Download MED E handbook 2012 2013

Guide for Residents and Fellows on Med E
Updated 3/2012
Contents
1. MED E Daily Schedule
2. Hematology/Oncology Competency Based Inpatient Curriculum
3. New patient schedulers, return schedules and nurse navigators
4. Contact information for 4 Oncology
5. Discharge Planning reminders
6. Documentation Tips
7. Common pharmacological management of MDE patients
a. Use of Acid Suppression in heme onc patients
b. Management of febrile neutropenia guidelines
c. Treatment and prevention of menorrhagia in premenopausal women undergoing
myelosuppressive chemotherapy
d. Management and prevention of nausea/vomiting guidelines
e. Guidelines for the use of white blood cell growth factors
f. Tumor lysis syndrome guidelines
8. Ipilimumab induced diarrhea. Algorithm for management.
9. Living Spiritually with Cancer
10. Algorithm for patients with Bone metatases
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Med E 4 Oncology Daily Schedule
Morning report for students and residents 7:30 to 8:30
Huddle 8:40 to 8:50
Talking points: (lead by the Oncology Fellow).
Scheduled admissions to L (hospitalists), E1(heme malignancy) and E2 (solid)
Team sizes
Capacity for the admitting team to take on new patients
Strategy to accommodate as many admissions as possible and appropriate
Team announcements
Scheduled teaching time
Oncology Fellow can contact Med L with the plan if capacity issues exist
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Work Rounds 8:40 – 11:00
Expect and welcome nurses to join work rounds
Strategy:
Round on the admissions that have been done by the night float first so that this person can
go home.
Consider rounding on the patient who is ready to go home so that discharges can get done
as early as possible. Excuse the intern to complete this work.
Round on all of the patients as a team unless the patient is stable and the attending, resident
and fellow have had a chance to discuss the stable patient’s case.
How should rounds “look”
Presentations
Goal of 3 minutes for even the most complicated patient. Focus only
on pertinent positives and negatives.
Acknowledge the patient
Knock before entering
Eye contact
TURN OFF THE TV!
Ideally sit down by the bedside
Decide who should speak for the team. It can be the resident, intern,
student or any member.
Spokes person introduces everyone else entering the room and
explains their roles.
If the patient has visitors in the room, ask if the visitor can hear the
information that will be disclosed.
Duration
Set expectations for the encounter – how long will you be in the
room? (It is appropriate and in many instances preferable for someone
to explain to the patient and his or her family that you are on work
rounds. You could explain that the purpose is to facilitate
communication with the team and for the team to meet the patient.
Be certain to return later in the day to go over the plans, test results, discharge
goals etc).
Use the White Board to fill in information about the daily plan and discharge
goals
Ask if the patient has any questions or if there is anything else you can do for
them before leaving the room. Say thank you before leaving.
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Interdisciplinary Rounds 11:15 daily Monday – Friday
Teaching 2pm M-T-W-F (The topic and whether or not the teaching session will take place is
announced at the huddle).
Check out 4pm with the attending or fellow.
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Hematology/Oncology Inpatient Curriculum Updated 2/2012.
Oncology Rotation Competency-based Goals and Objectives
Inpatient Teaching site: UNC Cancer Hospital, 4th Floor Inpatient Unit
Goals: The goal of this experience will be for the residents to gain experience in the inpatient setting and
treatment of patients with a broad spectrum of cancers.
1.
Objectives

Medical Knowledge
Describe the epidemiology, genetics, natural history, clinical expression of different types of cancers
encountered in the inpatient setting.
Summarize an approach to the evaluation of common cancer presentations
Exhibit understanding of the epidemiology, pathology, clinical presentation, diagnosis and treatment of
common complications of cancer, chemotherapy and radiation therapy, including but not limited to
tumor lysis syndrome, leukostasis, cord compression, neutropenic fevers and pain crises.
Interpret diagnostic tests used in the evaluation of inpatients with suspected cancer
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of inpatients with
cancer.
Do background reading as much as possible. Valuable websites include: uptoday, www.NCCN.org,
www.cancer.gov, pubmed
 Patient Care
Effectively perform a comprehensive history and complete physical examination in patients with cancer
and/or its complications. Do not take short cuts on the exam or the note such as saying a “non focal”
neuro examination or 10 point Ros is normal. Describe the Neuro exam. Describe the ROS.
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of
cancer and/or its complications
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of
cancer and/or its complications
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies.
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust
therapy.
 Practice-based learning and improvement
Effectively use technology to manage information obtained from multiple sources to the care of
inpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system or
processes of care

Systems-based practice
Discuss how the health care system affects the management of inpatients with endocrine diseases.
Demonstrate effectiveness of alternative proposed interventions.
Design cost-effectiveness plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care
system, cost of procedure, insurance coverage, and resources utilized
Work with Case management and pharmacy to plan and implement a safe discharge.

