Background: Oncology nurse navigators (ONNs) are key to empowering patients and caregivers with self-advocacy skills to identify and prevent treatment-related side effects. Symptom self-assessment and early intervention are key to effective symptom management and may prevent unnecessary emergency department utilization. Zone Tools have been used in several chronic diseases to facilitate rapid identification of clinical deterioration. To date, no Zone Tool has been published for use in patients with cancer.
Objectives: To describe the development and early experience of the Zone Tool for Oncology (ZT-O).
Methods: The ZT-O was developed by a 3-person oncology nurse team after attendance at the 2017 Geriatric Oncology Nursing Conference funded by a grant from the National Cancer Institute. The ZT-O is a geriatric-friendly, single-page, color-coded symptom self-assessment tool for patients undergoing anticancer treatment. It was translated for use with diverse patient populations and integrated into initial and ongoing education by ONNs, advanced practice providers (APPs), and clinical nurses at multiple sites in a single health system. The ZT-O was presented at the 2018 Geriatric Oncology Nursing Conference and was adopted by at least 2 additional sites for clinical and research use.
Findings: The ZT-O has been used by ONNs, APPs, and clinical nurses in both inpatient and outpatient settings in various geographic settings with diverse patient populations. In a pilot study of nurse/patient-family dyads, the ZT-O was feasible and acceptable to both nurses and patient/family caregivers. The ZT-O is associated with improved patient satisfaction and increased clinic visits for symptom management, possibly reducing unnecessary emergency department utilization.
Conclusion: The ZT-O is an easy-to-use summative teaching and communication tool that empowers patients/family caregivers to recognize signs of clinical deterioration. The ZT-O simplifies patient education, increases patient satisfaction, and may reduce unnecessary emergency department utilization. ONNs, APPs, and clinical nurses can customize the ZT-O for their unique patient populations to reinforce key symptom management priorities across the continuum of care.
Oncology nurse navigators (ONNs), advanced practice providers (APPs), and oncology clinical nurses advocate for patients by providing education about distressing symptoms that may emerge during anticancer treatments.1-3 Those symptoms range from mild to life-threatening. Most treatment-related side effects have evidence-based therapies to prevent or limit their severity; however, timely recognition is key to limiting the symptom burden.4,5 Many side effects can be treated in the outpatient setting, but some require urgent and emergent intervention.6,7 ONNs empower patients with self-management and self-advocacy skills by teaching them to recognize signs of disease progression and treatment complications and giving them the appropriate terminology to communicate their concerns to their oncology team.1-3,5,7,8 Given the range of possible treatment-related side effects and potential for life-threatening complications of cancer, a quick reference guide is needed to help patients determine when the urgency of their symptoms warrants notification to their oncology team or escalation to emergency services. Unnecessary emergency department utilization and hospital readmission in cancer patients is emerging as a key quality indicator in oncology care. In January 2022, the Centers for Medicare & Medicaid Services began tracking emergency department visits and inpatient admissions on patients receiving outpatient chemotherapy.9 Practical self-assessment skills are key to early recognition of distressing symptoms that arise during treatment.3,5 ONNs provide this kind of education and serve as trusted resources for patients across the continuum of care.3,5,10 In this capacity, ONNs may play a key role in cost avoidance by diverting patients with mild to moderate symptoms to appropriate outpatient management.10
Zone Tools for several chronic conditions, including heart failure, pneumonia, asthma, and chronic obstructive pulmonary disease, have shown promise in reducing disease morbidity and hospitalization.11,12 Zone Tools are single-page, color-coded patient education materials meant to help patients recognize when their disease symptoms are under control (green zone), require attention (yellow zone), or need urgent medical intervention (red zone). This paper will describe the development and adoption of the Zone Tool for Oncology (ZT-O)—from its inception at a Geriatric Oncology Nursing Conference in 2017 to its implementation at multiple sites in diverse geographic and practice settings in the United States. The article will also report a feasibility and acceptability study conducted on the ZT-O at a community oncology clinic and describe the personal experiences of ONNs and infusion center nurses who have been using the ZT-O as a foundational patient education tool since 2018. Together, these exemplars will demonstrate the value of the ZT-O for patients, caregivers, nurses, and hospital systems as a meaningful instrument to promote self-management and self-advocacy for patients undergoing treatment for cancer.
The purpose of this project was to develop a geriatric-friendly symptom self-assessment and communication tool—the ZT-O. The ZT-O was designed as a teaching tool for ONNs, APPs, and clinical nurses and as a quick reference guide for patients and family caregivers to recognize distressing symptoms and escalate them appropriately to the healthcare team.
The ZT-O was born at the 2017 Geriatric Oncology Nursing Conference funded by a grant from the National Cancer Institute. The conference was led by Arti Hurria, MD, and hosted by the City of Hope Cancer Center.13 Teams of 3 oncology nurses from hospitals around the country attended the workshop over 5 years. Contingent with participation was the commitment to develop and implement a project to improve the care of older adults with cancer. The ZT-O was the work product of the team from Providence Saint Joseph Medical Center (PSJMC) in Burbank, CA, a large suburb of Los Angeles. That team consisted of an oncology nurse educator, outpatient infusion center nurse manager, and an inpatient oncology unit nurse manager.
