care and support offered to cancer patients currently receiving multimodal therapy, is urgently needed.

Individuals diagnosed with different types and stages of cancer are often admitted to the hospital or cancer center as emergency cases for acute care compared to the general population (Dufton et al., 2022). Smith and Carlson (2021) established that cancer patients tend to experience increased exposure to infection, long wait times, and receive treatment from less experienced staff with treatment-related problems and cancer-related complications. With close to 1.6 million new cases of cancer reported each year in the United States, the number of morbidities and mortalities among people with cancer is increasing, whereby about 600,000 people are estimated to die of cancer annually (Haugen, 2020). Xu et al. (2021) indicated that while the survival rates have increased due to advances in the early detection, prevention, and treatment of cancer, the management of this chronic illness often demands a highly coordinated approach amongst the staff and patients as well as their caregivers beyond the primary oncology care. Radiology of Head And Neck Cancer Discussion Paper

Against this backdrop, genuine collaboration, and effective communication within the multidisciplinary teams of healthcare professionals involved in general oncology care is urgently needed. The various healthcare practitioners must work together (both formally and informally) and gain a leveraged understanding of their assigned roles and responsibilities to successfully meet the healthcare needs of cancer patients (Kurteva et al., 2023). Gallaway et al. (2021) indicated that such inter-professional collaboration and communication have the greater potential to contribute to a reduction in medical errors and fragmentation of care, enhanced access to optimal patient care and satisfaction, enhanced patient adherence to prescribed care, and reduced ED visits. Some indicators of ED performance that should be considered include reducing time to receive care, time to discharge from the emergency department, and reducing readmission rates among highly complex cancer patients (Stone, 2020). The utilization of multidisciplinary care in an ED setting can enhance the provision of adequate care to cancer patients at risk of unplanned ED visits, unnecessary hospitalizations, and nursing home placements (Eskander et al., 2018). Selby et al. (2019) argued that multidisciplinary teams are integral to enhancing cancer care coordination and treatment delivery based on their leveraged ability to reinforce best practices, procedures, and policies as well as to encourage comprehensive, tailored, and proactive care planning and execution.

Therefore, the utmost importance of this scholarly project proposal is to integrate the core findings from the field and the reviewed literature evidence to create a better understanding of how the incorporation of an evidence-based high-risk patient management HEART (High ED/Admission Risk Therapy) team protocol into the clinical practice of a healthcare facility can lead to a reduction in unnecessary ED visits and unplanned hospital admissions by 20% among adult cancer patients receiving multimodal cancer therapy. The core findings of this project will help to educate the various healthcare professionals and providers involved in oncology care on how the multidisciplinary approach can contribute to optimal care of people with cancer and, most importantly, help to boost effective communication, symptom management, and support decision-making by the outpatient Radiation Oncology clinic teams at the Mount Sinai West Hospital. Radiology of Head And Neck Cancer Discussion Paper

2.0 Problem Statement

The growing number of emergency department visits and high hospital admissions among patients receiving multimodal cancer treatment represents a significant problem behind the increasing healthcare costs, reduction in high-quality care delivery and management of patients’ clinical risks, and poor patient outcomes (Crawford, 2018). Moreover, findings from the reviewed literature revealed that increased ED usage among patients with cancer could be attributed to a myriad of factors, including fearfulness, insufficient communication and language skills, cultural background, insurance status, lack of social support, delays in seeking help, medication non-adherence, gender, race, socioeconomic status, among other reasons (Haas et al., 2021). As a quality improvement approach, implementation of the HEART team protocol at Mount Sinai West Hospital will have positive implications on the relationships between improvement in prevention, early detection, and recognition of the primary causes and risk factors for unplanned ED visits and admissions as well as improvements in the nurses’ knowledge of high-risk patient assessment and symptom management.

3.0 Need Assessment

More than 1.5 million attendances by Americans for managing cancer treatment-related complications through EDs annually (Jairam et al., 2019). People with cancer often present to the emergency departments of hospitals or cancer centers to manage concerns related to their cancer diagnosis and/or treatment. Some of the main reasons behind ED visits by people with cancer include infection, pain, fever, respiratory symptoms, gastrointestinal toxicities, bleeding, injury, neurologic complaints, circulatory symptoms, and other comorbidities (Huang et al., 2021). At Mount Sinai West, at least 14 cancer treatment-related unplanned ED visits among 40 patients who received multimodal cancer therapy were reported in 2022, representing about 35% of ED visit rates. Moreover, a majority of the ED visits at the facility were among older people (60 years and above) with cancer, and the chief complaints for this particular population included neurologic complaints, fatigue, respiratory symptoms, injury, metabolic/endocrine as well as gastrointestinal and respiratory complaints (Pettit, Sarmiento & Kline, 2021). As such, the adoption of a multidisciplinary team approach at the identified cancer care facility can boost the capacity of healthcare professionals to identify the fundamental causes and risk factors behind the high ED visits and unplanned admissions amongst cancer patients and survivors and to adopt patient-centered, evidence-based interventions improve the quality of care delivered to patients at high risk for preventable acute care (Hubler et al., 2022). Radiology of Head And Neck Cancer Discussion Paper