Interpersonal skills and communication
Apply empathy in all patient encounters
Make sure that the RN, pharmacist and case managers know the daily plan for the patient. The Case
managers and Pharmacists especially need to know the discharge goal (estimated or scheduled date of
discharge and discharge needs).
Demonstrate effective skills of listening and speaking with patients, families and other members of the
health care team
Reliably and accurately communicate the patient’s and his/her family’s view and concerns to the
attending
Compose clear and timely consult and clinic notes as well as interval notes/letters, including a precise
diagnosis whenever possible, differential diagnosis when appropriate, and recommend follow up or
additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate

Professionalism
Be prompt and prepared for rounds and/or clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and
equitable respect and care to all
Respect patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings,
following through on clinical questions, laboratory testing and other patient care issues, and recognizing
potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with patients and
respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
NEW PATIENT SCHEDULERS
BLACKWOOD, GLENDA
445-5590
BRYANT, KAREN
843-9084
COUSIN, INETHA
843-8442
DAWSON, TASHA
966-8128
FENNELL, JENNIFER
843-8716
GREEN, EVELYN
843-8843
GUNN, BELINDA
966-7782
PETTIFORD, AVA
966-9696
THEMES, LAURIA
843-8869
WHORLEY, SUSIE
966-9700
RETURN SCHEDULERS
BEASLEY, GRETCHEN
966-4086
BIGELOW, KIMBERLY
843-4992
COOPER, SHEILA
966-1673
FULLER, DEIDRA
966-7990
JEFFRIES, SHERRI
445-5557
MILLER, LAUREN
843-6092
SCRONCE, JEFFREY
966-4319
SMYLA, SANDRA
966-3093
NAVIGATORS
ALLRED, TAMMY
966-1669
Olson, Rivera
ARMSTRONG, DELMA
843-1884
DE PUE,AMY
966-9406
FLY, JULIE
843-8631
Veeramachanini
GALLAGHER, SEAN
843-6916
Hackman, Zanation,
HAYES, BROOKE
966-0826
Wood
HENRETTY, SONJA
843-9185
Yeh, Sadiq,
HORNE, LYNN
843-5316
KURCZAK, JOAN
843-5375
Rathmell, Kim
LICHT,LISA
966-6199
MALONEY, JUDY
843-9085
Sampat, Sadiq,
MARTZ, CAROLE
843-1178
Stitz)for Melanoma
MATSON, MELISSA
843-7306
SMITH, LUANN
843-5307
Whang, Godley
New Head & Neck
New Benign Hematology
New Breast Cancer (last names A-K)
New Lung
New Breast Cancer (last names L-Z)
GI/ Melanoma (last names A-L)
New Malignant Hematology
GU / Neuro
GU / Neuro
GI/ Melanoma (last names M-Z)
Surg/Onc
Surg/Onc
Return Breast
Return GI / Sickle Cell
Return Breast
Return GU/ Lung
Return Heme
Return Fellows
Lung/ Sarcoma
Carrie Lee, Weiss, Grilley-
Breast
Breast
Lung
Dees, Reeder-Hayes, Ollila
Carey, Muss, DeMore
Stinchcombe, Haithcock,
Head & Neck
Weissler, Shores,
Malignant Heme
Van Deventer, Foster,
GI SURG
Calvo, Kim, Stitzenberg;
Breast
GU
Anders, Irvin, Amos
Pruthi, Nielsen, Wallen,
Malignant Heme
GI/ Melanoma
Park, Voorhees
Bernard, Meyers, GI for
Melanoma
Ollila, Long, (Yeh, Amos,
Malig Heme Fellows
GU Onc
Richards, 1st yr Fellows
Pruthi, Nielsen, Wallen,
Contact information
Important Phone Numbers
4ONC A side 966-1661, 4ONC B side 966-1956, BMTU 966-7792
Workroom A side
Workroom B side
Physician Service Leader
Case Manager A side
Case Manager B side
Charge Nurse, 4ONC
Comprehensive Cancer Support
Hematology Oncology
Home Infusion/TPN
Nurse Manager (M, W, Fri)
Nurse Manager (Tu, Th, Fri)
Assistant Nurse Manger
Dietitian
Palliative Care Program
Pharmacy
Pastoral Care
Pastoral Care—on call
Physical Therapist
PT Office: 6-2056
Physician Assistant
Radiation Oncology
Recreation Therapy
Resident Assistant
Scheduler for fellows
Speech Therapist
Documentation Specialist
Surgical Oncology Consult Pager
Utilization Manager
Weekend CM Pager
445-5426, fax 843-3890
445-5421, fax 445-5346
Fran Collichio 216-2789
Angela Ford 216-0599, 6-5504, 4ONC—5-5424
Dave DeVito 216-6246, 6-4686, 4ONC—5-5420
445-7542
Mimi Alvarez, Pam Durham, Liz Sherwood,
Justin Yopp
WebXchange CCSP Pager: 216-1514
Clinic 966-1672; Office 966-4431; Fax 966-6735
Pam Miller 347-1935 Fax: 6-4295
Crista Creedle 123-9660, 6-4501
Summer Cheek 123-9660
Jackie Connely 216-3268
Andrea Manley 123-5608
Chip Baker 216-1549, 3-3650
Larry Buie 216-1144, Jill Bates 216-9497
Patricia Cadle 347-0942, 5-5400
123-3288 Office: 6-4021
Tara Thananetapon, PT 123-5154
John Strader 216-6420
5-5275
Michele Barr 123-2121, 6-2301
Alma Ngugi 843-4502
Sandee (Smyla) Cane, 6-3093 or via Webcis
123-2682, 6-8044
Kathy Kinser 216-0496
123-7083
