Managing Cytotoxic Extravasation: Simulation-based tutorials to improve quality of care and patient safety for chemotherapy patients

Abstract

This paper reports on a quality improvement project that was conducted collaboratively by an oncology clinical nurse coordinator and simulation nurse educator. The project utilized simulation- based tutorials with a stepwise approach to train and evaluate the self-efficacy of oncology registered nurses working in a tertiary care hospital. A general assessment of the problem of cytotoxic extravasation was explored using an Ishikawa diagram and the factors responsible for such common issues in chemotherapy administration and oncology nursing practice were plotted. The Plan- Do-Study-Act (PDSA) approach was utilized to apply the quality improvement project method and to strategize the learning for the oncology nurses. The simulation tutorials approach used was an innovative educational activity. The project was completed by training each oncology registered nurse to enhance their efficacy in identifying and managing extravasation. The innovation of simulation-based education tutorials was effective in enhancing nurses’ practices. It also provided insight for continuous nursing education and evaluation that will impact the clinical practice routines in oncology care, thus saving patients from potential adverse effects of chemotherapy.

INTRODUCTION

Cancer is one of the leading causes of death around the globe. According to the International Agency for Research on Cancer (IARC, 2020), Pakistan’s population is 220.9 million and sees 178,388 new cancer cases and 117,149 cancer deaths annually (Kim, Park, Lee & Cheon, 2020). Cancer treatment depends on the stage of the cancer (Langer, 2010). Different options are available to treat cancer, one of which is chemotherapy. The National Cancer Institute mentions that chemotherapy is a cytotoxic medication that shrinks or kills cancer cells (Wenstrom & Margulies, 2008), and is mostly administered through intravenous therapy. The administration requires specialized training as it might cause extravasation. Extravasation refers to the leakage of injected drugs from blood vessels causing damage to the surrounding tissues (Kim et al., 2020; Wenstrom & Margulies, 2008).

Common signs and symptoms of extravasation include pain, stinging or burning sensations, and edema around the intravenous (IV) injection site. In severe cases, extravasation may cause tissue dysfunction or physical defects, resulting in a delay of treatment, patients’ distrust, and numerous other issues (Kim et al., 2020). Reporting and managing extravasation through standard guidelines are essential strategies in caring for oncology patients (Kim et al., 2020; Langer, 2010).

Incidence rates of extravasation vary greatly but have been estimated at 0.5–6% of patients receiving chemotherapy. However, large numbers of patients are at risk since vesicants are commonly administered chemotherapy agents (Maldonado, Parsons, Chen, Haslam, & Prasad, 2020). Health professionals are also at risk of adverse health outcomes if chemotherapy is not administered safely. Adverse health outcomes for health care providers, including headache, vertigo, hair loss, skin rashes and burning eyes, have been reported due to continue exposure to low doses of chemotherapy (Anand et al., 2022).

Twelve percent of registered nurses were noticed in a clinical setting with serious issues with their psychomotor skills due to lack or no training about cytotoxic extravasations (Guerrero, Attallah, Gomma, & Ali, 2024). Yet, handling and administering cytotoxic medication safely is significant to ensure protection of registered nurses in the workplace. It is suggested that a registered nurse should have competency training in chemotherapy handling and administration. These registered nurses should be observed after the training to monitor their practices in clinical settings (Asefa, Aga, Dinegde, & Demie, 2021). In addition, each health facility should have a continuous educational program for competency review and efficacy development among registered nurses to ensure that skills are retained, and practice is updated according to evidence-based guidelines. This practice approach is helpful in terms of both clinical impact and preventing negative health consequences which could add to the burden on health and finances of an oncology patient (Asefa et al., 2021; Mamdouth, Mohamed & Mohamed, 2022).

