The nurse chemotherapy administration process varied greatly across a recently formed urban healthcare system. In addition to variance in nursing workflows, the following documentation issues were noted: 1) Inconsistent EMR (electronic medical record) documentation of the chemotherapy administration process in multiple flowsheet versions and note formats. 2) Fragmented, missing, and hard-to-locate documentation which did not present a clear picture of the patient’s care, particularly when treatment was administered at more than one site. 3) A lack of documented evidence of alignment to ONS (Oncology Nurse Society) chemotherapy administration standards. 4) Customization of multiple EMR tools that were not being updated with system upgrades.
An informatics nurse specialist (INS)-led workgroup was convened with oncology nurse clinicians from all system sites for the purpose of aligning the nurse chemotherapy administration process and moving the system to a single EMR documentation instance for this workflow. The workgroup met weekly for a period of 4 months. Each ONS chemotherapy administration standard was examined by the workgroup and both nursing process and documentation standardization recommendations were generated and operationalized.
Deliverables from this workgroup included: • A standardized nurse chemotherapy administration workflow was developed, and recommendations for operationalizing this workflow were disseminated to all sites. • A standard chemotherapy administration process document to be used by the system as a clinical resource for practice guidance, clinician training and competencies, regulatory compliance, and reference in site and system policies. • A series of EMR changes which were approved by the system oncology, hospital, and nursing collaboratives (HSC) to align all chemotherapy nurse documentation and assessment tool versions. o Adjustment of the MAR (medication administration record) documentation to reflect best practice dual verification workflow and subsequent medication administration for injectable chemotherapy. o Three independent chemotherapy review documentation processes were reduced to a single process and EMR location. Documentation verbiage was changed to account for physician and pharmacist verifiers where applicable. o Addition of a documentation field for noting the chemotherapy regimen was verified with the patient prior to administration, per ONS standard requirements. o Three versions of the CTCAE (common terminology criteria for adverse events) toxicity assessment were reduced a standard single short version of the tool (CTCAEv5). An additional row was added to the CTCAE flowsheet to indicate no toxicities were present on assessment, which facilitated charting by exception. o Multiple formats of outpatient note documentation were reduced to a single post-chemo infusion note template.
Lessons learned include: 1) Informatics nurses provide effective leadership and direction for clinical workgroups formed to standardize and operationalize workflows, particularly when this occurs in conjunction with design of EMR documentation for those workflows. 2) Validation of newly created documentation with system clinicians ensures the EMR design will support both the system standard nursing process and include the required elements to demonstrate regulatory compliance. 3) Exercising diligence in retiring outdated tool versions as new ones are created avoids more complicated EMR clean up down the road. 4) Minimizing EMR customization facilitates smoother EMR upgrades. 5) Verifying that correct customized tool migration occurred correctly during EMR upgrades avoids unnecessary post-update issues.