Claire Riggsbee 347-0706, 6-3938
123-2335
D/C Planning Reminders
*Case manager notes are in WEBCIS under Care management/discharge planning
*Nursing, Speech and Nutrition notes are in E Chart.
*PT/OT notes are in e-chart.
*Involve Pharmacy early:
a. Contact the covering pharmacists for all patients being discharged on home infusion
medications that require therapeutic drug monitoring for recommendations with
regard to monitoring after discharge (e.g. vancomycin, aminoglycosides)
b. Ensure all medications at risk for high patient cost-sharing are reviewed for
insurance coverage and the patient has access to the medication upon discharge
especially for specialty items such as pegfilgrastim.
c. Ensure patients that have severe adherence issues, new start oral chemotherapies,
etc are seen by a pharmacist and all those going home on anticoagulation are
discharge counseled by the pharmacist.
SNF/ ALF
FL2 signed by MD
Yellow DNR/DNI form signed if applicable
RX for narcotics
FULL DC summary
DOC
Resident/ Intern Call DOC at 733-0800, ask for someone
in ER at ext. 426 or 485 to notify of d/c plans
FULL DC Summary
HH/Home IV Infusion
Resident/ Intern to Notify PCP re: HH referral
BRIEF Discharge Summary
Home Hospice
RX for all meds
Yellow DNR/DNI form signed (DNR not necessary for
home hospice); life expectancy of 6 months or less
Verification of Hospice MD
FULL DC summary
Inpatient Hospice
RX for narcotics
Yellow DNR/DNI form signed—necessary for inpt. care
Life expectancy of 2 weeks or less
FULL Discharge Summary
New Dialysis
Order Hep B panel, Hep C, Albumin, EKG w/in last year,
CXR w/in 1 month, Vein Mapping, PPD, HIV, Chem 10
FULL DC Summary
Aspira
Notify CM as soon as you know this is taking place. CM will
order supplies to be delivered to the patient’s home
CHECK W/ CASE MANAGER BEFORE SIGNING FULL D/C SUMMARY IF PT HAS ANY OF THE ABOVE
DME
RX
Write RX with Diagnosis, height/weight, duration of need
Home Oxygen RX
Flow rate, RA sat (must be < 88% within 2 days of d/c), via nc (or
however it’s administered) height/weight, diagnosis, “portable and
concentrator,” Duration of need
Tube Feeds RX
Helpful to Copy recommendation from Nutrition consult. Include
diagnosis, height/weight
Flush RX for PICC line
Dressing change kits (see guide below orders)
Prefilled Heparin Flush 100 units/ml (3ml in 10ml syringe)
Flush QD each Lumen, # refill
Change claves twice per week (4/week)
Flush RX for Hickman/Powerlines/Pheresis
Dressing change kits (see guide below orders)
Prefilled Heparin Flush 100 units/ml (3ml in 10ml syringe)
Flush M-W-F each Lumen, # refill
Change claves twice per week (6/week)
Port Care Orders
Flush line with 10cc saline and 5cc heparin once a month
Dressing Change Guidelines
CVAD dressings are to be changed:
• At least every seven (7) days for transparent dressings (Tegaderm®, Sorbaview®, and Opsite 3000®).
When gauze is added to the dressing for any reason (oozing, bleeding, diaphoresis), the dressing is no
longer considered a transparent dressing, but is now a gauze dressing.
If gauze is used to stabilize the port access needle but does not obscure the site, the dressing is
NOT considered a gauze dressing and can be changed every 7 days.
• At least every other day or three times per week, (usually Monday, Wednesday and Friday), for any
gauze dressing. This is gauze and transparent dressing, gauze and tape, or gauze and Mefix®. Gauze and
tape or Mefix® should be used only if a patient is allergic to the transparent dressing.
Document Every Condition that Impacts the
Inpatient Stay, Including:
A gap exists between the provider’s clinical
documentation and coding guidelines.
Concurrent reviews are completed by the clinical
documentation specialist to help bridge the gap between
medical terminology and coding language.
Program Goal:
Accuracy and Quality within the Inpatient Medical Record
in order to support:
 Severity of Illness and Risk of Mortality
 Accuracy of Publicly Reported Data
 Quality Indicators
 Coding Accuracy (the assignment of codes is
based on physician documentation only!)
How it Works
 The MDE Clinical Documentation Specialist will
attend morning rounds.
 Specialist will verbally query or send a phone
message query in WEBCIS to the resident/intern
after rounds for any diagnosis clarification.
 The resident/intern will clarify/addend the
diagnosis in their next SOAP note & discharge
summary.
Always Document in DIAGNOSIS FORM
the REASON for Inpatient Admission



