Transcatheter arterial chemoembolization (TACE) has become the most common form of therapy for unresectable hepatocellular carcinoma (HCC) in both the Western world and Asia. TACE is intended as a palliative treatment for patients with unresectable primary liver cancer and as a neoadjuvant, preoperative treatment for patients with resectable disease. Complications of TACE most commonly include postembolization syndrome side effects such as abdominal pain and nausea. A SOS was created to address the most common and readily treatable complications experienced by post TACE patients. The two complications addressed included pain and nausea control. Additional potential benefits included time savings,ease of use, and reduced order confusion

• Arterial chemoembolization

• Abdominal pain

• Hepatic artery

Gibson GN (2017) Impact of Standardized Transcatheter Arterial Chemoembolization (TACE) Order Set on Hospital Length of Stay and Resident Satisfaction. JSM Clin Med Imaging Cases Rev 2(1): 10

 Transcatheter arterial chemoembolization (TACE) has become the most common form of therapy for unresectable hepatocellular carcinoma (HCC) in both the Western world and Asia. TACE is intended as a palliative treatment for patients with unresectable primary liver cancer and as a neoadjuvant, preoperative treatment for patients with resectable disease [1].

TACE involves transcatheter arterial regional injection of chemotherapeutic or antitumor agents immediately followed by embolization with mircrospheres or other embolic material into selected branches of the hepatic artery, which supplies nearly 100% of the blood supply to malignant tumors of the liver [2, 3]. Embolization renders the tumor tissue ischemic, depriving it of nutrients and oxygen. In addition, the ischemia directly limits washout of the chemotherapy from the tumor cells, allowing for higher concentrations of the chemotherapy agent, resulting in tumor necrosis. Complications of TACE most commonly include a combination of symptoms referred to as “post embolization syndrome” and include abdominal pain and nausea [4, 5].

Due to the variability in managing post embolization syndrome, a standard order set (SOS) was implemented and a cross-sectional analysis was then undertaken to determine if standardized control of post embolization symptoms impactedlength of hospital stay (LOS). Additional positive factors such time savings, ease of use, and fewer order clarification calls were assessed via resident satisfaction and feedback surveys.

 David Grant Medical Center is the U.S. Air Force’s largest medicalfacility on the west coast, serving military beneficiaries from eight western states and over 96,000 TRICARE and VA patients [6]. All admissions at DGMC for TACE between Jan 2009 and January 2013 were retrospectively observed. The criteria for selection included any patient undergoing TACE for primary hepatic tumor(HCC) or metastases to the liver

102 post TACE patients over a 4 year period (2009-2012) were randomly selected. The goal was to determine if a SOS implementing accepted practices in the control of pain and nausea had an impact (positive or negative) on length of hospital stay. LOS was compared between TACE patients who received non-standard orders and those where the SOS was used.

Resident feedback and suggestion surveys were emailed and the data collected to assess positive or negative response in regards to the SOS time savings, ease of use, and reduction in order confusion

Study Protocol

The study protocol was approved by the Interventional Radiology staff at David Grant Medical Center without the need for informed consent.

The DGMC IR Post Procedure SOS is a pre-selected order form containing anticipated scheduled and as needed (PRN) orders for patients undergoing TACE procedure. The orders are electronically based and entered in the hospitals computer system following completion of the procedure. The SOS is in a format familiar to IR staff and radiology resident physicians. The orders are designed to be all encompassing, potentially covering all orders required during admission (Figure 1).

Figure 1 IR post procedure (tace) admission order set

The SOS is designed to promote quality and efficiency of care, reduce errors of omission, and reduce clarification calls by nursing and pharmacy personnel. Critical portions of the SOS include IV and PO pain and nausea control, a combination of IV and PO hydration, thromboembolism prophylaxis, vital signs and daily labs. Because of the concurrent liver dysfunction of mostTACE patients, PO and IV antipyretic protocols were not included

 Statistical Analysis

A total of 51 TACE patients were randomly selected from 2009-2010 and compared with a randomly selected total of 51 TACE patients from 2011-2012. The average LOS for each group was calculated and compared. The average LOS for the 2009- 2010 group totaled 2.15 days and the average LOS for 2011-2012 group totaled 1.62 days.

