Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
UsingCOSTaRSpracticeguidesforcancersymptomsupport:
ATutorialforNurses
October2016
ThePan-CanadianOncologySymptomTriageandRemoteSupport(COSTaRS)projecthasreceivedfundingfromtheCanadianPartnershipAgainstCancer(2007-2011),theCanadianInstitutesofHealthResearch(2012-2014),andtheCanadianCancer
Society(2015-2017)
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
The2016COSTaRSworkshopwasdevelopedby:DawnStacey,RN,PhD,CON(C),OttawaHospitalResearchInstitute,UniversityofOttawaLynneJolicoeurRN,MScN,CON(C),TheOttawaHospitalBarbaraBallantyne,RN,MScN,CON(C),CHPCN(C),HealthSciencesNorth,SudburyAndraDavisRN,PhD,CollegeofNursing,WashingtonStateUniversity,VancouverMegCarley,BSc,OttawaHospitalResearchInstitute
Theoriginal2014COSTaRSworkshopwasdevelopedby:DawnStacey,RN,PhD,CON(C),OttawaHospitalResearchInstitute,UniversityofOttawaMyriamSkrutkowskiRN,MScN,CON(C),McGillUniversityHealthCentre,MontrealBarbaraBallantyne,RN,MScN,CON(C),CHPCN(C),HealthSciencesNorth,SudburyMegCarley,BSc,OttawaHospitalResearchInstituteErinKolari,BScN,CVAA,HealthSciencesNorth,SudburyTaraShawRN,CON(C),CapitalHealth,Halifax
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
OverallAim
ThepurposeofthistutorialistopreparenursesforusingtheCOSTaRSpracticeguidestoenhancetheirknowledgeandskillsinprovidingqualityandconsistentcancersymptomsupport
COSTaRS: pan-Canadian Oncology Symptom Triage and Remote Support
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
LearningObjectives1. Describeelementsofevidence-informedsymptomsupport
2. Explainhowtoassessandtriageclients‘cancersymptoms
3. Discussaclient-centredapproachtoself-caresymptomsupport
4. Useevidenceandtheory-basedpracticeguideswithclientsexperiencingcancersymptomsandwiththeirfamily
5. Documentsymptomassessment,triage,andself-caresupport
Note:Attheend,weaskforyourfeedbackonthetutorialFeedbackisnotmandatory;butifprovided,itwillbeusedtomakeimprovements
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Outline
1. Background
2. COSTaRSpracticeguides
3. Tipsforusingtheminpractice
4. Caseexemplar
5. Tryitandreflectonyourexperience
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Background• Adultswithcancer:
• Oftenexperiencesymptomsathome• Canbesupportedtomanagethesesymptoms• Havesymptomsthatcanprogresstobeingunsafewhenreceiving
treatment
• Nursessupportclientstomanagecancersymptomsandmanyalsoprovidetelephonesupport
• Cancersymptom-focusedclinicalpracticeguidelinesareavailablebutnotintegratedinclinicalpractice
(Macartneyetal.,2012;Staceyetal.,2007;Staceyetal.,2013)
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Whatcommonsymptomsdoyoumanage…
•Inperson?(Specify)
• Onthetelephone?(Specify)
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Symptoms adults on cancer treatment report to nurses.
Pan-CanadianOncologySymptomTriageandRemoteSupport(COSTaRS)
http://www.ktcanada.ohri.ca/costars/
Of100clientswithcancersymptomswhogototheemergencydepartment,abouthowmanycouldhavebeenmanagedathome?
A. None(0)B. One-quarter(~25)C. Ahalf(~50)D. About75(~75)E. All(100)
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Asystematicreviewidentified12studiesthatshowed:
• Abouthalfofemergencydepartmentvisitscouldhavebeenmanagedathome
Supportingclientswithmanagingsymptomsathomeshouldleadtomoreappropriateemergencydepartmentvisits.