The cause of presenting symptom(s)
If cause not definitive, please indicate
"suspected”, or “possible”, or “likely” etiology
Clarify, after testing, any suspected diagnoses
that have been eliminated.
Principal Diagnosis: “that condition established after
study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care” (Uniform
Hospital Discharge Data Set, UHDDS)
Secondary Diagnosis: “all conditions that coexist at the
time of the admission, that develop subsequently, or affect
patient care for the CURRENT hospital episode in terms of
requiring: monitoring, evaluating, treatment, or causing
increased nursing care or length of stay. (Uniform
Hospital Discharge Data Set, UHDDS)
Present on Admission (POA)
Document each condition not listed on H&P as:
Present on Admission, Not Present on Admission, or
Unable to determine if Present on Admission




Specify “Acute “and “Chronic” conditions: If
medications are continued during hospital stay
the corresponding diagnoses should be
documented. (i.e. diabetes, chronic systolic
and/or diastolic CHF, morbid obesity, COPD,
malnutrition)
Interpret the Clinical Significance of abnormal
labs, x-rays, and imaged studies.
Readdress treatment plans every day in the
progress notes. Notes that appear to be
“cut/pasted” are not acceptable.
Update the “Drop-down Box” diagnoses on the
H&P and daily progress notes. If not updated.
inaccurate diagnoses from previous admissions
are confused with the patient’s CURRENT
diagnoses
Avoid the Use of Arrows/Symbols/Acronyms
Examples:
 Use C-Diff colitis instead of + C-Diff
 Clarify ARF: acute renal failure, acute respiratory
failure, acute rheumatic fever
 Use Anemia (with type) instead of ↓ H/H
Common Diagnosis Clarifications
 Specify Metastases Sites from a primary cancer
site separately
 Malnutrition: A BMI of <19 accompanied by the
diagnosis of mild, moderate, severe malnutrition and
a BMI >40, accompanied by a diagnosis of morbid
obesity, should only be reported when it meets the
definition of a reportable additional diagnosis and
has a clinical significance to the case.
 Anemia, Pancytopenia, Neutropenia- chart the
underlying cause- i.e. Acute/Chronic Blood Loss,
Chemotherapy, Radiation, Iron Deficiency
 Altered Mental Status: Need to know the Acuity,
Nature, and Underlying Cause
 Encephalopathy- Type/Cause- Septic, Hepatic,
Toxic, Metabolic, Medication Induced,
Hypertensive
INDICATORS OF
CLINICAL SIGN of DEFICIENCY:
One or More Indicates SEVERE
One or Less Indicates MODERATE
Source:”Assessment of Protein Energy Malnutrition in Older Persons, Part II: Laboratory
Evaluation,” by M.L. Omran, MD and J.E> Morley, BC, BCh: Nutrition 16:pp.131-140, 2000
Degree of
Malnutrition
Indicators
Inadequate
Intake
Weight % IBW
BMI
% Weight
Change: UBW
Albumin
Transferrin
Pre-Albumin
Total
Lymphocyte
Count
SEVERE
MALNUTRITIO
N:
Two or more
Indicators
MODERATE
MALNUTRITION
:
Two or more
Indicators
Greater than 10
days: < 75% of est
nutrient needs
Less than 80%
Less than 16
>10% in 6 months;
> 7.5% in 3 months;
>5% in 1 month; >
2% in 1 week
2.8 gl
<100 mg/dl
<15 mg/dl
<800 g/ml
Greater than 7 days:
< 50% of estimated
nutrient needs
80-90%
16-18.5
>10% in 6 months; >
7.5% in 3 months;
>5% in 1 month; >
2% in 1 week
3.0 gl
<200 mg/dl
<20 mg/dl
<1500 g/ml
INDICATORS per CDC/NCHS effective 10/1/08
Nonspecific laboratory finding of bacteria in the
Bacteremia
SIRS
Septicemia
Sepsis
Severe Sepsis
Septic Shock
blood
Systemic Inflammatory Response Syndrome
refers to systemic response to infection
Systemic disease associated with the presence of
pathogenic microorganisms in the blood
An infection-induced syndrome without organ
dysfunction. SIRS due to an infection
Sepsis with associated acute organ dysfunction.
Severe sepsis in which the cardiovascular system
begins to fail, blood pressure drops, and vital
organs are deprived of adequate blood supply
SIRS: SYSTEMIC Inflammatory Response Syndrome