Simulation is one of the innovative and interesting educational ways to engage registered nurses in learning this rigorous skill and clinical practice activity. Simulation is an activity which is a replica of a natural phenomenon and is one of the evidence-based teaching pedagogies to build competency in skills and enhance the efficacy of clinical practice (Zafšnik, Cerovečki, Stojnić, Belec, & Klemenc-Ketiš, 2024). Simulation is utilized as a convincing learning tool that provides higher levels of competence to health care providers and eventually enhances patient safety (Al-Elq, 2010). This educational technique decreases errors, increases the satisfaction of participants with the educational process, and enhances their self-confidence, self-esteem, and comfort in skill performance (Koukourikos et al., 2021). A core feature of simulation is debriefing which “encompasses the cognitive domain assessing knowledge; the kinetic domain assessing skill and action; and the affective domain, or how the learner felt or interacted with the patient or other staff “ (Guerrero, Tungpalan-Castro, & Pingue-Raguini, 2022). Though simulation is widely used, little empirical evidence has been available to support its effectiveness in many aspects of cancer nursing education, particularly the possession of psychomotor skills of preparing and administering chemotherapy safely (Silva et al., 2023).

Context of the Problem

This initiative took place at one of the tertiary care teaching hospitals in Karachi, Pakistan. Taking a quality improvement and clinical practice enhancement approach, the nursing team of the oncology unit and the clinical simulation center joined together and created a team to work on this issue of extravasation. The issue was highlighted through the clinical management team led by the clinical nurse coordinator. Their routine observations were recorded on incident forms of the hospital. According to their list of clinical incidents, extravasation was one of the incidents noted and documented which was increasing. These incidents were also validated with the clinical nurse coordinator’s observations and reports. To focus on improvement regarding this issue was seen as not only enhancing teaching and learning, and the knowledge-based ability of registered nurses working in oncology, but also aid in solving a common issue which could potentially add a burden to a patient’s health.

As an initial step in this quality project, the Ishikawa diagram, also known as fishbone diagram, was used before preparing any educational program. Assessment using this tool helped to develop an understanding and map of the factors responsible for such a sensitive clinical issue with patients in oncology. This is a strong tool which is utilized for root cause analysis (McDermott, Antony, Sony, Fernandes, Koul & Doulatabadi, 2023). Its six components are categorized as material, machine, method, environment, measurement, and people (McDermott, Antony, Sony, Rosa, Hickey & Grant, 2023). By applying this tool, it will further help to build a strong implementation of the Plan-Do-Study-Act (PDSA) cycle.

To explore the depth of the causes of extravasation in our centre, the overall assessment was run in the clinical setting, guided by the components of the Ishikawa diagram. This assessment was led by the quality project team and facilitated by the clinical members of the team. It included two stages, one observational and the other an independent discussion (similar to interviews but unstructured) with each registered nurse in the oncology setting. Based on these two stages of data collection, potential causes for extravasation were identified.

An extravasation in a patient was seen as being potentially caused by numerous reasons (see Figure 1). The material cause for extravasation is the use of low quality or worn-out material for cannulation. A machinery cause includes the devices involved in causing the extravasation such as defected cannula or a malfunctioning intravenous line attached directly or through the infusion pump. The method in the fishbone diagram signifies the process by which the cannula is inserted. Discrepancy in the method may also lead to extravasation. For example, using the wrong site and techniques are two errors in the essential parts of cannulation skills. Choosing the wrong site for cannula insertion or not performing a proper flush with normal saline can serve as a cause for extravasation. Simultaneously, insufficient light in the environment and lack of skilled staff on the unit are also hindrances which are environmental causes.

Figure 1.

Ishikawa Diagram for Root Cause Analysis

To avoid these environmental causes, it was recommended an intravenous expert should be assigned to each unit and a conducive environment for nursing skills should be ensured. The manual inspection or physical dimension of the extravasation comes under the component of measurement. Identifying correct veins and monitoring of the process of the cannulation are important measurement elements. The last component in the fishbone diagram applies to people and indicates causes that are related to human beings. For example, sometimes increased workload and having multiple patient cannulations to perform can contribute to extravasation. In some cases, registered nurses lack intravenous cannulation skills or neglect the serious consequences of performing the significant skills with diligence. Such observations and self-reporting by registered nurses led the project team to decide the method of intervention needed was an educational action.

