The little girl was fighting high-risk neuroblastoma, but it wasn't just the cancer that was making her sick. The aggressive chemotherapy was causing around-the-clock nausea and vomiting, and she was miserable. Her parents were distraught: not only had they just learned that their daughter had cancer, but now they had to contend with the terrible side effects. She was vomiting so much she didn't want to move, sleeping throughout the day, and not eating.
I had just started my attending week on the inpatient chemotherapy service. After evaluating this patient's chemotherapy medications, I realized she had not been given the recommended cocktail of anti-emetics for her highly emetogenic chemotherapy. Instead, she was receiving monotherapy with Zofran, and when she became nauseated, she was treated with Benadryl and Ativan, both of which made her sleepy and unable to eat.
According to the Children's Oncology Group's clinical practice guidelines, she should have received a combination of Zofran, dexamethasone and Aprepitant prior to chemotherapy administration to prevent nausea and vomiting. I adjusted her anti-emetic regimen, and by the following day, her nausea had significantly improved.
About three weeks later, I ran into her father in the hallway. He was in tears. He told me during her second chemotherapy admission, she had been restarted only on Zofran and had become nauseous and started vomiting again. We were both frustrated. Finding exactly the right medications had made all the difference for this child and her parents. Why wasn't this process consistent from care team to care team?
At-a-glance chemo care
Prescribing anti-emetics for chemo patients is nothing new. However, there are various options for anti-emetic combinations, and studies continue to indicate which drugs in which combinations are likely the best. But not all oncologists have the time or interest to keep up with the latest research and recommendations.
Just as primary care physicians often have a "favorite" antibiotic for ear infections, many oncologists have a go-to anti-emetic—but is it the right drug, dosing or combination? How do we make it easier to match the chemo with the right type of anti-nausea drug, especially when patients' chemotherapy drugs and doses may change throughout the course of treatment?
The best practices are already known. But there was a gap between what we know we should be doing and what is actually done. Indeed, operationalizing best practices is a challenge in any specialty area and at every hospital as clinicians balance multiple complex patients and manage a million other details at any given moment.
I took the problem to Vinay Vaidya, M.D., Phoenix Children's chief medical information officer, and he went to work on a solution. Over the course of a year, and through collaboration with other clinicians, pharmacists and our IT department, we implemented the Chemotherapy Induced Nausea & Vomiting (CINV) Dashboard. The dashboard is designed to show the unit "at a glance" and displays each patient's chemotherapy, ordered anti-emetics, the number of times each patient has vomited, and whether they needed any additional medications to control their nausea.
Understanding the sheer volume of information doctors are required to know—as well as the practical challenges—Vaidya and his team created a simple, intuitive, web-based interface with clear visual cues that gives doctors the information they need to offset the risk of emesis. Clinical practice guidelines and reference materials are embedded in the interface.
Color coding to indicate risk
The dashboard uses color coding to indicate a chemo drug's risk for emetogenic potential:
- Red—high risk
- Orange—medium risk
- Yellow—low risk
- Green—minimal risk
Likewise, anti-nausea drugs designed to counteract high-emetogenic chemo are coded in red, drugs for medium-risk chemo are orange, and so on. A doctor needs to only check that the colors of the chemo drugs match the colors of the anti-emetics to ensure best practices are being followed for each patient. The dashboard, which pulls patient records from Phoenix Children's data warehouse, updates in near real time—every 30 minutes.
A member of our team checks the dashboard on a daily basis to ensure the chemo drugs are matched with the appropriate anti-nausea medications—to make sure all of the colors match—and we follow up with the other oncologists as needed. The interface allows us to view the entire floor at once, or to drill down to individual patients.
Consistency in clinical guidelines
I am encouraged to see our providers now more consistently adhere to the clinical guidelines. While the solution has only been in clinical use for a few months, early results are promising; vomiting among patients receiving chemo has noticeably decreased, and oncologists are more often choosing the right combination of medications to prevent nausea and vomiting in their patients.
We continue to refine the dashboard to ensure it is a quick and simple tool for our providers. Soon, it will be incorporated right into the patient's electronic health record. When an oncologist with a patient receiving in-patient chemo opens the EHR, the CINV Dashboard will be a simple click to the next tab over.
Our team believes this program has the potential to enhance clinical practice in a significant way, and provide a simple and efficient method for bringing best practices right to the bedside. For this area of oncology care, we are closing the gap and it is positively affecting patients' quality of life.