Our busy community practice first began treating patients with immunotherapy through participating in the original ipilimumab clinical trials. We quickly realized that this new treatment paradigm would require us to create and implement an effective screening and management tool for our immunooncology (IO) patient population. Then, when a patient who called in over the weekend to report persistent and worsening diarrhea after cycle 2 of combination immunotherapy and was told to increase his Imodium and start a “BRAT (bananas, rice, applesauce, toast)” diet, we recognized that we had missed an opportunity to prevent the subsequent high grade colitis, which required prolonged high-dose steroids and other interventions.
We were also listening to our nurses, as they expressed frustration with the variance in responses they received when talking to different physicians about the management of IO toxicities. For example, the dose and duration of steroids ordered differed not only from physician to physician, but also from patient to patient. Simply put, we lacked a practice-wide guideline. As a result, it was left to the doctor-nurse team to decide on the steroid, proper dosing, how to administer (topical/oral/IV), and how/when to taper.
In response, we put together an IO team, discussed implementation challenges, and ultimately developed an action plan. We created a nurse-driven education tool for our patients and an EMR triage, response, and documentation system that is guideline-based and standardized. All patients on IO therapy are flagged as “in active therapy” in our EMR and ANY call received by the front desk is channeled to the treatment nurse. The nurse initiates the standardized interventions, documenting the type and dose of steroids administered in the EMR flow sheet. This information is then communicated to the treating physician.
Patients are thoroughly educated. For after-hour calls, patients have a well-rehearsed script identifying them as IO patients and alerting the on-call physician to the potential IO side effects. Some of our high-risk patients even have prescription steroids at home, which they will initiate after first confirming with the nurse/physician to allow for speedy access. This program is highly effective and was seamlessly integrated into our practice. In 2017 our team won an ACCC Immuno-Oncology Institute Innovator Award for our program, Turning on the Light Switch: A Model Immunotherapy Program at an Oncology Practice. The recent release of comprehensive guidelines for the management of IO toxicities from the American Society of Clinical Oncology and National Comprehensive Cancer Network is wonderful; in fact, some of our team members actively participated in their development!
It is with great pride, but also with significant humility, that we continue to expand our IO program, one patient, one nurse, and one physician at a time. As we grow, we continue to prioritize key success factors in navigating the complex terrain of IO.
Brianna Hoffner, MSN, ANP-BC, AOCNP
September 11, 2018
