1. Impact of NCCN Distress Thermometer screening at new patient oncology visits in a large community cancer institute
Shanthi Sivendran M.D.1, Patti Inama Roda MSN,BS, RN1 , Kristen De la Torre MJ, BSN, RN1, Kristina Newport M.D.2
1 Ann B. Barshinger Cancer Institute, Lancaster General Health, Lancaster, PA, ; 2Palliative Medicine Consultants, Lancaster PA
RESULTS
RESULTS
INTRODUCTION
Psychosocial distress can impact a patient’s quality of life and potentially impact timely and effective cancer management.  The National Comprehensive Cancer Network (NCCN) developed a distress thermometer that includes a ten point scale of distress and checklist of psychosocial issues. The NCCN recommends use of this tool at initial visits and when clinically indicated, with referrals to appropriate support services for a score of 4 or greater.
In this analysis we compare rates of referrals to support services prior to and post implementation of this tool in our cancer institute. The institute on average cares for 1320 new patients in a six month period.
Data on referral patterns to support services was collected from July June 2013 (pre - implementation).
The NCCN Distress tool was introduced in July of 2013 and administered to new oncology patients at their initial appointment.
Epic Distress Screening Tool
July June 2013 Pre - Implementation:
Patient referral to oncology support service team occurred based on physician and staff clinical judgment, without use of a standardized tool.
829 referrals were made to support services.  Specifically, 322 (39%) of these referrals were to social work, 159 (19%) to chaplaincy, and 317 (38%) to nutrition. 
Financial counseling started May Prior to May 2013 social work provided financial support.
July 2013-June 2014 Post - Implementation:
1116 of 2564 (44%) respondents reported a distress score of 4 or greater
1574 referrals were made to support services.  Specifically, 572 (36%) of these referrals were to social work, 153 (10%) to chaplaincy, 321 (20%) to nutrition, and 528 (34%) to financial counseling. 
Referrals to social work were most impacted by implementation of the NCCN distress screening with a median monthly increase from 26.5 (range 14-45) to 45 (range 32-68). 
Referrals to other support services were not impacted. 
Referrals to financial counseling were most impacted by the re- education process with a median increase from 38 (range 28-42) to 53 (range 42-58).  Tool completion rate was also impacted, increasing from 76% to 87%.
METHODS
DISCUSSION
The NCCN Distress Thermometer is a helpful tool to systematically uncover distress in new oncology patients.
The greatest effect is on social service referrals due to identification of emotional, practical and family problems that were not previously recognized without standardized assessment.
It is unclear what effect the NCCN Distress tool had on financial counseling referrals since our available services changed dramatically during the study period.
The tool was as effective as standard care at generating referrals to nutrition and chaplaincy. 
Comprehensive staff education is imperative to ensure completion of the NCCN distress tool and appropriate referrals to support services.
Future investigation may include correlation with stage and disease process as well as application of the distress tool during subsequent patient visits in order to measure the impact of support services on distress scores.
Nurses were instructed to refer to social work, chaplaincy, nutrition, or financial counseling for a distress score of 4 or greater, identified patient need, or patient request.
Data on referral patterns to support services was collected from July June 2014 (post - implementation).
Screening compliance was monitored during implementation. To increase compliance, staff reeducation on the NCCN Distress tool administration and referral process was completed in January of 2014. .