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Oncology Nutrition Standards of Practice and Clinical Practice Guideline Development : A Canadian Experience Charitini Orphanidou, MSc, RDN Clinical Practice.

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Presentation on theme: "Oncology Nutrition Standards of Practice and Clinical Practice Guideline Development : A Canadian Experience Charitini Orphanidou, MSc, RDN Clinical Practice."— Presentation transcript:

1 Oncology Nutrition Standards of Practice and Clinical Practice Guideline Development : A Canadian Experience Charitini Orphanidou, MSc, RDN Clinical Practice Leader - Nutrition, BCCA, Kelowna BC Catherine Morley, PhD, RDN, FDC Consultant - Nutrition and Dietetics, West Vancouver BC Karen Biggs, MHSc, RD Team Leader Clinical Nutrition, HRCC, Hamilton ON

2 HAMILTON REGIONAL CANCER CENTRE

3 BC Cancer Agency Centre for the Southern Interior

4 Agenda Standards of Practice Defined National Working Group Review of the Standards National Review Dissemination Clinical Practice Guidelines Defined Quality of Evidence National Working Group Work to date Future work

5 Key Stakeholders Canadian Association of Provincial Cancer Agencies (CAPCA) Canadian Strategy for Cancer Control (CSCC)

6 CAPCA A national board consisting of chief executive officers of each of the provincial cancer agencies plus trustees drawn from provincial cancer agency boards and a representative from the Canadian Cancer Society/National Cancer Institute mission CAPCA is an interprovincial organization engaged in cancer control

7 CAPCA: Key Policy Advisory Committees Clinical Practice Guideline Initiative Psychosocial Oncology Policy Advisory Committee Supportive Care Policy Advisory Committee ( Joint effort of CAPCA and CSCC).

8 Canadian Strategy for Cancer Control (CSCC) “ Cancer control is too complex and broad a challenge for any single jurisdiction or organization to achieve by acting alone. This strategy presents an unprecedented opportunity for coordinated and collaborative action on a number of fronts that promises to change the cancer control landscape in Canada ”.

9 CSCC: Priority Areas 1.Establish a Council 2.Standards and Guidelines 3.Primary Prevention 4.Rebalance Focus 5.Human Resources 6.Research

10 CSCC Priority Areas: Standards and Guidelines Standards of Practice Leader Dr. Brent Schacter, CEO Cancer Care Manitoba Mandate: Develop national Standards of Practice Clinical Practice Guidelines Leader Dr.George Browman CEO Hamilton Regional Cancer Centre Mandate: Facilitate a national coordinated approach to CPGs

11 R E C A P…... Two National Groups citing Standards of Practice and Clinical Practice Guidelines as key priority areas Supportive Care Advisory Group Working encouraging these priority areas Members of these groups encouraging dietitians to begin work in these areas

12 Standards of Practice: Defined A Standard: a measure, criterion or specific behavior against which something or someone is measured are norms that express an agreed upon level of practice that has been developed to characterize, measure and provide guidance for achieving excellence provides a guide to the knowledge, skills, judgments and attitudes that are needed to practice safely

13 Standards: Common Components DESCRIBE: what dietitians do what dietitians are accountable for acceptable level of performance in a given situation 1.Patient population is defined 2.Statement of objectives and rationale 3.Process of care 4.Identifies personnel to deliver care 5.Defined initiation and monitoring of care 6.Documentation of care

14 Standards of Practice IMPERATIVE that they are established Outline roles and competencies that guide practice Links are proposed within the standards regarding basic and graduate education, clinical practice, continuing education and research

15 Standards are the Foundation... Decisions are made for: Defining appropriate levels of staffing Establishing nutrition roles and responsibilities within an agency or organization Determining core curriculum for dietetic education Determining outcome of care influenced by nutrition intervention Defining public policy on the role on nutrition in patient care

16 National Working Group: Oncology Nutrition Standards of Practice Working group consisted of interested members of DC Oncology Network in collaboration with the BCCA Dietitians working in oncology Teleconferencing efficient/effective in accomplishing work nationally