4.0 Review of  Literature

The DNP student conducted a systematic review of available literature findings on ED visits and hospital admissions among cancer patients. The main online databases utilized in this study to search for appropriate information and data on the research topic include MEDLINE (n= 32), PubMed (n= 68), Science Direct (n=50), and Cochrane (n=53). With regard to the inclusion criteria, only peer-reviewed articles and books that focused on the application of a multidisciplinary team approach to provide optimal care for people with cancer in the emergency department were included in the final review. Moreover, the search strategy focused on articles published in English and written within a five-year span, 2018-2023. The keywords and terms used in the search include cancer patients, emergency department visits among people with cancer, multidisciplinary team cancer team, unnecessary emergency visits, unplanned hospital admissions, and burden of cancer care. Regarding the exclusion criteria, the review did not include research studies that failed to comprise full-text, abstracts, and those published before 2018 and in foreign languages other than English. Only 40 sources were included in the final review based on their credibility, timeliness, validity, and relevance to the research topic. Radiology of Head And Neck Cancer Discussion Paper

Research findings have shown that cancer patients and survivors are increasingly more likely to visit an emergency department of a cancer center or healthcare facility for acute care compared to the general population (Qian et al., 2021; Hamilton et al., 2016). In a retrospective study, Gallaway et al. (2021) established some of the common symptoms reported by cancer patients and survivors presenting to the ED, and they include respiratory complaints (e.g., shortness of breath, pneumonia, respiratory distress, cough, acute bronchitis, hemoptysis), gastrointestinal symptoms ( e.g., loss of appetite, vomiting, gastroenteritis, abdominal pain, food poisoning, nausea, bloating), neurologic complaints (e.g., dizziness, altered mental status, seizure, drowsiness), pain (e.g., abdominal pain, chest pain, extremity pain, other pain), and dehydration (e.g., hypernatremia, tachycardia, vomiting, diarrhea, dehydration). Other symptoms include bleeding and injury (e.g., cut, sting, bite, injury, poisoning, motor vehicle accident, excessive heat, drowning, firearm), fever (e.g., febrile, chills, neutropenia), hypertension (high blood pressure), fatigue (e.g., weakness, malaise), and medication refill (e.g., prescription, refill medication, lost script, requesting script) (Hubler et al., 2022; Crawford, 2018). The studies concluded that a better understanding of the core symptoms and chief complaints behind the ED visits and hospital admissions of people with cancer is needed in order to inform the adoption of best practices aimed at boosting care coordination and proper management of symptoms as well as timely referral to supportive or palliative care and access to high-quality oncology care at an outpatient setting.

In a cross-sectional descriptive survey study, Waller et al. (2023) attempted to examine the perceptions of brain cancer patients about what comprises optimal care for cancer patients presenting to the emergency department. The study found that cancer patients who present to the emergency department during their multimodal cancer therapy tend to experience a higher risk of hospital admission. The researchers in other different studies recommended the need for adopting a collaborative, inter-professional approach to care that brings together an effective team of specialists working in emergency medicine, oncology, and other areas such as neurology, nursing, and general practice (Zaccagnini & Pechacek, 2021; Pettit, Sarmiento & Kline, 2021). In a qualitative study, Jairam et al. (2019) argued that genuine collaboration and effective communication within a multidisciplinary team of healthcare professionals (including leaderships, nurses, physicians, nurse practitioners, and supportive oncology staff operating in outpatient and inpatient environments) is needed to guarantee the delivery of high-quality, patient-centered care. Some of the positive outcomes associated with the multidisciplinary approach include improvements in patient satisfaction, increased patient adherence to prescribed treatment and care, reduction in medical errors and fragmentation of care, and enhanced management of symptoms and complications associated with cancer-related problems and treatment-associated complications. Radiology of Head And Neck Cancer Discussion Paper