The Zone Tool format from other chronic conditions was adapted to develop the ZT-O. The ZT-O tool was constructed with large bold lettering and background contrast for easy readability for the aging adult population and was translated into the 3 most common languages spoken by patients served at PSJMC (English, Spanish, and Armenian; Figure 1). The ZT-O content was developed based on Oncology Nursing Society (ONS) symptom resources,14 a literature review,4-8 and analysis of emergency department visit data from clinic patients at PSJMC. Consistent with findings elsewhere, the most common reasons for emergency department visits were pain, nausea, dehydration, fever, and infection.6,7 While not all emergency department visits are avoidable, pain, nausea, diarrhea, constipation, and dehydration can often be managed in the outpatient setting.15 To develop the ZT-O, the nurse team worked with physician colleagues to rank symptoms as green, yellow, or red based on their potential for serious outcomes. Although originally designed for geriatric patients, nurses eagerly requested to use the ZT-O as a teaching tool for all adult patients. At that time, PSJMC had 3 disease-specific ONNs (breast, lung/head & neck, and gastrointestinal/genitourinary). PSJMC ONNs, infusion center nurses, radiation nurses, inpatient oncology nurses, and clinic nurses were trained to integrate the ZT-O into their initial and ongoing patient education. Contact information for both the ONNs (when available) and the provider were handwritten on the top of the ZT-O with instructions to call when new symptoms presented. They were instructed to call 911 or go to the emergency department for new symptoms in the red zone. The teach-back method was used to verify understanding.16
PSJMC ONNs, infusion center nurses, radiation nurses, inpatient oncology nurses, and clinic nurses were trained to integrate the ZT-O into their initial and ongoing patient education.
After implementation of the ZT-O at PSJMC, clinic staff noticed an increase in calls for symptoms in the yellow zone resulting in increased infusion center volume for hydration, antiemetics, and pain management. ONNs noticed calls for mild symptoms, which allowed them to provide additional education and treatment recommendations. Anecdotal evidence suggested those early interventions may have prevented emergency department visits and hospital admissions during regular clinic hours. An informal survey of nurses demonstrated their approval of the ZT-O and appreciation of its simplicity, which summarized their comprehensive drug and disease-specific patient education. Nurses also reported patients and their family members appreciated how the green/yellow/red visual format gave them a systematic way to assess for symptom severity. Based on that feedback, the ZT-O was shared with sister hospitals in the area and in a poster presentation at the 2019 ONS national conference. The ZT-O was also presented at the 2018 Geriatric Oncology Nursing Conference. The next sections will describe implementation of the ZT-O at 2 additional Providence sites in the Los Angeles area, at an outpatient clinic associated with Bon Secours Mercy Health in Richmond, VA, and an outpatient clinic associated with Denver Health in Denver, CO.
Providence Holy Cross Medical Center (PHCMC) is in Mission Hills, a large urban area of Los Angeles with a racially diverse and large Hispanic population. It has a dedicated inpatient oncology unit and an 11-chair outpatient infusion center that averages 450 visits monthly. The ZT-O quickly became an important tool and framework for symptom communication between patients/family caregivers, infusion center nurses, and a newly hired oncology APP. It was included in initial and ongoing education for all adult patients at the clinic and proved so useful, it was adapted as a scripted communication tool for clinic staff conducting follow-up phone calls and setting appointments. Family caregivers were included in education and encouraged to hang the ZT-O in a prominent location in the home for frequent referral.
Standardized symptom communication aided by the ZT-O has helped to improve patient satisfaction scores at PHCMC related to nurse communication, communication regarding medication, and nurse courtesy and respect (Figure 2). Prior to ZT-O implementation, scores were below benchmark but improved after implementation and have remained above the national benchmark for the past 5 years.
Clinic nurses stated ZT-O empowered their patients and family caregivers to seek early symptom management that may have prevented worsening conditions requiring emergency care.
Providence Saint John’s Health Center (PSJHC) serves a diverse patient population in an urban setting in Santa Monica, CA. It has a dedicated inpatient oncology unit, outpatient cancer center with specialty clinics, and an infusion center. The PSJHC infusion center has 15 chairs and averages 375 visits monthly. The ZT-O was implemented in the infusion center in 2018 by clinic nurses who included the ZT-O in initial and ongoing education. Clinic nurses stated the ZT-O empowered their patients and family caregivers to seek early symptom management that may have prevented worsening conditions requiring emergency care. While the ZT-O did not completely eliminate emergency department visits, electronic health record evaluation of patients seeking emergency department care showed a relative increase in appropriate visits related to red zone symptoms, including trauma, respiratory distress, sudden weakness, and uncontrolled pain, and decreased visits for dehydration and nausea/vomiting after implementation. Based on the positive feedback, the ZT-O was adapted by the neuro-oncology team for use in their specialty clinic (Figure 3). According to Mariah Mahotz, BSN, RN, OCN, ONN, at the neuro-oncology clinic, “when patients are transferring care to our clinic or just received a new diagnosis, they receive a lot of information during their first appointments. Having the ZT-O helps to simplify the best ways for questions or symptom reporting, allowing our team to be able to care for their needs more efficiently and effectively. This really helps patients and families feel empowered to address any concerns they are experiencing and have a better understanding of the symptom severity.”
