Implementing a Clinical Pathway for Malignant Bowel Obstruction in Patients with Gynecologic Malignancies

Outcomes 1. Recognize key aspects of care for hospitalized patients with malignant bowel obstruction.2. Describe opportunities and challenges in implementing a clinical pathway to improve quality of care among patients with malignant bowel obstruction. Key Message An initiative encouraging provider use of a clinical pathway for gynecologic oncology patients with malignant bowel obstruction can promote high quality care. Some aspects of a clinical pathway may be more readily adopted by providers than others. Introduction Care for patients hospitalized with malignant bowel obstruction (MBO) involves complex symptom management and interdisciplinary coordination. As these hospitalizations signal serious and often progressive disease, serious illness conversations (SIC) should routinely occur. To this end, we developed a clinical pathway for MBO to promote high quality care. We describe experience to date in encouraging provider use of this pathway for MBO in patients with gynecologic malignancies. Objectives To increase provider use of a clinical pathway that incorporates routine serious illness conversations in patients with gynecologic malignancies hospitalized with MBO. Methods Two teams caring for patients with gynecologic malignancies at our institution—one based in gynecologic oncology and a second in medical oncology—have been encouraged to use the pathway since 2/2022 and 2/2023, respectively. Results Among 23 admissions for MBO, 20 patients received one of the first-line antiemetics recommended by the pathway (metoclopramide, olanzapine, or haloperidol). Dexamethasone was administered in 18/21 admissions (2 patients had contraindications). When failing to improve, 0/6 patients received octreotide as recommended. A SIC (suggested for all patients admitted with MBO) was documented in our electronic medical record flowsheet in 4 admissions. Conclusion This feasible initiative holds promise in ensuring patients receive high quality, standardized symptom management and serious illness communication. Barriers to SIC, including the acute nature of MBOs and clinicians’ discomfort with SIC, will need to be addressed. We are reviewing patient charts post-discharge and soliciting feedback from providers to identify facilitators and barriers to use of the pathway. Proactive efforts by the project team will assist clinicians in gaining comfort with aspects of the pathway that are not routinely integrated into their preexisting practice. Keywords Managing Suffering and Distress / Quality Improvement