*
*
INDICATORS
SOURCE
Temp <36C (96F) or >38C (100.9F)
• Infection
WBC < 4K or >12K; or >10% bands
• Trauma
Tachycardia: HR > 90 BPM
Tachypnea: RR > 20 or PCO2 >32 on ABG
Must deviate from physiologic baseline for patient
If only tachycardia and tachypnea are present NOT SIRS
SIRS + Indicators Below = SEPSIS
Hyperglycemia without presence of DM
Elevated CRP
Hypotension (SBP <90, fall of 40, MAP <70)
Lactate>1
Skin changes: decreased cap refill or mottling
Cardiac index >3.5 L-min
Coagulopathy: INR>1.5 or PTT >60
Blood infection: fungal, bacterial, viral, parasitic
* Urosepsis = Urinary Tract Infection
* Bacteremia does NOT mean Sepsis
Iron
Zinc
Copper
Vit C
Thiamin
Riboflavin
Niacin
Vit K
Vit D
Vit A
Microcystic anemia- spoon nails-fatigue/lethargylow Hct/Hgb- low MCV
Dermatitis-impaired taste-impaired wound healing
& immune function- diarrhea-low serum alk phos
Depigmented hair-neutropenia-leucopenia
Increasing bleeding/bruising-impaired wound
healing-painful joints
Beriberi-dry/muscle tenderness/CNS symptomswet: fluid retention/ Heart Failure/Wernicke’s
syndrome
Magenta tongue-cheilosis/angular stomatitis-greasy
dermatitis
Scarlet tongue-inflamed mucosa-pellagra-diarrheadermatitis- dementia (the 3 D’s)
High PT/ INR- bruising/ bleeding
Osteomalacia- hypophosphatemia/ hypocalcemiaincreased alk phos
Night blindness- Bitot’s spots- impaired immune
function
SIRS + SEPSIS + Indicators Below = SEVERE SEPSIS
ORGAN DYSFUNCTION HYPOPERFUSION ABNORMALITIES
• Altered Mental Status
• Lactic Acidosis
• Sepsis Induced Hypotention
• Altered Mental Status
• Hypoxemia
• Oliguria
• Rise in Cr of > 0.5 or acute oliguria
• Ileus
• Thrombocytopenia (<100k)
• Hyperbilirubinemia (>4)
SIRS + SEPSIS + SEVERE SEPSIS + Below = SEPTIC SHOCK
REFRACTORY HYPOTENTION
SBP <90 or MAP <60 or drop of 40mmHg of SBP from baseline
Hypotention despite adequate fluid resuscitation and cardiac output
Children: BP<2 standard deviations of normal
Deficiency of all types of blood cells
 Idiopathic often autoimmune
 Aplastic Anemia
 Environmental: Radiation or Chemotherapy
Treatment/ Drug Reaction/ Toxin Exposure/ Viral
Infections
Signs/ Symptoms/ INDICATORS
Thrombocytopenia
Neutropenia
Platelet Count < 150,000
Absolute neutrophil count (total white count
multiplied by the percentage of neutrophils
and bands) less than 1,500
Anemia
Hematocrit < 32
Fatigue, rash, high fever, unexplained bleeding, easy bruising,
rapid heartbeat, nosebleeds, LOC
Common pharmacological management of MDE patients
PPI or H2 antagonist therapy
Chronic therapy with proton pump inhibitors (PPI) or H2 antagonists is common in patients with, or at risk for, chronic gastroesophageal reflux dise
use is recommended by the 2008 guidelines issued by the American College of Cardiology Foundation, the American College of Gastroenterology, a
Heart Association entitled, Expert Consensus Document on Reducing the GI Risks of Antiplatelet Therapy and NSAID Use. Acid suppression therapie
prescribed short-term in the non-ICU, hospitalized patients to prevent development of stress ulcers. Studies have shown that approximately 50% o
did not receive this therapy prior to admission and that almost half of those new patients will receive prescriptions to continue therapy once discha
suppression therapies have traditionally been viewed as safe; however, recent evidence suggests potential harm, including an increased risk of pne
Clostridium difficile-associated disease and hip fractures. As such, it is recommended to follow the guidelines below when prescribing acid suppres
hematology/oncology patient paying particular attention to appropriate discharge prescribing practices.
1.
Indications for PPI therapy
 Gastric and duodenal ulcer
 Pathologic hypersecretory conditions
 GERD
 Indigestion symptoms (within the last 3 months)
 H. pylori eradication
 NSAID gastric ulcer prophylaxis (for scheduled therapy)
 Zollinger Ellison syndrome
 Mucositis or esophagitis
2.
Most patients only require 3 months of therapy
3.
Use an H2 blocker for patients who do not need a PPI and who do have:
 Coagulopathy
 Thrombocytopenia (platelets <50,000)
4.
For patients receiving steroid doses >250 mg hydrocortisone, 9 mg dexamethasone, 60 mg prednisone or equivalent daily, PPI should be
prescribed concurrently with steroid if:
 Thrombocytopenia (platelets <50,000) or other coagulopathy
 Receiving anticoagulation therapy
Since steroids can cause GI upset all other patients not meeting criteria for PPI use may benefit from an H 2 blocker while on steroids.
Patient discharge or continuation on acid suppression therapy after completion of steroid therapy should not occur.
5.
PPI agents should be avoided in those individuals receiving concurrent: posaconazole, erlotinib, atazanavir, clopidogrel and dasatinib
1.
2.
3.
4.
Dial S, Delaney JAC, Barkun AN, Suissa S. Use of gastric acid suppressive agents and the risk of community acquired clostridium
difficile associated disease. JAMA 2005;294:2989-95.
Yang YX, Lewis JD, Epstein S, Metz D. Long term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006;296:2947-53.
Laheij R, Sturkenboom M, Hassing R, et al. Risk of community acquired pneumonia and use of gastric acid suppressive drugs. JAMA
2004;292:1955-1960.
Herzig S, Howell M, Ngo L, Marcantonio E. Acid suppressive medication use and the risk of hospital acquired pneumonia. JAMA
2009;301:2120-8.
Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients
with Cancer: 2010 Update by the Infectious Diseases Society of America
Clinical Infectious Diseases 2010;52:e56-e93.
12
This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was
published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer
who experience chemotherapy-induced fever and neutropenia. Recent advances in antimicrobial drug development and technology, clinical
trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of
this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from
antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection
according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the
treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition,
earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although
algorithms are still evolving. What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all
patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gramnegative pathogens. Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were
developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas
where differences in available antibiotics, in the predominant pathogens, and/or in health care–associated economic conditions exist.
Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or
