What ONS Does When the Question Can’t Be Answered Definitively
How frustrating it can be not to have enough evidence to answer a question definitively. That happens often in clinical practice, even as we build evidence for it.
Expert opinion can help when the body of research does not. This spring, we have continued work in two areas in which answers are not definitive.
Ambulatory Center Staffing
As I have written about in both ONS Voice and the Clinical Journal of Oncology Nursing, how to staff ambulatory infusion centers is a consistent inquiry to our clinical help line (clinical@ons.org) and the ONS all-member community (http://communities.ons.org/). Answering the question is not as easy as giving a nurse-to-patient ratio, and the answers that many of you have shared illustrate the different variables that go into determining staffing and assignments.
Evidence indicates that infusion center managers must understand their organization’s measurement of productivity and staffing budgeting and, in turn, advocate for resources based on their knowledge of the clinical context of the measurements used. The number of patients or drugs never is complete evidence of what a day will bring because patient condition, complexity of the treatment protocol, and other factors influence workload. Ultimately, the evidence must be built for each setting and modified as treatments or patient populations change. Staffing decisions should always put patient safety first, and who better to advocate for that than the oncology nurse? The more members share how they are determining staffing, the better all will be in establishing the standard in their infusion centers.
Safe Handling Guidelines
The second area of focus is guidelines for safe handling of chemotherapy and immunotherapy agents. Because their introduction is more recent, we have only begun to determine the answer of what the risk is to the nurse or pharmacist handling immunotherapy agents. ONS has long established guidelines on the use of personal protective equipment (PPE) when handling chemotherapy because we have a much longer base of experience with these agents.
USP <800>, which regulates hazardous drugs, most of which are chemotherapy, has had its implementation delayed until 2019 (https://voice.ons.org/news-and-views/usp-implementation-delayed-to-december-2019). It outlines requirements that some contend are not based in sufficient evidence and will raise costs for practices. PPE has been a standard for many years, and although it’s widely accepted, not all who handle chemotherapy use it, according to queries we receive and comments on surveys. I do not understand why. Requirements such as the use of closed system transfer devices and how chemotherapy mixing hoods should be vented may not have conclusive evidence to support their use. However, in both cases, our member and staff experts advise compliance with those requirements until evidence demonstrates otherwise. As the saying goes, an ounce of prevention is worth a pound of cure, so it makes sense to comply with the USP <800> guidelines once they are implemented, if not before.
In both of these situations, members are on the frontline asking for answers to these questions. ONS, as your professional home, works to ensure that you have the best solutions to your questions. Not only is patient safety a concern, but nurse safety is too. We will always err on the side of caution and support the need for ongoing research to build the evidence for our practice.