The study by Hjermstad et al. (2018) recommended close collaboration between palliative and oncology care as the basis for achieving fewer admissions to acute care facilities and fewer visits to the emergency departments. Similar findings were reported by Majka and Trueger (2023), who claimed that adopting evidence-based interventions by multidisciplinary teams could contribute to improvements in cancer care and outcomes. Klotz et al. (2021) pointed out that the HEART team protocol is geared mainly at ensuring the team of specialists involved across the care continuum remains organized, well-led, and efficient, communicates well and effectively within the multidisciplinary team and with their respective patients, and base their decisions on timely and sound information and data. Moreover, Terrones-Campos et al. (2022) asserted that the enforcement of the HEART team protocol can provide a highly flexible, multidisciplinary, and collaborative approach aimed at enabling the implementation of clinical guidelines and protocols to identify potentially preventable ED visits and enhance hospital outcomes for cancer patients in the emergency setting. Eskander et al. (2018) indicated that conformity with measure OP-35 can form a strong basis on which contemporary healthcare providers and cancer centers can actively monitor ED visit rates, hospitalization, re-hospitalization, and hospital mortality across all principal diagnoses of cancer. Moreover, considering the multifactorial nature of the leading causes and the risk factors behind increased ED visits and hospital admissions among cancer patients, the adoption of the HEART team protocol can go ahead to inform the realization of cancer-specific pathways within a triage system to enhance outcomes in terms of reduced ED visits and reduced risks of hospital admission and death (Neugut & Bates, 2021). Radiology of Head And Neck Cancer Discussion Paper

Findings from the reviewed literature indicate that a multidisciplinary team approach can be made effective by implementing the HEART team protocol. Smith and Carlson (2021) found out that the HEART team protocol can be considered an evidence-based guideline aimed at informing the outcomes of team discussions of staging and diagnostic investigations and, most importantly, enhancing collaboration amongst healthcare providers and patient-clinician communication and interactions. Ideally, the application of the HEART team protocol by the multidisciplinary team may play a fundamental role in improving survival through a strong focus on the provision of individualized care, identification of patient needs, and proper and timely coordination of suitable ancillary services (Teggart et al., 2022). Other research findings by Haugen (2020) revealed that the use of a high-risk patient management team protocol can go ahead to boot multidisciplinary team working and team decision-making, thus enhancing minimize cancer treatment-related adverse effects, improving patient knowledge, increasing patient satisfaction with the multidisciplinary team (MDT) decisions, lowering decisional conflict, and enhancing the perception of risk. These findings indicate that the HEART team protocol is a critical evidence-based intervention capable of streamlining the process of MDT working in terms of boosting all care team involvement including patients and patient knowledge to enable them to make well-informed decisions regarding their treatment preferences and other aspects of cancer care beyond the initial oncology care (Klotz et al., 2021).

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The findings indicate that using evidence-based guidelines and collaborative interventions by the multidisciplinary team involved in the care of cancer patients presenting to an ED setting can significantly reduce potentially avoidable ED visits and unplanned hospital admissions and mortality (Patel et al., 2021).  As a Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) decision-making tool, the HEART team protocol can provide the requisite tools, algorithms, and procedures that the multidisciplinary team can follow to monitor trends for patients at risk of cancer-related problems and treatment-associated complications while receiving and the acute phase after completion of multimodal cancer therapy (Taberna et al., 2020). Radiology of Head And Neck Cancer Discussion Paper

In terms of rationale, the quality improvement project was primarily implemented to meet the criteria for measure OP-35 and identify some of the driving and restraining factors behind the facility’s high ED visits and admission rates for patients receiving cancer treatments. Implementation of the HEART team protocol is intended to evaluate the effectiveness of OP-35 in the identification of potentially avoidable ED visits for adult oncology patients receiving multimodal cancer therapy (Shelburne et al., 2022). Moreover, the project is justified by the extent to which guideline-based management of supportive care for treatment-related problems and cancer treatment-related complications can be fully integrated into oncology care for the very sake of enhancing the quality of care delivered to cancer patients currently undergoing multimodal treatment at Mount Sinai West Hospital (Haugen, 2020).

