NEUROTOXICITY RECOGNITION

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Recognizing Chemotherapy Induced Neurotoxicity: The Use of a Standardized Pathway by
Nurses
Alison K. Agemak
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Alison K. Agemak is a certified pediatric registered nurse and a graduate student at the Edson
College of Nursing and Health Innovation at Arizona State University.
I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Alison K. Agemak, Edson
College of Nursing and Health Innovation, Arizona State University, 550 N. 3rd Street, Phoenix,
AZ 85004, United States. Email: aagemak@asu.edu

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Abstract

As pediatric oncologic medicine evolves, chemotherapy-induced neurotoxicity is becoming more
prevalent with certain medications. A delay in recognizing neurotoxic effects from medication
can lead to detrimental patient health outcomes. Pediatric bedside nurses are at the forefront of
recognizing clinical changes in these patients. Moderate-level evidence-based literature shows
that education regarding patient decline paired with the proper use of a standardized
neurotoxicity grading scale by nurses increases confidence in assessment skills and early
recognition of neurotoxic effects leading to better outcomes. Applying Lippitt’s theory of change
with consideration of the results of the evidence reviewed, a need for education and the
formation of a standardized chemotherapy-induced neurotoxicity pathway was developed and is
to be initiated to a population of pediatric oncology nurses (Lippitt et al., 1958). The framework
for implementing education using the new standardized follows Deming’s plan, do, check, act
model (Taylor et al., 2014).

Keywords: Chemotherapy, Neurotoxicity, Chemotherapy induced neurotoxicity,
Recognition, Standard Grading Scale, Assessment, Nursing Education

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Chemotherapy Induced Neurotoxicity Recognition
Bedside nurses have a vital role in the recognition of clinical changes in patients and
reporting the change to a provider to initiate interventions promptly. As new medication
regimens emerge for the treatment of pediatric oncologic disorders, more adverse effects are
being reported. Many of the medications incorporated within these regimens can cause varying
degrees of neurotoxicity in patients. The neurotoxic effects of the medications are central,
peripheral, or both nervous systems which may cause rapid clinical deterioration and lasting
neurological damage. As bedside nurses are at the forefront in recognizing acute clinical
changes, education on proper grading of neurotoxicity effects is crucial to initiate appropriate
interventions. The implementation of a standardized chemotherapy-induced neurotoxicity (CIN)
pathway for grading neurotoxicity should be administered by pediatric hem/onc/BMT nurses to
ensure early recognition and the initiation of proper interventions for patients at an increased risk
of developing neurotoxic effects from medications.
Problem Statement
As oncologic treatment regimens continue to change as pediatric cancer research evolves,
it is realistic to infer that the prevalence of neurotoxicity will continue to rise. For example,
leukemia accounts for the majority of childhood cancers and the five-year survival rate is high,
but the treatment to prevent central nervous system involvement can result in neurotoxic effects
(American Cancer Society, 2023; Bhojwani et al., 2021). The effects of neurotoxic
chemotherapy medications can be acute, such as seizures or alteration in mental status, or
chronic, as seen in chemotherapy-induced peripheral neuropathy (Baer et al., 2019). Oncology
nurses are responsible for recognizing and reporting these neurological changes to complete
interventions before the patient's deterioration. There are inconsistent neurotoxicity rates and

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interventions because of multiple neurotoxicity grading systems and the differences in the
grading scales (Pennisi et al., 2020).
Purpose and Rationale
There is a great need for proper nursing use of neurotoxicity grading scales since
neurotoxic adverse effects are becoming more prevalent with new oncologic treatment
modalities. The grading scales traditionally have been used to grade neurotoxic effects in patients
receiving Blinatumomab infusions and chimeric antigen receptor t-cell therapy (CAR-T) but
apply to other oncologic medications that have been associated with neurologic changes. To
apply this grading scale to patients at a higher risk for neurotoxicity, the implementation of a
standardized chemotherapy-induced neurotoxicity pathway will allow nursing staff to recognize
the degree of potential neurotoxicity and alert providers to intervene earlier. Early interventions
based on proper neurotoxic assessment and the use of a standardized grading pathway can assist
in helping initiate interventions before neurotoxic effects become detrimental to the patient.
Proper use and charting of the neurotoxic grading scales by nurses in the electronic medical
record will lead to better patient outcomes. Early intervention will help achieve better patient
outcomes, less traumatic patient care, and reduce the overall transfers to the intensive care unit
for neurological changes.
Background and Significance
A recent literature review shows that acute and chronic neurotoxic symptoms are
common in patients actively being treated for malignancy. Neurotoxicity is commonly
recognized in stem-cell therapies as a symptom of cytokine release syndrome (Baer et al., 2019).
Along with stem-cell therapies, certain medications and chemotherapy can lead to symptoms of
neurotoxicity that include encephalopathy, altered mental status, and seizures. For example,