Resident satisfaction surveys regarding the post procedure SOS for TACE patients were conducted to determine time savings, ease of use, and reduced order confusion. Of the 12 residentspolled, 9 responses were received with positive response to time savings (55.6% agree, 33.33% strongly agree), reduced order confusion (55.56% agree, 44.44% strongly agree), and user friendly (55.56% agree, 33.33% strongly agree, 11.11% neither agree nor disagree (Figure 2)

Figure 2 Resident Survey of IR Post Procedure Standard Order Set

Implementation of a standard order set (SOS) in the post Implementation of a standard order set (SOS) in the postprocedure management of TACE patients at DGMC proved beneficial by minimally reducing LOS. Additionally, the SOS had a positive impact on resident satisfaction as it saved time, was easy to use, and reduced order confusion

 The implementation of a post TACE procedure standard order set led to a minimal reduction in LOS while maintaining quality of care. The main effect occurred by reducing the time from clinical stability to discharge. Additional benefits were highlighted through resident satisfaction surveys which concluded a post procedure standard order set saved time, was easy to use, and reduced order confusion.

Complications of TACE most commonly include postembolization syndrome side effects such as abdominal pain and nausea. A SOS was created to address the most common and readily treatable complications experienced by post TACE patients. The two complications addressed included pain and nausea control. Additional potential benefits included time savings,ease of use, and reduced order confusion.

A retrospective cross sectional analysis was performed on the length of hospital stay (LOS) in patients who underwent TACE procedure over a 4 year period (2 years prior to implementation of a standard order set, and 2 years after implementation of a standard order set). Prior to the implementation of the SOS, post procedure orders varied from attending physician to attending physician and were frequently modified by residents throughout the LOS based on the condition of the patient or input by nursing or pharmacy personnel.

Examples of SOSs were compared from various institutions include the University of Minnesota and the University of California San Francisco. In coordination with Interventional Radiology (IR) staff at David Grant Medical Center (DGMC), a consensus on standard of care regimens in the treatment of pain, nausea and post procedure care was achieved. The SOS was approved and implemented in January 2011

A minimal and not statistically significant reduction in LOS with the use of post procedure SOS was demonstrated in TACE patients at DGMC. The magnitude of reduction was approximately: 0.5 days vs non standard orders.

The minimal reduction in LOS after implementation of the SOS was also accompanied by improvements in process quality measures. In particular, there was increased use of appropriate deep venous thrombosis prophylaxis, incentive spirometry, as well as vital sign and laboratory monitoring.

There was positive resident response to the SOS with regards to time savings, ease of use, and reduced order confusion by nursing and pharmacy personnel (Figure 2).

Although the predefined primary outcome measure was mean LOS, a secondary analysis could have been conducted with LOS outliers excluded (2 SDs above the mean; ie, 6 days), since an extremely long stay is likely to reflect medical complications rather than care practices [7]

Resident surveys highlighted several recommended additions to the SOS and include: 1. Adding post procedure bed rest orders with femoral access site checks and progressive ambulation 2. Adding patient controlled analgesia (PCA) to prevent deviation of the SOS in these patients refractory to standard IV and PO pain regimens 3. Review and possibly eliminate current pain medications containing Acetaminophen given the majority of TACE patients have comorbid end stage liver disease (ESLD) 4. Add a template for standard/routine notes (e.g. procedure, consults, etc.) which is beyond the scope of this analysis but would be beneficial in the realm of patient care nonetheless.

Because most TACE patients have a component of concurrent hepatic dysfunction, adding antipyretic medications to the SOS may prove beneficial after careful coordination with inpatient pharmacy and current care standards in the treatment of fever.

In conclusion, an IR post procedure SOS led to a minimal reduction in LOS in TACE patients at DGMC. Additional benefits included increased resident satisfaction secondary to time saving, ease of use, and reduction of order clarification questionsby nursing and pharmacy personnel.

Application of this SOS has the potential to improve patient care and outcomes as well as organizational efficiency. The costeffectiveness of this approach as well as its suitability for other medical diagnoses is uncertain and may be worthy of study [8].

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6. David Grant USAF Medical Center.USA.
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