infection.
Management of Menorrhagia Associated with Chemotherapy-Induced Thrombocytopenia in
Women with Hematologic Malignancy
Jill S. Bates, Pharm.D., M.S., Larry W. Buie, Pharm.D., and C. Brock Woodis, Pharm.D.
(Pharmacotherapy 2011;31(11):1092–1110)
Abnormal uterine bleeding in women with a blood dyscrasia, such as leukemia, or who experience thrombocytopenia secondary to
myelosuppressive chemotherapy is a clinical condition associated with significant morbidity. Consequently, effective management is
necessary to prevent adverse outcomes. Prevention of menorrhagia, defined as heavy regular menstrual cycles with more than 80 ml of
blood loss/cycle or a cycle duration longer than 7 days, in this patient population is the goal of therapy. Gonadotropin releasing hormone
analogs (e.g., leuprolide) are promising therapies that have been shown to decrease vaginal bleeding during periods of thrombocytopenia
and to have minimal adverse effects other than those associated with gonadal inhibition. In patients who experience menorrhagia despite
preventive therapies, or in patients who have thrombocytopenia and menorrhagia at diagnosis, treatment is indicated. For these women,
treatment options may include platelet transfusions, antifibrinolytic therapy (e.g., tranexamic acid), continuous high-dose oral
contraceptives, cyclic progestins, or other therapies for more refractory patients such as danazol, desmopressin, and recombinant factor VIIa.
Hormonal therapies are often the mainstay of therapy in women with menorrhagia secondary to thrombocytopenia, but data for these
agents are sparse. The most robust data for the treatment of menorrhagia are for tranexamic acid. Most women receiving tranexamic acid in
randomized trials
experienced meaningful reductions in menstrual bleeding, and this translated into improved quality of life; however, these trials were not
performed in patients with cancer. Further clinical trials are warranted to evaluate both preventive and therapeutic agents for menorrhagia
in premenopausal women with cancer who are receiving myelosuppressive chemotherapy.
Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update
Published in the Journal of Clinical Oncology. vol 29. No 31.(November 1):4189-4198
Ethan Basch, Ann Alexis Prestrud, Paul J. Hesketh, Mark G. Kris, Petra C. Feyer, Mark R. Somerfield, Maurice Chesney, Rebecca Anne ClarkSnow, Anne Marie Flaherty, Barbara Freundlich, Gary Morrow, Kamakshi V. Rao, Rowena N. Schwartz, and Gary H. Lyman
Special Announcement (September 26, 2011): The U.S. Food and Drug Administration (FDA) is informing the public of an ongoing safety review
of the anti-nausea drug Zofran (ondansetron, ondansetron hydrochloride and their generics). Ondansetron may increase the risk of developing
abnormal changes in the electrical activity of the heart, which can result in a potentially fatal abnormal heart rhythm. Please visit the FDA
website for additional information.
13
Purpose: To update the American Society of Clinical Oncology (ASCO) guideline for antiemetics in oncology.
Methods: A systematic review of the medical literature was completed to inform this update. MEDLINE, the Cochrane Collaboration Library,
and meeting materials from ASCO and the Multinational Association for Supportive Care in Cancer were all searched. Primary outcomes of
interest were complete response and rates of any vomiting or nausea.
Results: Thirty-seven trials met prespecified inclusion and exclusion criteria for this systematic review. Two systematic reviews from the
Cochrane Collaboration were identified; one surveyed the pediatric literature. The other compared the relative efficacy of the 5hydroxytryptamine-3 (5-HT3) antagonists.
Recommendations: Combined anthracycline and cyclophosphamide regimens were reclassified as highly emetic. Patients who receive this
combination or any highly emetic agents should receive a 5-HT3 antagonist, dexamethasone, and a neurokinin 1 (NK1) receptor antagonist. A
large trial validated the equivalency of fosaprepitant, a single-day formulation, with aprepitant; either therapy is appropriate. Preferential use
of palonosetron is recommended for moderate emetic risk regimens, combined with dexamethasone. For low-risk agents, patients can be
offered dexamethasone before the first dose of chemotherapy. Patients undergoing high emetic risk radiation therapy should receive a 5-HT3
antagonist before each fraction and for 24 hours after treatment and may receive a 5-day course of dexamethasone before fractions 1 to 5.
The Update Committee noted the importance of continued symptom monitoring throughout therapy. Clinicians underestimate the incidence
of nausea, which is not as well controlled as emesis.
American Society of Clinical Oncology 2006 Update of Recommendations for the Use of White Blood Cell Growth Factors: An Evidence-Based
Clinical Practice Guideline
Published in Journal of Clinical Oncology, Vol 24, No 19 (July 1), 2006: pp. 3187-3205
Thomas J. Smith (Chair), James Khatcheressian, Gary H. Lyman, Howard Ozer, James O. Armitage, Lodovico Balducci, Charles L. Bennett, Scott
B. Cantor, Jeffrey Crawford, Scott J. Cross, George Demetri, Christopher E. Desch ,Philip A. Pizzo, Charles A. Schiffer, Lee Schwartzberg, Mark
R. Somerfield, George Somlo, James C. Wade, James L. Wade, Rodger J. Winn, Antoinette J. Wozniak, and Antonio C. Wolff
Special Announcement on Leukine (sargramostim) (Updated January 25, 2008): Voluntary market suspension of the current liquid
formulation because of an upward trend in spontaneous reports of adverse reactions, including syncope (fainting). The lyophilized form of the
drug is not affected. See the U.S. Food and Drug Administration (FDA) web site for more information.
Purpose: To update the 2000 American Society of Clinical Oncology guideline on the use of hematopoietic colony-stimulating factors (CSF).
Update Methodology: The Update Committee completed a review and analysis of pertinent data published from 1999 through September
2005. Guided by the 1996 ASCO clinical outcomes criteria, the Update Committee formulated recommendations based on improvements in
survival, quality of life, toxicity reduction and cost-effectiveness.
Recommendations: The 2005 Update Committee agreed unanimously that reduction in febrile neutropenia (FN) is an important clinical
outcome that justifies the use of CSFs, regardless of impact on other factors, when the risk of FN is approximately 20% and no other equally
effective regimen that does not require CSFs is available. Primary prophylaxis is recommended for the prevention of FN in patients who are at