5.0 Theoretical framework

Kotter’s 8-step change model is the theoretical framework that underpins the capstone project. Introduced in 1996 by John Kotter, this theoretical framework was developed following comprehensive research of more than 100 organizations undergoing a change process. As shown in Appendix 1, the eight steps in the process of change include the establishment of a sense of urgency, creation of powerful guiding coalitions, development of a strategy and vision, communicating the vision, removal of obstacles, and empowerment of employees for action, creation of short-term wins, consolidation of gains, and the strengthening of change through embedding change in the culture of the given organization (Kotter, 2022). Radiology of Head And Neck Cancer Discussion Paper

In terms of application, the basic tenets of this theoretical framework will be employed to inform the implementation of the HEART team protocol to boost care coordination and treatment outcomes for oncology patients receiving multimodal cancer therapy at the selected agency. The creation of a strong sense of urgency regarding the rising rates of ED visits and unplanned admissions amongst cancer patients and survivors under multimodal treatment will raise awareness of the risk factors and causes of this problem, identify opportunities and benefits of evidence-based interventions, and initiate stakeholder engagement and collaboration in an attempt to enhance the quality of care and support offered to people with cancer beyond the initial oncology care (Kurteva et al., 2023). The formation of powerful guiding coalitions comprising key stakeholders, organizational leaders, and healthcare practitioners, and support staff will also prove highly instrumental in ensuring multidisciplinary working and decision-making in favor of the successful implementation of the proposed evidence-based intervention, the HEART team protocol (Waller et al., 2023). Another step involved the development of a clear vision and strategy using the SMART decision-making algorithm and checklist, timely provision of feedback) to ensure the proposed change process in favor of reduced ED visits and unplanned hospitalizations are reduced by implementing the HEART team protocol. Achieving success throughout the change proves that all the team members and other involved parties maintain effective communication to ensure the goals and objectives, as well as the mission and vision of the prosed project, are successfully attained using the available resources. Equally, the removal of barriers (through staff training and employee empowerment) to the realization of the multidisciplinary team approach can also enable the project team members to overcome resistance to change and to amplify the benefits of the HEART team protocol in line with the need for achieving higher quality care for cancer patients and survivors currently receiving multimodal therapy (Xu et al., 2021). Other key steps include the creation of short-term wins (e.g., project approval, employee engagement) well as consolidation of gains (e.g., success stories) will also go ahead to inform the realization of holistic, patient-centered and high-quality care to patients at risk of unnecessary ED visits and unplanned hospital admissions (Bayrak & Kitiş, 2018). Lastly, it is highly imperative to anchor the desirable change into the corporate culture of the healthcare facility through integrating the HEART team protocol into the mainstream clinical practice, capacity-building, and the sharing of success stories related to the project to ensure replication and further quality improvements (Selby et al., 2019). Radiology of Head And Neck Cancer Discussion Paper

6.0 Goals, Objectives, and Expected Outcomes

Goal

The main purpose of the DNP scholarly project is to incorporate the HEART team protocol into the clinical practice of Mount Sinai West to reduce unnecessary ED visits and unplanned hospital admissions by 20% for adults receiving multimodal cancer therapy.

Objectives

This DNP project is guided by the following objectives:

1. Improve nurse recognition and early detection of primary causes and risk factors of unnecessary ED visits and unplanned admissions of adult oncology patients receiving multimodal cancer therapy.
2. Improve the nurse knowledge of high-risk patient assessment and symptom management.

Expected Outcomes

1. Reduce ED visits and hospital admissions by 20% among high-risk cancer patients receiving multimodal therapy at the radiation oncology department within the selected healthcare facility.
2. To integrate the HEART team protocol into the clinical practice of the facility to enhance the prediction and management of cancer-related problems and treatment-associated complications in order prevent avoidable ED visits and hospitalization.
3. To reduce the adverse health outcomes associated with unnecessary ED visits and unplanned hospital admissions among cancer patients and survivors receiving multimodal cancer therapy at the facility.
4. To foster multidisciplinary team collaboration in a quest to improve coordination of care across the care continuum for adult cancer patients to prevent unplanned admissions and preventable ED visits within 30-days of multimodal cancer therapy Radiology of Head And Neck Cancer Discussion Paper

Obtaining support from stakeholder’s process

Implementation of the HEART Team protocol is in line with the facility’s multidisciplinary and collaborative approach to cancer care. Therefore, the Mount Sinai West Hospital seeks to implement the OP-35 measure to come up with facility-specific reports on the list of cancer-related problems and treatment-associated complications behind the high rates of preventable ED visits and unplanned hospitalizations after the 30-days of multimodal cancer treatment.

