Abstract
Introduction:
Chemotherapy-induced nausea and vomiting (CINV) is a feared side effect of chemotherapy, contributing to malnutrition and decreased quality of life. Despite established evidence-based clinical practice guidelines (CPGs) for prophylactic antiemetic selection, only 46% of patients receiving moderately- or highly-emetogenic chemotherapy worldwide receive CPG-concordant prophylaxis (Sugalski et. al. Pediatric blood & cancer 2024). Within Children's Mercy Hospital (CMKC), a quaternary care children's hospital, 49.8% of chemotherapy episodes follow CPG-consistent antiemetics. Our project aimed to increase the percentage of chemotherapy episodes (low-, moderately-, or highly-emetogenic chemotherapy) with CPG-concordant antiemetic prophylaxis in pediatric patients from 49.8% to >67% by March 1, 2025.
Methods:
Preliminary data was gathered from encounters via manual data extraction from the electronic medical record (EMR) prior to implementing interventions. A multidisciplinary team, including clinicians, pharmacists, nurses, and QI leaders from the CMKC oncology division, was convened. Tools, including fault trees, fishbone diagrams, and Possible-Implement-Challenge-Kill (PICK) charts, were utilized to identify contributing factors and prioritize interventions. Ultimately, five plan-do-study-act (PDSA) cycles were implemented over ten months. Interventions initially brainstormed on the PICK chart were implemented, allowing for varying degrees of difficulty and payoff. Those implemented included education, guideline revisions, updating EMR plans, and pediatric oncology section education. To analyze the impact of the interventions, antiemetic and chemotherapy encounters were extracted from the EMR biweekly from 5/1/2024 to 3/1/2025 and manually analyzed for concordance to current guidelines. Results were displayed on control charts.
Results:
The outcome measure (% of highly-, moderately-, and low-emetogenic chemotherapy with CPG-concordant antiemetics) displayed special cause variation, with a centerline (CL) shift upwards from 49.8% to 69.1%. The process measure (% of under-prophylaxis in intrathecal chemotherapy) also demonstrated special cause variation, with a CL shift downwards from 83% to 40%. The balancing measure (% of highly-, moderately-, low-, and minimal emetogenic chemotherapy with over-prophylaxis) showed common cause variation, with the CL remaining at 10.0%.
Discussion:
This project aimed to increase CPG-concordant care for CINV prophylaxis. The outcome and process measures displayed special cause variation, with our outcome measure displaying a CL shift above the goal at 69.1%. The balancing measure, utilized to assess unintended consequences of our interventions, remained stable as intended.
Several important barriers were identified during the course of the project. Providers have different experiences with the emetogenicity of chemotherapy agents, sometimes resulting in skepticism about the recommendations proposed, especially for those related to intrathecal chemotherapy. Thus, while objective data may display gaps in systems, there is an element of subjectivity to address as well. Our project analyzed chemotherapy orders placed through the EMR. While EMR changes to chemotherapy orders may serve as a high-payoff intervention, they were found to be limited during this project due to a planned transition to a new EMR platform at CMKC. Despite these barriers, however, both outcome and process measures indicated improvement.
Moving forward, data will continue to be monitored for further improvement as additional interventions are implemented to build upon the progress of this project. Abnormalities and provider views will continue to be discussed at division and section meetings. As the hospital system transitions to a new EMR, there is an opportunity to implement clinical support tools to optimize chemotherapy ordering workflows. High-priority targets will include areas with the greatest observed gaps, such as intrathecal chemotherapy, where pre-selection of CPG-concordant CINV prophylaxis can be embedded to improve standardization and adherence.