high risk based on age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. CSF use allows a modest to
moderate increase in dose-density and/or dose-intensity of chemotherapy regimens. Dose-dense regimens should only be used within an
appropriately designed clinical trial or if supported by convincing efficacy data. Prophylactic CSF for patients with diffuse aggressive
lymphoma aged 65 years and older treated with curative chemotherapy (CHOP or more aggressive regimens) should be given to reduce the
incidence of FN and infections. Current recommendations for the management of patients exposed to lethal doses of total body
radiotherapy, but not doses high enough to lead to certain death due to injury to other organs, includes the prompt administration of CSF or
pegylated G-CSF.
14
Guidelines for the Management of Pediatric and Adult Tumor Lysis Syndrome: An Evidence-Based Review. J Clin Oncol 2008;26:2767-78.
Purpose Tumor lysis syndrome (TLS) has recently been subclassified into either laboratory TLS or clinical TLS, and a grading system has been
established. Standardized guidelines, however, are needed to aid in the stratification of patients according to risk and to establish prophylaxis
and treatment recommendations for patients at risk or with established TLS.
Methods A panel of experts in pediatric and adult hematologic malignancies and TLS was assembled to develop recommendations and
guidelines for TLS based on clinical evidence and standards of care. A review of relevant literature was also used.
Results New guidelines are presented regarding the prevention and management of patients at risk of developing TLS. The best management
of TLS is prevention. Prevention strategies include hydration and prophylactic rasburicase in high-risk patients, hydration plus allopurinol or
rasburicase for intermediate-risk patients, and close monitoring for low-risk patients. Primary management of established TLS involves similar
recommendations, with the addition of aggressive hydration and diuresis, plus allopurinol or rasburicase for hyperuricemia. Alkalinization is
not recommended. Although guidelines for rasburicase use in adults are provided, this agent is currently only approved for use in pediatric
patients in the United States.
Conclusion The potential severity of complications resulting from TLS requires measures for prevention in high-risk patients and prompts
treatment in the event that symptoms arise. Recognition of risk factors, monitoring of at-risk patients, and appropriate interventions are the
key to preventing or managing TLS. These guidelines should assist in the prevention of TLS and improve the management of patients with
established TLS.
Ipilimumab Induced Diarrhea.
Ipilimumab is a CTLA 4 inhibitor that has been shown to increase survival for patients with metastatic melanoma. It can cause autoimmune
side effects or “Immune related events”. Autoimmune diarrhea from this medication is a potentially life-threatening toxicity that requires
immediate attention. The oncologist will “grade” the toxicity and determine if the patient should be admitted to the hospital. Most of the
time the diagnosis is obvious but when it doubt the oncologist or admitting team can also obtain stool studies to rule out infectious
etiologies. A GI consultation for a colonoscopy can also be done if the information from the study will help with management. For example, if
the degree of toxicity or grade (see below)is not clear, the colonoscopy can help to sort this out.
Degree of toxicity:
Grade 2: Diarrhea with up to 6 stools above baseline, abdominal pain, mucus or blood in the stool.
Grade 3: Diarrhea of greater than or equal to 7 stools above baseline, fever, ileus, peritoneal signs.
Treatment:
Grade 2 diarrhea can be managed in the outpatient setting with dietary modification (bland, low fiber diet), steroids (1mg/kg
prednisone followed by a slow taper over a month), frequent visits to the office setting, occasionally IV hydration. Patients are
sometimes admitted for IV steroids, IV fluids and monitoring.
Grade 3 diarrhea: Hospitalize, NPO, IV hydration, Steroids (the equivalent of 2mg/kg prednisone in divided doses. Solumedrol is
the most convenient treatment). Monitor and treat for side effects of high doses of steroids. Have a very early threshold, e.g.
about 2 days, to order a PICC line and a consultation for Total Parenteral Nutrition (TPN). That is, if the patient is still having 3 or
more stools above baseline, it is unlikely that he or she can begin oral intake. TPN helps the colon recover faster. If TPN has
been started and the patient is still having frequent stools or other signs of severe toxicity on hospital day 7, order infliximab
5mg/kg times one. Consult with oncology before ordering infliximab (usually one dose is all that is needed). Once the diarrhea
subsides, begin re-feeding (clears and advance to low fiber, bland diet. A nutrition consult can help with this). Taper off of the
TPN. Discharge to home on a slow steroid taper over 1 to 2 months, a bland diet, and early follow up with oncology.
15
LIVING SPIRITUALLY WITH CANCER, A RESOURCE FROM THE UNC HOSPITALS DEPARTMENT OF PASTORAL CARE
Life can change in many ways when you or a loved one is diagnosed with cancer. Spiritually, you might find yourself turning more often to
your beliefs to help you cope. Or, you may find new questions concerning your faith emerging. Both of these are natural as you try to
reorient your life during this difficult time.
Life changing issues may include:
 Managing anxieties and frustrations about an unpredictable disease; dealing with the unknown
 Facing fears about pain, disfigurement, physical and emotional isolation, and/or imminent death
 Experiencing grief about the loss of hopes and dreams, independence, self-esteem, and/or self-image
 Worrying about the future (i.e., the possible spread or recurrence of the disease, the cost of medical treatment, the well-being of loved
ones)
 Experiencing concerns about your quality of life, your role in the family, and the condition of significant relationships
 Living with judgement from society and dealing with the misconceptions and fears of others
 Experiencing strong emotions (i.e., denial, anger, despair, depression, loneliness, guilt)
 Re-examining your beliefs/philosophy and the meaning of life
SPIRITUAL BENEFITS
At times you and those who love you may feel deeply troubled spiritually by a diagnosis of cancer. It is important to remember that you are
not alone at this time. Many have walked this road of spiritual re-examination before you.
Regardless of your religious background or spiritual practice, your faith can:













Provide a sense of peace
Nurture hope and joy
Clarify the meaning and purpose of life
Offer strength for the journey
Allow connection with the Holy
Provide emotional support
Give direction and guidance
Impart wholeness
Afford a deepening sense of the sacred
Provide opportunities for self discovery
Allow for spiritual growth and development
Supply ways of coping
Present new/healthy perspectives
SPIRITUAL DIRECTION
Each person’s spiritual beliefs may be nurtured in different ways. Whatever your spiritual practice, remember it is a dimension of your life
which can be strengthened and developed. The following ideas may be helpful as you look inward for a stronger connection to what is most
meaningful and sacred:

Meditate or pray daily. Through these practices peace and strength can be discovered and experienced.

Join a group for meditation, prayer and support. Sharing with others with similar difficulties brings about understanding and hope.

Read sacred/religious texts and other inspirational writings. These writings can enlighten your spirit and guide your path.
16

Speak with your chaplain, spiritual leader or counselor. Clergy and other spiritual leaders can be a source of support, compassion and
direction.

Attend worship and practice religious rituals. These practices allow for a sense of community and connectedness.

Inform the members of your faith community of your situation and needs. Invite them to walk with you on your journey to find
wholeness. They can be helpful to you both practically and emotionally.

Retreat to spiritual spaces or natural settings. In these sacred places you can experience a close connection with the Holy.

Express your thoughts, feelings and memories in a journal. This activity can contribute to your process of self-discovery and spiritual
development.

Open your heart, mind and spirit to divine presence. Allow yourself to be gently guided, nurtured and supported.
Above all, remember you are not a hopeless, powerless victim of cancer. There are many actions you can take to fight for your own recovery
and improve the quality of your life. Out of the turmoil of this difficult time, your spiritual life may be strengthened and deepened; a sense of
meaning, purpose and connection beyond yourself can help you to have a higher quality of life while living with cancer.
CONTACTING THE DEPARTMENT OF
PASTORAL CARE
A chaplain is available 24 hours a day seven days a week. For pastoral needs Monday through Friday between the hours of 8:00 AM and 5:00
PM call the following phone numbers to reach a staff chaplain:
General Oncology
Patricia Cadle
445-5400
Gynecological Oncology
Darryl Owens
966-7801
Pediatric Oncology
Hadley Kifner
966-5026
After 5:00 PM, Monday through Friday, and on weekends, please call the hospital operator at 966-4131 and ask for the On-Call Chaplain.
17
Activity Level for Patients with Bone Metastases
A Guide for Physical and Occupational Therapists
Presence of
Bone Metastasis
Old Diagnosis
New Diagnosis
Location in spine
Bedrest until work-up
completed
Location in NWB bone
Location in WB bone
Bedrest until work-up
completed
Prior to mobility:
 General activity
orders
Location in WB bone or spine
Location in NWB bone
Prior to mobility:
 General
activity orders
(+) change in pain level
in area of bone
metastasis
(-) change in pain
level in area of
bone metastasis
Bedrest until work-up
completed
(+) impending fx
(+) pathologic fx
(+) impending fx
(+) pathological fx
(-) impending fx
(-) pathologic fx
(-) impending fx
(-) pathological fx
Treat as new
diagnosis
Prior to mobility:
 General activity
orders
 WB orders for
involved extremity
from orthopedics
Prior to mobility
 General activity
orders
 Spine clearance by
orthopedics or
neurosurgery consult
 Patient education on
spine precautions
Prior to mobility:
 General activity
orders
 Patient education
on spine
precautions
(+) pain
Prior to mobility:
 General activity orders
 Consider assistive
device if metastasis is
in lower extremities
(-) pain
Prior to mobility:
 General activity
orders
Research clinic
notes or previous
inpatient notes for
mobility
recommendations
and precautions
Guidelines for working with
patients with bone metastases:
 Patient and caregiver should
understand risks and benefits
of mobilization versus
bedrest
 Limit activity to pain-limited
active range of motion
 Do not perform manual
muscle testing or resistance
training to involved extremity
Evidence Table by Amy Kushner, PT
Flow chart created by Emily Sourisak, PT & Elizabeth Stauffer, SPT, MHS
References on page 2
18
References
1.
2.
3.
4.
5.
6.
Bunting RW, Shea B. Bone metastasis and rehabilitation. Cancer Rehabilitation in the New Millenium.
Supplement to Cancer. 2001; 92(4):1020-1028
Bunting RW, Boublik M, Blevins FT, et al. Functional outcome of pathological fracture secondary to
malignant disease in a rehabilitation hospital. Cancer. 1992; 69:98-102.
Johnson, SK & Knobf MT. Surgical interventions for cancer patients with impending or actual pathologic
fractures. Orthopaedic Nursing. 2008; 27(3):160-171.
Mirels H. Metastatic disease in long bones: a proposed scoring system for diagnosis impending pathological
fractures. Clin Orthop 1989; 249:256-264.
Struthers C, Mayer D, Fisher G. Nursing management of the patient with bone metastases. Seminars in
Oncology Nursing. 1998; 14(3):199-209.
Weber KL, Randall RL, Grossman S, Parvizi J. Management of lower-extremity bone metastasis. J Bone Joint
Surg Am. 2006; 88:11-19.
Content of flow chart generated by Fran Collichio, MD and Emily Sourisak, PT in consultation with Jordan Renner,
MD, Eldad Hadar, MD, and Robert Escher, MD.
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