The ZT-O was implemented by an APP at the St. Francis Cancer Institute, a clinic affiliated with Bon Secours Mercy Health System in Richmond, VA. The St. Francis Cancer Institute is a suburban outpatient clinic staffed by 3 physician-led clinical teams consisting of APPs, registered nurses (RNs), and licensed practical nurses. The implementation was conducted as an institutional review board–approved doctor of nursing practice quality improvement pilot study to assess the feasibility and acceptability of the ZT-O among nurses and patients.
Eligible patients were ≥65 years of age and beginning the first course of cancer treatment or changing to a new regimen with curative or palliative intent. An RN gave the ZT-O to eligible patients during usual cancer treatment education sessions and reviewed its use for monitoring cancer symptoms at home. The ZT-O was printed in color on card stock with magnetic strips attached for easy placement on a home refrigerator. The teach-back method was used to assess patient and family comprehension.16 Thirty- one patients received the ZT-O during the study period. Feasibility was measured by email survey to clinic RNs. Participating patients received a phone call survey from the project lead to assess acceptability.
One hundred percent of the RNs found the ZT-O very easy to use; 70% of patients who responded to the telephone survey thought the ZT-O was easy to use and had used it at least once to manage symptoms at home; 80% were very satisfied with the ZT-O, and all were very likely to recommend this tool to others in their situation. Due to the success of the ZT-O trial, at least one of the medical oncologists at the St. Francis Cancer Institute requested the ZT-O be included in the cancer treatment resource packet for all his patients. The results of this study were presented in March 2020 at the Virginia Cancer Patient Navigator Network, where it was well received by the navigators in attendance and made available for their use in an editable Word document.
Although the team had planned to restrict use of the ZT-O to geriatric patients, they quickly recognized the instrument’s potential and have been using the ZT-O for all adult patients.
The ZT-O was also implemented at an outpatient oncology clinic affiliated with Denver Health that serves a large, urban, underrepresented Hispanic population. Clinic nurses were eager to use the English and Spanish versions in their outpatient safety net oncology clinic. Although the team had originally planned to restrict use of the ZT-O to geriatric patients, they quickly recognized the instrument’s potential and have been using the ZT-O for all adult patients since 2018. According to Elaine Tucker, BSN, RN, OCN, infusion center charge RN at the time of the implementation, “patients sigh a breath of relief when I get to the ZT-O in the packet; relief that there is a concise document that can be quickly referenced when needed; relief that there is a 1-page flyer they can hang on the refrigerator that sums up all the highlights of an hour-long teaching.”
This paper described the development and implementation of the ZT-O since its creation in 2017. Created by oncology nurses, the ZT-O was developed for geriatric patients, but it has since proven useful among younger adult populations in multiple geographic areas among diverse communities and across specialty services. The ZT-O is a simple, feasible and acceptable, customizable tool that can be easily translated and used at the initiation of treatment, reinforced throughout treatment cycles, and integrated into scripting to create a shared understanding between clinicians and patients of triggers to contact the healthcare team. Standard 12 of the Oncology Navigation Standards of Practice requires clinical nurse navigators to “monitor and facilitate interventions to address symptoms and side effects.”17 That standard—focused on treatment, care planning, and intervention—also calls on navigators to use evidence-based information to facilitate communication between patients and their care teams regarding preferences and priorities for treatment throughout the care continuum. Integrating the ZT-O into clinical practice is a simple way for oncology nurses and navigators in all clinical roles to support patients’ self-advocacy—which should be a priority for all oncology nurses.1
The ZT-O empowers patients and their caregivers with self-advocacy skills to recognize and report distressing symptoms early that may minimize symptom severity. ONNs, APPs, and oncology clinical nurses play an important role in helping patients understand when to report symptoms before they reach the red zone. Zibelli et al8 found that patients who presented to the emergency department while receiving outpatient treatment did not believe they had other options to manage their symptoms—despite often presenting with a mild to moderate symptom burden. Reinforcement of symptom self-assessment and outpatient resources using the ZT-O could reduce that inappropriate usage. Howell et al5 argued that oncology clinicians need to improve patients’ cancer self-management skills by integrating self-management strategies into routine care, preparing the oncology workforce to teach self-management skills, and expanding access to self-management support services. Those are skills particularly suited to ONNs, who may find the ZT-O a helpful tool to meet those objectives.
None of the authors have any financial disclosures or conflicts of interest to disclose. We would like to thank Nancy Loporchio, BSN, RN, OCN, who participated in the development of the ZT-O in 2017 and all the nurses at Providence, Bon Secours, and Denver Health who have used the ZT-O and encouraged us to share the instrument with the oncology nursing community.
Special Acknowledgment: Thank you to Elaine Tucker, BSN, RN, OCN, who was the charge nurse at Denver Health when this manuscript was conceived.
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