Institution Meets Magnet Designation by Incorporating ONS Standards in Care Delivery

By Chris Krall, MSN, RN, OCN^®, and Penny Moore, MSN, RN, NEA-BC, OCN^®

Identifying Gaps in Care Delivery

At our large Midwestern cancer hospital, the standard of care in our infusion clinics incorporates rescue medication into treatment plans for hypersensitivity reactions. If a patient has a reaction to treatment, rescue medications are initiated and a provider is called to evaluate the patient. Additional medication can be required for severe reactions. If the patient is stable and responds well to rescue medications, chemotherapy can often be restarted at a lower rate. 

Because of its close physical proximity, historic practice had been that physicians or nurse practitioners (NPs) in the exam clinic responded when the infusion nurse identified urgent or emergent needs during regular business hours. However, those providers were not physically available for coverage after clinic hours. If the nurse felt that the patient needed to be seen after clinic hours, the patient was sent to the oncology emergency department (ED). Immediate urgent or emergent issues were managed by the nurse calling the emergency response team or calling a code blue if warranted by the patient’s condition. The attending physician was called for nonurgent patient care issues.

Nurses on the infusion unit were concerned that the intermediate patient care needs encountered after hours were not able to be addressed in a timely manner, often leading to lengthy delays in patient care and adding additional hours to treatment. Patients who experienced minor drug reactions, developed a new symptom, or needed a prescription or consent were often delayed while the infusion nurse would make several calls in an attempt to find an inpatient NP to assist with patient care issues. Without a specific provider assigned to cover the infusion unit, nurses frequently encountered resistance and were often unable to manage the care of the patient without sending the patient to the oncology ED. 

Using Standards to Update Practices

The American Society of Clinical Oncology (ASCO)/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards (https://doi.org/10.1200/JOP.2016.017905), Including Standards for the Safe Administration and Management of Oral Chemotherapy require that “a licensed independent practitioner is onsite and immediately available to staff who administer chemotherapy in the healthcare setting.” 

Nurse leaders cited the ASCO/ONS safety standard and Centers for Medicare and Medicaid Services (CMS) standards (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-Preliminary-Decisions-Hospital-OP-Payment-Panel-Supervision-Levels.pdf) to address the gap in our after-hours provider coverage for the care delivery system. An organizational decision was made to have defined coverage for the infusion unit during all hours of operation. NPs were assigned to cover patients in the infusion unit until 7 pm, Monday through Friday. NPs staffing the oncology ED were assigned to cover patients on weekends, holidays, and evenings after 7 pm. 

NPs from the oncology ED spent time shadowing nurses in the infusion unit to familiarize themselves with common treatments and prepare to respond to any infusion reactions. Infusion nurses now have one pager number they can call to access a provider. 

The ASCO/ONS standard that all patients receiving chemotherapy have direct supervision by a provider is echoed in CMS’s standard as having a provider in close physical proximity and being available to intervene if needed. The current coverage plan by the nurse practitioners ensures that we meet these standards. Most importantly, an improvement in our care delivery system has been made to ensure that our nurses are supported at all times by a designated provider in close proximity.