METHODOLOGY

The overall simulation tutorial project for managing cytotoxic extravasation was guided by the PDSA framework. PDSA cycles offer a framework for evaluating changes iteratively to enhance system quality (see Figure 2). The cycle is used extensively across healthcare settings for various kinds of quality improvement and patient safety projects (Taylor et al., 2014). Below, our project is described according to the steps of the PDSA cycle.

Figure 2.

Plan-Do-Study-Act Cycle Details

Plan (P)

Aim

The goal of the quality improvement project was to provide training to registered nurses to manage extravasation effects in patients receiving chemotherapy through a PICC line.

Instruction Components

Simulation-based tutorials with different clinical situations, a theoretical section, low fidelity simulation on mannequins, and medium fidelity simulation for handling techniques.

Requirements

Course grid, checklist and clinical flow diagrams or a clinical tool for teaching and learner’s evaluation. Other resources included mannequins, debriefing rooms, and common clinical instruments including intravenous line, pole, alcohol swabs, gauze, gloves. etc.

Do (D)

For the ‘do’ part, we developed, evaluated and finalized the course design document as a team and developed a checklist to conduct simulation-based tutorials. A literature search was carried out to find relevant evidence-based clinical tools which could be used as a flow diagram to assist learners’ understanding. The identified flow charts and diagrams were finalized through review by the clinical nurse coordinator and were approved for use in teaching and learning situations. The charts and diagrams were easy to follow during simulation-based practice and matched the guidelines followed in this specific hospital. Later, we used mannequins to perform low-fidelity simulation in conjunction with the theoretical portion. We also developed and conducted simulation-based lessons with which learners worked and critically thought about clinical cases. They then showcased their response to the mannequin like a routine interaction with patients. The interaction was followed by the use of communication skills and providing health education to patients to increase their literacy about the issue and its management. Lastly, the activity also included a medium fidelity simulation that used moulage to demonstrate extravasation and blood pumping. Participants identified and provided their management and clinical implications accordingly. They performed psychomotor skills and documentation as part of the simulation.

The simulation tutorials as strategy

The theoretical information was provided along with low fidelity simulation on mannequins as part of the overall tutorial (see Figure 3). Simulation-based tutorials were designed where learners went through multiple scenarios and simulated patient responses to their communication, health education and queries related to extravasation. As a hybrid learning experience, this theoretical portion was also offered with a medium fidelity arm where blood is pumped, and extravasation can be showcased through already prepared wounds and discoloration patches (moulage). Learners’ technique in attaching chemotherapy, identifying extravasation and handling extravasation through a proper protocol was assessed in phases through this hybrid attached medium fidelity arm. After the overall training, learners were evaluated regarding each of the steps learned during this simulation-based tutorial through the standard tools of care from the clinical area.

Figure 3.

Flow of Simulation-Based Tutorials

After the completion of the overall phases of tutorial, each learner was individually given a scheduled time for a debriefing session, where nursing and simulation experts provided their feedback to the nurse. The details of the debriefing for the experiences during all phases were provided through use of the PEARLS tool (Meguerdichian et al., 2022). The individual debriefing focused on the learning outcomes of the simulation tutorials and the assigned simulation-based tasks at each phase. Further, the feelings and experiences of learners in each situation and phase were discussed in detail. The discussion connected patient care and safety related to nursing outcomes, which were seen as essential to be reviewed and reflected upon.

Study (S)

Evaluation included observation of the methods used by learners to attach chemotherapy, recognize extravasation, and handle it according to protocol. In addition, learners’ reactions were evaluated regarding the developed scenarios, their ability to communicate, how they presented health education, and how they handled cytotoxic extravasation. The efficacy outcomes were also gathered from learners regarding the overall simulation-based tutorials. A standard self-efficacy grid relevant to the simulation training was utilized for this purpose which had been recommended by the simulation education team. The checklists and tools from the literature (See Figure 4) that were part of the theory and scenarios were also added into the grid in terms of outcome analysis. The overall project was analyzed based on identifying strengths and areas for improvement.