Initial implementation steps

The implementation begins with performing a comprehensive review of available literature on the risk factors behind the high rate of preventable ED visits and hospitalizations amongst cancer patients and survivors receiving multimodal cancer therapy. Another step entails organizing a meeting and presenting the project plan to the senior management at the facility on the need for adopting a multidisciplinary team approach to cancer care beyond the initial oncology care (Keller, Wexner & Chand, 2018). Also, meeting with the supportive oncology team and the nursing manager is an essential step aimed at ensuring the proper allocation of roles and responsibilities. The development of the HEART team protocol algorithm is integral to ensuring the key elements of the program are integrated into clinical practice (Colley, Pracy & Jennings, 2021). Moreover, the development of the educational materials and provision of proper training and education to the nursing team and the multidisciplinary QI team will ensure enhanced awareness of the key goals and objectives of the project as well as other key areas of interest (Kowalczyk & Jassem, 2020). Creation of the evaluation criteria and tools will ensure the HEART team is evaluated thoroughly to determine and compare the pre and post-implementation of ED visits and admission rates. Combined, these implementation steps are essentially focused on integrating the HEART team protocol into the corporate culture of the healthcare organization to ensure effective management of treatment-related complications and emergencies experienced by adult cancer patients receiving multimodal therapy (Appendix 2). Radiology of Head And Neck Cancer Discussion Paper

Outcome Measure/Measurement Instruments

To measure the outcomes of the DNP project, the following instruments will be used to evaluate the impact of the proposed project:  HEART Assessment chart Audits, Referral rates for HEART Team, Pre/post-implementation ED/Admission rates, and the pre/post knowledge survey.

Benefits/Risks

Some of the benefits associated with the project include reduced social and economic costs associated with high rates of ED visits and hospital admissions among people with cancer. Others include improved psychological and physical well-being due to enhanced management of treatment-related emergencies and complications (Klotz et al., 2021). However, the loss of the subject’s privacy and confidentiality of data collected and produced in the study may have detrimental effects on the participants. Strong emphasis will be made on upholding the ethical principles of beneficence, non-maleficence, informed consent autonomy, and responsibility to ensure these risks of harm are minimized (Hjermstad et al., 2018).

Participant Recruitment

The data will be collected using stratified sampling whereby only adult cancer patients receiving multimodal cancer therapy at the facility will be included. Equally, the multidisciplinary team of experts will be recruited using purposive sampling to ensure that only the most relevant members are included in the team. The use of flyers will form a crucial part of the recruitment materials. Radiology of Head And Neck Cancer Discussion Paper

Ethical and Consent Procedures

All the participants involved in this DNP scholarly project were served with a written informed consent form by the DNP student prior to the commencement of the project. This enabled informed consent to be obtained from all subjects involved in this proposed project.

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Project Timeline

The proposed evidence-based project plan will be developed, implemented, and evaluated over the next two semesters. Each of team member of the multidisciplinary team will assume a set of responsibilities, tasks and deliverables as follows: the DNP Student and the agency mentor (identify gap in practice, planning, and mentorship) to were conducted between July 22 to the end of August, 2022; the DNP Student, leadership, mentor (meeting with nursing/medical directors to discuss adoption of high-risk patient management algorithm) to be conducted during the months of July, August, September, October, November, December of 2022 as well as February, March, April, and June, 2023; the DNP student, nursing leadership (Meeting with nursing manager to discuss using high-risk nursing assessment tool in weekly On-treatment Visit) to be performed in October, November, December of 2022 and March, April, and June of 2023); the DNP Student, RNs (pre-educate nursing team survey) to be conducted in May of 2023; the DNP student, RNs (meeting with nursing team/ educate nursing them on the HEART algorithm and high-risk patient assessment checklist) to be conducted in May and June of 2023; the DNP student, MDs, Nursing Manager, RNs, Social Worker, and Nutritionist (HEART team building) to be realized in May and June of 2023; the DNP student, MDs, Nursing Manager, RNs, Social Worker, and Nutritionist (Implementation) to be conducted in June, July, August, and September; the DNP student, HEART Team, stakeholders (monthly meeting with HEART TEAM, RN champion, and MD champion) to be executed in June, July, August, September and October of 2023; RNs (Post-Implementation RN survey) to be conducted in October of 2023;  the DNP student (data collection and data analysis) to be conducted in October and November of 2023; the DNP student (project completion) to be conducted in November; the DNP Student, Senior leadership (Evaluation and Feedback) to be conducted in November and December of 2023) the DNP student, Faculty (Dissemination of project and manuscript completion) to be conducted in 2024; and DNP student, senior management (discussion on sustainability and further study) to be conducted in 2024 (See Appendix 3). Radiology of Head And Neck Cancer Discussion Paper