17 National Working Group MEMBERS Karen Biggs MHSc, RD ON Sandra Gentleman RDN BC Angela Martens RD MB Catherine Morley PhD, RDN, FDC BC Charitini Orphanidou MSc, RDN BC Satnam Sekhon RDN BC

18 Canadian Oncology Nutrition Standards of Practice…... SECTIONS Introduction Overview of Nutritional Care in Oncology Nutrition Issues for Persons Living with Cancer Foundations Programs and Services References Glossary

19 Standards of Practice Introduction Population defined How to use the Standards What is included in the document

20 Standards of Practice Nutritional Care in Oncology Significance of nutritional care Proactive vs. reactive Well referenced

21 Standards of Practice Nutrition Issues in Persons Living with Cancer Potential effects of malnutrition Continuum of care Cancer survivorship

22 Standards of Practice Foundations Section 1:Organization and Structure Section 2:Professional Attributes

23 Standards of Practice Section 1: Organization and Structure Standard 1:Organizations will provide Nutrition Care Standard 2:Position Profile Standard 3:Representation in the Administrative Structure Standard 4:Membership in Interdisciplinary Teams

24 Section 1: Organization and Structure Standard 5:Program Resources Standard 6:Supportive Research Environment Standard 7:Integrated Documentation Standard 8:Program Workload Data

25 : Section 1: Organization and Structure Standard 9:Oncology Nutrition Leadership Standard 10:Performance Reviews

26 Standards of Practice Section II: Professional Attributes Standard 11:Qualifications Standard 12:Ethics Standard 13:Unique Body of Knowledge Standard 14:Competent Application of Knowledge

27 Section II: Professional Attributes Standard 15:Continued Competence Standard 16:Evidence Based Practice

28 Standards of Practice Programs and Services Section III:Oncology Nutrition Services Section IV:Research Section V:Education and Training Section VI:Evaluation of Programs and Services

29 Standards of Practice: Programs and Services Section III: Oncology Nutrition Services A) Nutritional Care of Individuals B) Nutrition Education for Groups C) Management of Practice

30 Standards of Practice: Oncology Nutrition Services A)Nutritional Care for Individuals Standard 17:Access to Services Standard 18:Nutrition Screening Standard 19:Nutrition Consultation Standard 20:Nutrition Counseling and/or Education Standard 21:Continuity of Care

31 Standards of Practice: Oncology Nutrition Services B)Nutrition Education for Groups Standard 22:Group Nutrition Education

32 Standards of Practice: Oncology Nutrition Services C)Management of Practice Standard 23:Administrative Responsibilities Standard 24:Health Care Team Members Standard 25:Community Liaison

33 Standards of Practice: Programs and Services Section IV: Research Standard 26:Supportive Research Environment Standard 27:Promotion of and Participation in Research

34 Standards of Practice: Programs and Services Section V: Education and Training Standard 28:Participation in Education and Training

35 Standards of Practice: Programs and Services Section VI: Evaluation of Programs and Services Standard 29:Evaluation of Programs and Services

36 Standards of Practice: Review Critical Review 1.Provincial Supportive Care Leaders –CAPCA & CSCC –Administrators at BCCA and HRCC 2.Medical Oncologist ( Director of Supportive Care) 3.Provincial Groups of Dietitians –Ontario and British Columbia 4. Dietitians of Canada Oncology Network Members

37 Standards of Practice: Review Printed copy provided to every reviewer or member; comments requested

38 Standards of Practice: Reviewers’ Feedback Provincial Leaders in Supportive Care, Provincial RD Groups, Medical Oncologist provided useful comments and guidance Limited feedback from DC Oncology Network members

39 Standards of Practice: Update Revisions complete Submitted to CSCC/ CAPCA Standards of Practice Leaders

40 Well Deserved BREAK!

41 Clinical Practice Guidelines in Oncology Nutrition

42 CPGs: CPGs: Agenda Clinical Practice Guidelines Defined The Practice Guideline Development Cycle National Working Group Work done to date Future work

