Background: The oncology nurse navigators (ONNs) at Lehigh Valley Health Network-Cancer Institute, comprising 8 oncology-certified registered nurses, were presented with an initiative from the administration to assist with preventing patient readmissions due to severe toxicities that could otherwise be managed in the outpatient setting. Over a period of 2 years, the ONNs alternated weekly to review the daily medical oncology on-call provider sign-out e-mails in addition to internal site postings of patients who reported posttreatment side effects or were admitted from the emergency department.
Objective: To develop criteria to identify patients who were admitted for the following diagnoses postchemotherapy treatment: nausea, vomiting, diarrhea, constipation, acute kidney injury (AKI), dehydration, generalized weakness, and neutropenic fever.
Methods: From July 1, 2017, through June 30, 2019, the ONNs evaluated the above criteria to determine eligibility of the patient for the initiative. Once eligibility was established, the reviewing ONN assigned the patient to the appropriate disease-specific ONN for initial contact. The designated ONN would complete a barrier assessment at the initial contact within 48 hours, review discharge instructions from their hospitalization, upcoming appointments, and the Chemotherapy Symptom Worksheet. Patients were provided with the ONN’s contact information and description of the navigator’s role. The practice provider and nursing staff were notified by the ONN that they were now part of the patient’s multidisciplinary care team for additional support. The ONNs contacted the patient weekly, or as appropriate, to assess their symptoms, answer any questions, and mitigate any barriers to their treatment plan. In a literature search focused on the Potentially Preventable Readmission methodology, navigators provided transitional care, home support, discharge planning, medication reconciliation, postdischarge phone calls, and follow-up appointments. These 6 interventions resulted in a reduction in the readmission rate leading to a noteworthy financial benefit, reduction in penalties from the Centers for Medicare & Medicaid, and improved reimbursement by 25% from private insurers.1
Results: Data were collected and analyzed by the ONNs at team meetings. Of 160 patients reviewed, 109 were navigated (70 of these already had an established ONN), with 39 newly navigated as part of this initiative over the 2-year period; 55 of these (34%) did not accept navigation services, expressing satisfaction with their current care team or that the services of an ONN were not beneficial. Of patients admitted postchemotherapy, 53% were due to neutropenic fever, 31% nausea/vomiting, 28% diarrhea, 3% constipation, 13% weakness, 29% dehydration, and 10% AKI. According to 2016 Medicare data, “nausea and vomiting account for almost 10% of avoidable toxicity-related post-chemotherapy hospitalizations.”2
Each ONN spent 2 to 4 work hours per week, equating to several hundred hours over the 2-year period. In addition to the criteria, common chemotherapy regimens were identified as the cause for an increased risk of hospital readmissions. These regimens were discussed with the director of the Oncology Quality Team for further exploration and interventions, such as addition of granulocyte colony-stimulating factor for specific regimens known to cause neutropenic fever or IV hydration for those causing dehydration. In 2012, the “total cost of cancer-related neutropenia hospitalizations was $2.3 billion for adults,” with a mean length of stay of 9.6 days.3
Conclusion: It was agreed that neutropenic fever was not preventable, and constipation alone did not contribute to readmission. The ONNs determined that the time spent during the extensive review caused duplication of work and did not equate to preventing readmissions as defined by the goals of the initiative. The ONN team continues to foster relationships with the multidisciplinary oncology team in the assessment, evaluation, and management of patient treatment toxicities, while implementing a navigation plan to prevent readmissions.
- McKale BM. Reducing hospital readmissions using a multimodal evidence-based approach. University of Hawaii at Manoa. 2014.
- Roeland E, Nipp RD, Ruddy KJ, et al. Inpatient hospitalization costs associated with nausea and vomiting among patients with cancer. J Clin Oncol. 2018;36:112. Abstract 112.
- Tai E, Guy GP Jr, Dunbar A, Richardson LC. Cost of cancer-related neutropenia or fever hospitalizations, United States, 2012. J Oncol Pract. 2017;13:e552-e561.