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Nursesmanagecancersymptomsandtreatmentsideeffectsby…
– integratingandapplyingknowledge(pathophysiology,diseaseprogression,treatmentmodalities,treatmentsideeffects,complication,andsymptomproblems)
– assessing,planning,implementingandevaluatingtheoutcomesofbestpractice/evidence-basedcare(Standard3)
– engagingincriticalthinking,integratingbestpractice/evidence-basedknowledge,exercisingethicaljudgment(Standard7)
(CanadianAssociationofNursesinOncologyPracticeStandards&Competencies)
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Fornursesthatprovidetele-practice/telephoneservices:
• Nursespracticeinprovince/territorywheretheyarelocatedandregistereddespitewheretheclientislocated
• Dutytoprovidecareisestablishedassoonasthenurseinteractswiththeclient
• Toreduceriskofliabilityintele-practice:– Nursesuseclinicalguidelines,standardizedprotocols,agencypolicies/procedures
– Nursesdocumentallinteractions(paper/electronic)– Nursesparticipateinorientationandcontinuingeducation– Researchisconductedtoinformandevaluatetheseservices
(CanadianNursesAssociation,2007)ProvincialColleges:Manitoba;Ontario;NovaScotia;NewfoundlandandLabrador;BritishColumbia
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Outline
1. Background
2. COSTaRSpracticeguides
3. Tipsforusingtheminpractice
4. Caseexemplar
5. Tryitandreflectonyourexperience
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
COSTaRSPracticeGuides• Goal:toenhancethequalityand
consistencyofcancersymptommanagementbynurses
• Clinicalpracticeguides:– supportclient-centredcarebynurses– narrowtheknow-dogapby:
ü presentingbestavailableevidenceü usingaformatsensitivetohownursesthinkandwhat
nursesdoü complementsnurses’ criticalthinkingBUTdoesnot
replaceit
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
COSTaRS:15Symptoms
AnxietyAppetiteLossBleedingBreathlessness/dyspneaConstipationDepressionDiarrheaFatigue/tiredness
FebrileneutropeniaMouthsores/stomatitisNausea/vomitingPainPeripheralneuropathySkinreactionSleepproblems
Developed by: researchers, advanced practice nurses, nurse leaders, graduate students, library scientist, and an information systems researcher from 8 Canadian provinces.
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
COSTaRSPracticeGuideshave5sections
1. Assesssymptomseverity
2. Triageclientforsymptommanagementbasedonhighestseverity
3. Reviewmedicationsbeingusedforthesymptom
4. Reviewself-carestrategies
5. Summarizeanddocumenttheplanagreeduponwiththeclient
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
APRACTICEGUIDEINDETAIL…
Edmonton Symptom Assessment Scale: Ask client/family to rate severity on scale of 0 (none) to 10 (worst possible).
Ask client/family about their symptom to assess severity
Space to make notes
Rate severity and triage to highest level
(use nursing judgment)
Ask client/family what medications they have/use for the symptom. Encourage use as prescribed and based on patients’ goals
Engage client/family by asking what they would agree to try
Guide client/family in choosing self-care strategies
Learn about the effectiveness of medications based on the current evidence
Document agreed upon plan to empower client/family
If not confident, explore ways to support client/familyFor more information,
see guidelines
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) Project
www.ktcanada.ohri.ca/costars
When should COSTaRS be used?1. When a client/family expresses concern
about a symptom (in person or by telephone)*
and/or2. When face to face assessment indicates
a symptom* score of ≥4/10
*If multiple symptoms, start with most burdensome or high risk (life-threatening) symptom based on the nurses’ assessment and judgment
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Howcouldyoudocument COSTaRS use?(choose all that apply to your organization)
A. UseCOSTaRSpracticeguidesaspaper-baseddocumentationtoolsfiledonthehealthrecord
B. UseCOSTaRSpracticeguidesembeddedintotheelectronichealthrecord
C. Useadry-erasemarkertodocumentonplasticizedpracticeguidesandtransferresultswhendocumentingonusualformsandindicateCOSTaRSused
D. DocumentwhatCOSTaRSpracticeguidewasusedandsummaryoffindingsonusualformsstandardforms
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Documenting
Ataminimum,documentationofsymptommanagementincludes:1.Symptomseverity(mild,moderate,severe)withfindingsfromassessmenttosupporttheseverityrating
2.Medicationsreviewedconsideringpatients’goalsforsymptomrelief3.Self-carestrategiesclientagreestotry
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
BackgroundonCOSTaRSpracticeguides…• Informedbyqualityratedclinicalpracticeguidelines
– Ifsomethingismissing,itislikelybecausethereisnosupportingevidencefromguidelines
• MeetsAGREEIIrigourcriteriaforguidelines by:– Makingexplicittherecommendations(Steps1to5)– Linkingtoevidence(referencesprovided)– Usingfindingsfromguidelinesidentifiedviasystematicreviews– Werereviewedbyexpertsfrom8provincesacrossCanada
• Areusableinpracticebeyondaresourceontheshelf• Useplainlanguage– Flesch-KincaidGrade6.4• Steps4&5basedonbriefmotivationalinterviewing
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Outline1. Background
2. COSTaRSpracticeguides
3. Tipsforusingtheminpractice
4. Caseexemplar
5. Tryitandreflectonyourexperience
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
TipsforusingCOSTaRSpracticeguides• Afterprovidingyournameanddesignation,startbylisteningtothe
client/familyThefirst10-20secondssignificantlyimpactsclient’s/family’sperceptionsofnurse’sdesiretomeettheirneeds
• Asktheclientifyoucanaskthemafewspecificquestions
• Befamiliarwithpracticeguidestogowiththeflowinconversationratherthanaskquestionswordbyword
• Startwiththepracticeguideforthemostproblematicsymptom
• Engagetheclient/familybylisteningtotheirsymptomdescriptionandguidingtheminenhancingtheirself-carestrategies
• Integratemotivationalinterviewingtechniques
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Outline
1. Background
2. COSTaRSpracticeguides
3. Tipsforusingtheminpractice
4. Caseexemplar
5. Tryitandreflectonyourexperience
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Triaging symptom calls with and without practice guides: A case exemplar
• Tracey, 49 years old, with colon cancer metastases to liver
• Treatment: surgery with 6 months of chemotherapy• At 6 months, liver disease stable and chemotherapy
discontinued• 3 months later restarted chemo for retroperitoneal
progression• Oxaliplatin IV day 1 and oral Xeloda 2 pills per day for
2 weeks• Between day 3 and day 7, Tracey called the cancer
centre 3 times regarding nausea & vomiting (N&V)
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
• Call #1 – Oral chemo Day 3: Tracy called her Primary Nurse– Clerk message: “Has not taken her chemo pill
today. Medication tastes bad and stomach feels awful”. Clerk attached N&V COSTaRS guide to the written message
– Primary nurse returned call in 2.5 hours and documented:“Patient advised to take Xeloda if she can. Advised to try Stemetil first.”