43 CPGs…….. Defined Defined: Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances Evidence based

44 WHY… Do We Need CPGs Evidence of unexplained and inappropriate variations in clinical practice patterns Concern that further limitations in resources will effect the delivery of high quality health care To assist clinicians in assimilating rapidly evolving scientific evidence into practice

45 CPGs…… continued What We Know: Attributes Methodologic Rigour Barriers to development/ implementation

46 Practice Guideline Development Cycle Facilitates a uniform approach to guideline development Consists of eight well-defined steps Expert panel required for relevant areas

47 Practice Guidelines Development Cycle 8. Schedule Review 7. Adopt guideline, policies 6. Negotiate practice policies 5. Independent review 1. Select/frame clinical problem 2. Generate evidence- based recommendation (EBR) 3. Ratify EBR 4. Formulate practice guideline update Browman et al, 1995, JCO, 13(2),

48 Practice Guideline Development Cycle 1.Select/Frame Clinical Problem Priorize/select topic Select outcomes Frame the problem 2.Generate EBR Search, gather and synthesize evidence Grade the strength of evidence Generate preliminary EBR

49 Levels of Scientific Evidence Level I Evidence RCT that are big enough to detect benefit Meta-analysis Level II Evidence RCT that are too small therefore showing trends Level III Evidence Formal comparison with nonrandomized controls Level IV Evidence Formal comparisons of historical controls

50 Practice Guideline Development Cycle 3. Ratify the Final EBR Reconcile differences in interpretation of evidence Document important opinions and reasons for them 4.Formulate Practice Guidelines Foster clinical flexibility and credibility through consensus building

51 Practice Guideline Development Cycle 5.Independent Review of EBR and Guideline Independent review Discipline specific experts Modify if warranted 6.Negotiate Practice Policies Implement guideline Problem solve systematic constraints

52 Practice Guideline Development Cycle 7. Adoption of Guideline and Policies Adopted formally and given official status 8.Guideline Review and Update Regularly scheduled reviews and updates imperative

53 CPGs….. Oncology Nutrition Initially confused –How to get started? –Where to focus? –What is important?

54 CPGs National Working Group Charitini Orphanidou Co-Chair BC Karen Biggs Co-ChairON Catherine Morley Contractor BC Satnam Sekhon BC Angela Martens MB Donna Danelon ON Patricia Campbell NS

55 CPG National Working Group: Work to date…….. INITIALLY: Where to begin and how to get started? Ensure national perspective and needs identification What were the key clinical practice issues?

56 CPG National Working Group: Work to date…….. Reviewed CPGs in other areas of nutrition practice and non-nutrition areas Realized this project was/is HUGE and not to be done independently of oncology nutrition clinicians Wanted to formulate a plan of action within a research context

57 CPG National Working Group: Work to date…….. CFDR grant application process discussed Broad national perspective required Smaller working group prepared a letter of intent TITLE: Basing Oncology Clinical Practice Guidelines on the Collective Experience of Dietitians Working with People Living with Cancer

58 CPG National Working Group: Work to date…….. Preliminary project: BCCA and Hamilton oncology dietitians Funding from BCCA, HRCC, DC-ONN To identify key clinical practice issues Piloted data gathering approaches (to assess potential use should study receive funding)

59 CPGs… Project Findings Key Clinical Issues Identified as: 1.Nutrition Risk Screening 2.Enteral Feeding: Indications and Approaches

60 Other Findings: 1.Need for a Foundations of Oncology Nutrition Care Manual 2.Oncology Nutrition Research Agenda (with staffing/ resourcing issues) 3.Enhanced cancer centre- community setting networking/ communication CPGs… Project Findings

61 CPGs… Currently… Plan to move ahead with Evidence Summaries using Systematic Literature Reviews on the two key clinical issues identified in the project

62 To Conclude… Tremendous strides A lot of hard work Wonderful growing and colleague building experience A lot to learn Proud of where we are at Thank you for your attention Questions/discussion welcome!


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