APNs Give Practical Advice for Establishing Clinics and Implementing Programs

July 12, 2018

Advanced practice nurses (APNs) are creating new and innovative programs that educate patients and help them live better, healthier lives.

Lorraine Drapek, DNP, FNP-BC, AOCNP®, nurse practitioner of radiation oncology at Massachusetts General Hospital in Boston, Geline Joy Tamayo, MSN, RN, ACNS-BC, OCN®, TTS, of UC San Diego Health in La Jolla, CA, Suzanne McGettigan, MSN, CRNP, AOCN®, ANP-BC, nurse practitioner and clinical manager of Abramson Cancer Center at the University of Pennsylvania in Philadelphia, and Edward Bentlyewski, MSN, APN, NP-C, AOCNP®, research nurse practitioner at the Herbert Irving Comprehensive Cancer Center at Columbia University Medical Center in New York, NY, discussed their experiences with APN-run clinics and program implementation during a session at the 43rd Annual Congress in Washington, DC (https://ons.confex.com/ons/2018/meetingapp.cgi/Session/1590).

A Sexual Health Clinic for Patients With Cancer

Drapek created a continuity of care program to minimize vaginal effects in women with lower gastrointestinal and gynecologic cancers and studied it in 16 women. In 2015, she created a sexual health needs assessment for her patient population. After the majority of patients completed the assessment, she learned that participants wanted a sexual health clinic and to be asked about their sexual health, even when they were hesitant to start the initial conversation. Drapek noticed from her assessment that when treatment started, sexual health was not a focus for patients. However, as patients started to feel better during chemotherapy, they regained interest in their sexual health.

Vaginal dilator therapy can be helpful for women with lower gastrointestinal and gynecologic cancers, Drapek said. The International Guidelines on Vaginal Dilation After Pelvic Radiotherapy, as well as National Comprehensive Cancer Network (NCCN) guidelines, recommend that women use vaginal dilators for two years following completion of pelvic radiation. Drapek said that adhering to the use of vaginal dilators can help prevent long-term sexual dysfunction in patients receiving pelvic radiation.

Using the assessment information and various literature, Drapek developed a continuity of care follow-up process. The visits help women understand the importance of appointment attendance and follow up, and they also offer Drapek the opportunity to provide them with education and treatment to manage vaginal changes that can result from pelvic radiation.

Drapek developed a three-visit, nurse practitioner-run program that consisted of assessment, education, and materials to minimize or prevent vaginal stenosis. To help “wrap patients’ heads around the fact that they were going to have to use vaginal dilators during treatment,” Drapek said that the first visit in the follow-up process was at radiation planning. The second visit was at the end of treatment, and the third visit was six to eight weeks later.

To track process measures and outcomes, Drapek developed a 19-item Patient-Reported Outcomes Measurement Information System (PROMIS) survey. Patient interviews were also conducted, and patients reported data in diaries that Drapek created.

By the second visit, Drapek was not surprised that patients still experienced pain and did not engage in sexual activity. However, results showed that by the third visit, patients began to recover and feel better, leading to an increase in sexual activity. Eighty-three percent of enrolled patients used vaginal dilators by their third visit, compared to just 6% at the first visit.

Drapek said that 75% of patients who completed the program indicated a positive impact. Based on the data, she concluded that the implementation of a multimodal program could be beneficial for the patient population.  

Lung Cancer Screening Programs

Although the primary prevention of lung cancer does include modifiable risk factors such as decreasing tobacco use, Tamayo explained, quitting smoking, or not starting at all, former smokers and nonsmokers do not have the benefit of primary prevention; this is where the importance of early screening comes into effect.

Many national organizations have noted that screening helps with the treatment of lung cancer. Components necessary for high-quality lung cancer screening were developed by the American College of Chest Physicians and American Thoracic Society and were also endorsed by the American Association for Thoracic Surgery, American Cancer Society, and American Society of Clinical Oncology:

Benefits of lung cancer screening include decrease in lung cancer mortality, increase in quality of life (e.g., reduction in disease-related morbidity, improvement in healthy lifestyles, reduction of anxiety), and the possible discovering other significant health risks. Tamayo also described risks of lung cancer screening, including patient anxiety, false-positive results, false-negative results, radiation exposure, and cost.

Support is critical for the success of these types of programs, and “we collaborated with our electronic medical record group, internal medicine physicians, and family practice physicians,” she said. She expressed the possibility of other challenges, including the coordination of care and scheduling issues when the clinic is especially busy.

The Oncology Evaluation Center Formation

McGettigan discussed the patient volume growth at Perelman Center for Advanced Medicine (PCAM); her team was experiencing difficultly in treating patients with cancer and managing complications, even after an expansion.

“We are still space confined, and it can be hard to find clinic room,” she said.

Because of the lack of space at PCAM, patients began to visit the emergency department (ED) for cancer-related symptoms. McGettigan stressed that the ED is “not really the best place for our opatients to be.”

She noted three specific issues with cancer patients who visit the ED frequently:

The Oncology Evaluation Center (OEC) was formed to facilitate same-day and urgent appointments for established patients in hematology/oncology and gynecologic oncology. The center provides treatment for new symptoms related to patients’ cancer, cancer treatment, or comorbid conditions, including:

The OEC was not equipped to manage the following types of patients or symptoms, McGettigan explained:

Since the program began in July 2017, the OEC has had 722 patient encounters; of these, 77% were treated and sent home. Only 12% of patients were sent to the ED because lack of available beds, insurance situations, and patients being “sicker then they sounded on the phone or clinically unstable,” McGettigan said.

Implementing a Research Nurse Practitioner-Led Clinic

“The demand for oncology nurses is expected to increase,” Bentlyewski said. “It’s a hard job. There are a lot of balls in the air and a lot of juggling.”

As the need for oncology nurses grows, the research setting is subject to strain and may be felt more acutely because of clinical trial demands. A potential solution is increased use of nurse practitioners and physician assistants and nurse practitioner-led clinics that can be implemented in various oncology settings.

Bentlyewski piloted a nurse practitioner-led clinic in the phase I setting designed to meet the needs of patients enrolled to early phase studies.

A nurse practitioner-led clinic provides a better use of the NP skill set, provides increased job satisfaction and autonomy, and “is also helpful for continuity of care,” he added.

Limitations to this type of clinic include multiple workflows (e.g., working with different providers), space issues, and role ambiguity.

Bentlyewski said that nurse practitioners are uniquely positioned to help bridge the gap of provider shortages in oncology and oncology research and provide quality care for all patients on clinical trials.

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