– No documentation reflected use of the COSTaRS practice guide
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
• Call #2 – Oral chemo Day 5: Tracy called again– Clerk message: “Vomited last night. Not sure if
she should take chemo pill”. Clerk attached the N&V COSTaRS guide.
– Replacement nurse returned call within 2 hours and documented: “Took Stemetil once with effect. Not nauseated now. Drinking OK. Advised to proceed.”
– No documentation reflected used of the COSTaRS practice guide
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
• Call #3 – Oral chemo Day 6: Tracy called again– Clerk message: “Patient requesting primary nurse
call her ASAP. Feels terrible. Nauseated and medication is not helping. Has not taken chemotherapy.” Clerk attached N&V COSTaRS practice guide to the written message
– 2nd replacement nurse (3rd nurse in 4 days) documented her assessment, triage and interventions on the COSTaRS practice guide…
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Nurse documentation revealed:– Constipation was also contributing to nausea– The nurse assessed, triaged and managed both
symptoms using COSTaRS guides– Medication review revealed:
• She was not using stemetil as prescribed and not aware metoclopramide was also for nausea and/or vomiting
• Granisetron with her IV chemo frequently causes constipation and she had Colace and Senokot for constipation but not using them
– Self-management strategies were reviewed and next steps agreed upon were clearly documented.
In summary, using COSTaRS practice guides led to improved symptom management and may have reduced the number of calls and improved communication
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Outline
1. Background
2. COSTaRSpracticeguides
3. Tipsforusingtheminpractice
4. Caseexemplar
5. Tryitandreflectonyourexperience
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Tryitoutwithsomeoneelse!
• Getintogroupsof2to3– 1personisintheroleoftheclient– 1personisintheroleofthenurse– 1personisintheroleoftheobserver/family
• Take5minutestoroleplaywitha‘client’reportingaspecificsymptom(simulatedclientorrealclient)
• Discussyourexperienceintherole(seenextslide)
Hintsa) Introductionb) Listenc) Assess
symptomsd) Discuss tips for
managinge) Document
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Reflectingonyourexperience(s)• Whatwentwellusingthepracticeguide(s)?
…
• Whatwouldyoudodifferentlynexttime?
…
• Whatquestionsdoyouhaveafterusingthepracticeguide(s)?
…
Note:NursesgraduallyfeelmorecomfortablewithusingCOSTaRSafterrepeateduse
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
Whatdidothernursessay?•OverallfeedbackonCOSTaRSpracticeguides:
• clear,user-friendly,comprehensiveassessment• verythorough;yetconcise• offersdirectionwithoutneedingtoseekmoreinfo• excellentself-carestrategies
•ProcessofusingCOSTaRSpracticeguides:• tickboxessaveexcessivedocumentation• easytofilloutwhentalking• cleardifferencesbetweenmild/mod/severesymptoms
•Linksevidencetopractice•Applicabletonearlyeverycancer
Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS)
www.ktcanada.ohri.ca/costars
KeyMessagesForgoodsymptommanagement:• Staypatient-centered:
• Listentotheclient• Provideguidancethatisbasedontheirpriorities unlessthereis
aclinicalconcernyouhaveidentified,requiringintervention
• Assessthesymptominathorough,stepwisefashion
• Discussevidenceinformedtipsformanagingsymptoms• Documentthesymptomsupportprovided
To make it a habit, use practice guides daily