Figure 4.

A Commonly Used Step-By-Step Guide to Managing Extravasation

Source: Adapted from Kim, J. T., Park, J. Y., Cheon, Y. J. (2020, August). Guidelines for the management of extravasation. Journal of Educational Evaluation for Health Professionals, 10, 17.

Act (A)

Based on evaluation and outcome analysis, the team identified and understood the need to adjust practice routines to enhance the clinical competencies and patient care processes in the clinical settings. The details can be reviewed in the implication of practice described at the end of this report.

Project outcome

To make certain every oncology nurse was trained and well versed in the skills related to extravasation, the complete project ran for almost 6 months, with tutorials given periodically. A total of 65 learners were part of these simulation-based tutorials. Participants were given a quick online self-administered survey based on the expected outcomes to understand how this activity had enhanced their learning in all phases (see Figure 5).

Figure 5.

A Basic Graphical Representation to Show the Pre Post Self-Efficacy Percentage Self-Administered by Nurses

As per the desired outcomes of the simulation-based tutorials, one of the significant learnings was to understand the effect of cytotoxic extravasation (39.2% improvement) in terms of identifying extravasation and managing it properly in the chemotherapy areas. This learning also includes knowledge of medications that have the potential to cause extravasation (39.4% improvement). Overall, understanding was comparatively lower than expected immediately after the tutorial learning. Understandably, a new concept requires further clinical observation and practice which can be acquired later. A noticeable increase in self-efficacy was observed over time and assured us that at least the practice on low fidelity mannequins enhanced learners’ knowledge and hands on practice to a beginning or basic required level.

Another important aspect in handling extravasation is the provision of health education for the patient. Such instruction will support and enhance patient’s healthcare when they have a better understanding of the situation. Patients will report and share signs of extravasation and their feeling in a timely manner which have been discussed. In turn, this will prevent worsening of the site where chemotherapy is administered. All the items of self-efficacy assessed in the nurses following the tutorial were improved with a collective difference of 39.7% (see Figure 5).

Strengths and limitations

The simulation-based tutorials, from planning to implementation, have been monitored and evaluated throughout the six months. The summative evaluation was conducted through a SWOC analysis (see Figure 6) approach through informal discussions with attendee registered nurses, members from clinical and simulation teams, and patients during their visits. Strengths, weaknesses and challenges in the educational program, as well as opportunities for improvements, were identified.

Figure 6.

SWOC Analysis Diagram

Implication for practice

Teaching nurses how to manage cytotoxic extravasation brought on by chemotherapy through simulation-based education has greatly improved nursing practice and patient care. These educational programs have given registered nurses practical experience and promoted a deeper grasp of the appropriate procedures and solutions by immersing them in realistic circumstances that mimic the difficulties of extravasation. Registered nurses receiving these kinds of training are adequately equipped to identify extravasation symptoms quickly, taking the necessary precautions to lessen the damage of patient health. This has enhanced interaction with patients and the multidisciplinary team in an effective manner. It is anticipated that better patient safety and a decreased chance of complications will translate into better clinical results and higher levels of patient satisfaction.

CONCLUSION

Combining case scenarios, practice sessions, theoretical review and overall simulation-based evaluation with a detailed individual debriefing is an effective pedagogical approach to train and enhance skills of adults functioning at clinical setups. Chemotherapy settings in oncology are sensitive areas and patients receiving care in those settings are potentially vulnerable due to their health status. Improper technique and ineffective communication will impair the experience and can lead to poor experiences, like extravasation, which can be prevented or managed without any delay in care. Simulation-based tutorials can make learners’ lives easy with an experiential and reflective approach.