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Ifosfamide and Aprepitant, chemotherapy, and antiemetic drugs, both very common in treatment
protocols, have been shown to cause neurotoxic symptoms in 30% of patients receiving them
(Vazirian et al., 2022). The correct use of neurotoxicity grading scales and neurologic assessment
education is essential to identify early signs of neurotoxicity to intervene and improve patient
outcomes.
Pediatric Oncology Nurses (P)
Nurses are at the frontline of reporting assessment findings to the healthcare team to
initiate interventions when needed. As the United States continues to have approximately 10,000
new cases of pediatric cancer diagnosed each calendar year, the number of oncology nurses
continues to grow as well (American Cancer Society, 2023). Providers rely on knowledgeable
nursing staff and assessment skills to identify neurotoxic symptoms in patients and understand
the patients at great risk for developing neurotoxicity (Baer et al., 2019). Mandatory oncology
nursing education sessions, interprofessional collaboration with physicians, and using a chosen
standard neurotoxicity grading scale are beneficial in boosting nursing confidence and
understanding chemotherapy adverse effects, leading to better assessment and recognition of
patient decline (Gallegos et al., 2019).
Standardized CIN Grading Scale and Pathway (I)
Oncology nurses need to be competent in how to grade and assess neurotoxicity using a
standardized CIN grading scale and intervention pathway. Competence in implementing a
standardized grading scale on identified patients at high risk of neurotoxicity can be obtained
through nursing education. Education presented to oncology nurses regarding chemotherapy
administration has been shown to decrease nursing anxiety related to the recognition of adverse
effects (Gallegos et al.,2019). Gaining knowledge of the medications that place a patient at

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greatest risk for neurotoxicity along with nursing use of a standardized age-appropriate grading
scale for immune effector cell-associated neurotoxicity syndrome (ICANS) leads to proactive
management of neurotoxicity (Lee et al., 2019). The grading scales that assess ICANS
traditionally are the immune effector cell-associated encephalopathy (ICE) score for patients
over the age of twelve or the Cornell assessment of pediatric delirium (CAPD) score for patients
under the age of twelve (Brown et al., 2021).
Current Practice (C)
Despite two neurotoxicity grading scales developed for patients going through CAR-T
cell therapy, these scales are not validated for use on other medications due to more research
needing to be done. The grading scales to assess ICANS related to CAR-T cell therapies can be
applied to other oncologic medications that place patients at high risk of developing
neurotoxicity; thus, the grading scales can still serve as a helpful guideline to identify risks and
subtle changes in a patient's neurologic status (Jordan et al., 2020). The current practice of
recognizing neurotoxicity relies heavily on the bedside nurses' understanding of neurotoxic
medications and the ability to recognize, document, and report changes in assessment promptly.
Increase Recognition of Neurotoxicity in Patients (O)
Early recognition of neurotoxic symptoms is crucial to prevent severe nervous system
damage. Early signs of neurotoxicity that can be educated on and are represented on the ICANS
grading scale are inattention, personality changes, and inability to do simple tasks (Burton et al.,
2021). If caught in earlier stages, pharmacologic measures are implemented to potentially reverse
the neurotoxic effects. Proper understanding of the grading scales by the nursing staff helps tailor
the pharmacologic intervention as the intervention differs with the severity of toxicity (Lee et al.,
2019). The goal of education on proper assessments is to increase overall recognition of

