1. Abstract: Context/Aim: The BC Cancer Agency identified the importance of a comprehensive risk assessment, nursing flow sheet and care plan in identifying and reducing patients’ functional difficulties and co-existing health problems not only in the elderly cancer patient, but in all patients. The project aim was to amalgamate all interdisciplinary documentation and create one risk/functional assessment, flow sheet and care plan. Problem/Issue: Geriatric oncology is a growing specialty as just over half of the newly diagnosed patients are over 70 years of age. Often the cancer is the least of their problems and cancer impacts these co-morbidities. The BC Cancer Agency has adopted this interdisciplinary approach with patients of all ages to ensure and early and appropriate assessment and care plan to address the effects of treatment of cancer that may tip them over the edge. Description of the Context/ Aim Statement: Hospital Care for Seniors (48/6) was identified as a Provincial Clinical Care Management Guideline in 2011. As a result, the Provincial Seniors Hospital Care working Group collaborated with representatives from the Ministry of Health, BC Patient Safety & Quality Council and geriatric experts from each health authority with the goal of implementing 48/6 within all BC acute inpatient settings by the Fall of 2014. The Hospital Care for Seniors (48/6) guideline involves: Screening and assessment of the patient including 6 key areas of patient functioning and Development of the patient’s individualized inter-professional care plan To address identified issues within 48 hours of the decision to admit. The 6 key areas of patient functioning are: Cognition Medication Management Pain Management Nutrition and Hydration Bowel and Bladder Management Functional Mobility In Canada, 30% of seniors admitted to acute care will be discharged at a significantly reduced level of functional ability and most will never recover to their previous level of independence (BC Patient Safety and Quality Council, 2013) Research has shown that: the 6 key care areas have interrelated effects on health which, when addressed, reduce functional decline and improve patient outcomes. Although the 48/6 guideline for care was developed to address the specific needs of the frail elderly, the BC Cancer Agency, believing that the guidelines are basic care applicable to all patients, adapted the guideline for patients of all ages admitted to the inpatient unit for longer than 24 hours. As a result, the BC Cancer Agency aimed to amalgamate interdisciplinary documentation and create one Risk/Assessment Document in addition to a 24 hour Patient Care Flow Sheet and Care Plan. Description of the Problem/Issue: While Geriatric Oncology is a growing specialty, the effects of cancer and it’s treatment has effect on the key areas of functioning in patients of all ages: Hospitalized patients with cancer have higher fall frequencies and higher fall injury rates among hospitalized patients. Falls may be related to pathophysiclogical or behavioural effects of chemotherapy or radiation as well as disease manifestations. One study shows that more than one- half of patient falls are related to elimination needs, regardless of patient age, and impaired gait. (Capone et al, 2010) The BC Cancer Agency, recognizing that many oncology patients have pre-existing co-morbidities as well as the effects of oncology disease/treatment, has adopted the 48/6 Guidelines to ensure early assessment and care planning for admitted patients of all ages, Identification of the Intervention/Strategy for Change: While introducing the concept of the 48/6 Guidelines to the BC Cancer Agency, the interdisciplinary team identified multiple assessment documents and processes during an environmental scan. In addition, the need for assessing and documenting other key areas of patient functioning were identified. This lead to the implementation of 48/10 guidelines at the BC Cancer Agency. Interdisciplinary Team involvement resulted in the creation of one comprehensive patient risk/functional assessment document, a 24 hour Patient Care Flow Sheet, as well as a Patient Care Plan to cover all key areas of patient function: BC Cancer Agency’s 48/10 Implementation: 1. Patient Risk/Assessment Document: The Patient Assessment Document was created to ensure the complete assessment of admitted patients of all ages within 48 hours of the patient’s admission. In addition to the 6 Key areas of Patient Functioning (Cognition, Medications, Pain, Nutrition/Hydration, Bowel/Bladder, and Functional Mobility), four other key areas of function are also assessed. These include: Falls Prevention, Pressure Ulcer, Infection and Medication Reconciliation. The patient’s involvement in the assessment is crucial to the interdisciplinary team’s overall understanding of the patient’s condition. To meet this need, the Patient Assessment Document also includes a Patient Symptom Self Assessment. 2. 24 Hour Patient Care Flow Sheet: The Patient Care Flow Sheet is an amalgamation of multiple patient assessment and care documents. The Flow Sheet ensures that a head to toe patient assessment is documented on an ongoing basis (day and night – once per shift),in addition to any daily care provided within 24 hours. The Flow Sheet allows any team member to add information or see at a glance what has occurred with the patient within a 24 hour period. 3. Interdisciplinary Patient Care Plan: Interdisciplinary Team Members identified that they were cohesive in their communication but needed to find a method to document the communication in one place that could be easily accessed. An interdisciplinary Care Plan with a checklist of the key areas of patient functioning is utilized during patient rounds. Implementation of these documents and processes involved engagement of the Interdisciplinary team. Feedback huddles, group meetings, education sessions and one on one conversations were held to assist in the change process toward a new, comprehensive method to identify, communicate and mitigate patient concerns. Interdisciplinary education consisted of sessions to address Delirium and Pain Assessment, recognition of Cognitive Changes, as well as Falls Prevention measures. Sustainability of Compliance/Measurement: The completion of Patient Assessment documents and care plans was measured from the Spring 2014 implementation through to Fall 2014. Audit results show a steady rise in the team involvement in ensuring completion of these documents and processes of 20 – 86% during this time period. In addition to the completion rates of the new assessment forms, flow sheets and care plans, the interdisciplinary team explored how the 48/10 implementation would impact the patient’s over all experience. A review of the Patient Safety Learning System shows a decrease in Patient Falls reports within the inpatient population at the BC Cancer Agency during the 48/10 implementation. Outcome data shows that inpatient falls have decreased to one every two months. Effects of the Changes/Lessons Learned: With the introduction of the 48/6 guidelines, BC Cancer Agency team members identified that they were proud of their cohesive team communication and interdisciplinary approach to patient care. As the team members explored their existing processes and documents, they discovered replication and assumptions about documentation and communication of patient care issues. There was initial reluctance from team members to offer suggestions for change until they came to realize their ability to create documents and processes that had meaning to an oncology patient’s care. Including the patient and keeping them at the centre of communication, the interdisciplinary team developed new methods to assess, document and communicate patient care concerns. The 48/6 guidelines at the BC Cancer Agency have become 48/10 guidelines…with the capacity to grow as more key areas of patient care are being identified by the team. 48/10 Advancing Cancer Care for the Younger and Older Adult Tracy L. Lust RN BSN MA Quality, Safety and Accreditation Leader PHSA/BCCA BC Cancer Agency Interdisciplinary Team: Janice Dirksen Clinical Coordinator, Arlyn Heywood Education Resource Nurse, Karen Janes Nursing Professional Practice, Dr Don Cooper, Dr Mike Mamacos, Winnie Cheng Pharmacy, Shirley Hobenshield Dietician, Rob Thayer Respiratory Therapist, Suzanne Butler Physiotherapist, Sarah Sample Patient and Family Councilor Patient Patient Symptom Self Assessment Document Patient Assessment Document (10 Key Areas) Patient Care Flow Sheet Interdisciplinary Care Plan