Telephone Intervention Reduces Unplanned Hospital Visits for Patients With Blood Cancers

A navigator-designed, proactive, weekly, telephone support call to help patients with blood cancers manage their symptoms between appointments was able to significantly reduce unplanned hospitalizations at a Colorado cancer center.

“Since the implementation of the telephone intervention, we have maintained an average 8 percent rate of unplanned admissions,” said hematology nurse navigator Lori Dagostino, BSN, RN, OCN, during a podium session at the 2015 ONS Annual Congress.

The hematology navigator role was established in 2011 at the Penrose Cancer Center in Colorado Springs where Dagostino primarily focuses on patients who are newly diagnosed with lymphoma, leukemia, and myeloma; 534 patients have been navigated since the program’s inception through 2014.

Approximately one-fourth of the patients in the program are diagnosed with diffuse large B-cell lymphoma, and 10 percent with multiple myeloma, a “very navigation-appropriate” patient population, she said, due to their multiple needs, including treatment for skeletal-related events, pain, and renal dysfunction, as well as their complex anticancer therapy.

A retrospective chart review over two quarters between 2011-2012 showed high rates (27 percent) of unplanned hospitalizations among navigated blood cancer patients at her institution, so Dagostino embarked on designing an intervention to tackle the problem.

“This rate was completely unacceptable to us on the multidisciplinary team … it’s not good for anybody for these patients to be in the hospital … and all stakeholders can be invested in reducing these events,” said Dagostino.

She reviewed the literature and modeled her intervention around a French study of a successful telephone support program for ambulatory patients undergoing chemotherapy specific to diffuse large B-cell lymphoma patients receiving R-CHOP.

The intervention she designed involves weekly calls from a navigator to patients at high risk for hospitalization, including those who live alone, are uninsured or have limited financial means, have poorly managed depression and/or anxiety, or who have been diagnosed with dementia or cognitive deficit. These were all identified as risk factors for unplanned hospitalization in Dagostino’s baseline evaluation.

Any patient with one or more of these criteria would be deemed high risk, and the risk factors are evaluated quarterly to make sure they still hold true, she explained. Her institution is likely to add patients receiving treatment with hyper-CVAD for ALL or Burkitt lymphoma to the list shortly, she added, because of significant toxicity with these regimens.

Being proactive is key, said Dagostino. “In most of my experience, our ways of managing chemotherapy side effects are reactive. Certainly, we’re proactive in how we teach patients … but after that time, we become reactive. We instruct patients to call the clinic; here are the red flags … we want to hear from you.”

But, she acknowledged, many patients won’t call, and on the flip side, some call when it isn’t convenient for the nurse, for example, when the doctor isn’t there if a consult is needed or there are five other calls to triage.

“By making this proactive,” Dagostino said, “by saying ‘I’m going to call you every week,’ and with our expertise, we can anticipate symptoms and have better outcomes.”

Dagostino described the weekly telephone calls as both “informal and formal,” with conversations tailored to each patient, based on diagnosis and anticipated treatment-related side effects. They discuss general well-being, common sites and signs of infection, psychosocial issues, and she asks symptom-focused questions focused on such issues as fatigue, pain, oral side effects, and gastrointestinal problems.

“What I think has led to a lot of success with this intervention, is that these phone calls take place within a very well established relationship,” Dagostino said. “As a navigator, I have been with patients when they are first diagnosed; I’ve had the privilege of being at several follow-up visits, and also been with them and their family during chemotherapy sessions.

“We’ve come to know each other, so when I make that call, and trust has been established, I think they’re more willing to talk about things that are bothering them.”

Compaci G, Ysebaert L, Oberic L, et al. Effectiveness of telephone support during chemotherapy in patients with diffuse large B cell lymphoma: the Ambulatory Medical Assistance (AMA) experience. Int J Nurs Stud. 2011;48(8):926-932.