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neurotoxicity and determine more medications that place these patients at higher risk of
developing toxicity.
Internal Data
A pediatric hematology/oncology unit within a children’s hospital in the southwestern
United States found that neurotoxicity screening tools are available for use, but are not being
utilized effectively by the nursing staff to identify neurologic changes early in patients at greatest
risk. In casual conversations with the nursing staff and providers, along with a documented rise
in rapid response or code blue calls, there has been an increase in patients being transferred to the
intensive care unit due to signs of late-stage neurotoxicity (seizure, altered mental status, strokelike symptoms). The severe signs of progressive neurotoxicity can be detrimental to patient
outcomes and difficult for the family to witness. While education has been conducted on this unit
in a previous quality improvement project regarding components of the neurotoxicity grading
scales and identified medications that place patients at high risk for CIN, the scales are rarely
administered to patients. The grading scales are consistently used with Blinatumomab infusions
and CAR-T cell therapy but should include patients who are receiving high-risk CIN
medications. The additional high-risk chemotherapies identified by the institution include
methotrexate, ifosfamide, cytarabine, peg asparaginase, and nelarabine. Patients with any
elevation in immunosuppressive therapy levels or who experience posterior reversible
encephalopathy syndrome (PRES) are also considered at high risk for neurotoxicity. Patients
receiving these medications are to be graded using the appropriate scale by nursing staff and
proper provider ordering of the appropriate standardized neurotoxic grading scale.
This project will take place on the oncology unit where nurses report a concern about
their ability to recognize subtle neurologic changes and are unable to identify which medications

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place a patient at higher risk. The goal of this project is to measure compliance and accuracy in
using and documenting a standardized CIN grading scale pathway. This project includes
expanding neurotoxicity education, that BMT nurses received in a previous quality improvement
project to all hem/onc nurses. The additional education will include how to chart the new CIN
pathway scale and the interventions associated with each grade. The goal is for nursing staff to
identify neurological changes in high-risk patients through proper assessment and documentation
of the correlating neurotoxicity grade in the electronic medical record, thus improving
recognition and patient outcomes.
PICOT Question
For pediatric oncology nurses, does (I) accurate use and adherence of a standardized
chemotherapy-induced neurotoxicity screening pathway versus (C) current practice (O) increase
the recognition of neurotoxicity in patients who are at an increased risk due to medication
treatment?
Search Strategy
A review of current literature took place to answer the PICO question. Three databases
were extensively searched: PubMed, Cumulative Index of Nursing Allied Health Literature
(CINAHL), and ProQuest Medline. These databases were selected for their relevance to the
PICO question. Keywords included: standardized scale, nursing education or teaching, cancer,
oncology, neurotoxicity or chemotherapy toxicities, cytokine release syndrome, ICANS or ICE
grading, evaluation, assessment, recognition, pediatrics. The search was completed in order of
the PICO question. Oncology and cancer were frequently combined to yield more results.
Oncology on all databases tended to have articles with more adult patient populations as opposed
to pediatrics, so the addition of the term pediatric was added. The Boolean phrase “or” was

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utilized to assist in finding articles relevant to the intervention of education on the use of
standardized pathways. The intervention was defined as education or teaching or assessment or
recognition. The phrases standardized assessment, grading scale, documentation, neurotoxic or
chemotherapy toxicities, were also used to support the intervention in nurse utilization of a
standardized scale to improve recognition of toxicity.
On PubMed, peripheral neuropathy was excluded from the search to tailor the focus to
more central nervous system toxicity, as not excluding this term resulted in 4,231 articles, after
exclusion there were 100 articles to review. Articles including the education or incidence of
posterior reversible encephalopathy syndrome (PRES) were included as the project organization
includes this syndrome as a form of neurotoxicity from chemotherapy. CINAHL and ProQuest
Medline provided my search with practice guidelines and more research on how to educate
healthcare on the ICANS score. The average number of articles within all databases was 60,
multiple articles discussed neuropathy as opposed to neurotoxicity and were excluded from the
search. The Boolean phrase “NOT” neuropathy was added as a result.
Limitations, Inclusion, and Exclusion Criteria
The majority of the studies were qualitative, the results were based on pre and post
education questionnaires or how nursing staff described the quality of education received. Thus,
the majority of studies were excluded from the exhaustive search because of the low quality of
evidence. Grey literature was scarcely used to develop background and signific and included
many practice guidelines or ongoing trials of various assessment tools being utilized. Studies that
were earlier than five years ago were excluded from the exhaustive search.
Critical Appraisal and Synthesis of Evidence

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The rapid critical appraisal and level of evidence for literature included in this paper were
guided by the Melnyk and Fineout-Overholt (2019) guidelines. A combination of both
qualitative and quantitative studies was included and reviewed. Overall, most of the studies
included followed a similar design with pre- and post-intervention questionnaires provided to the
participants of the studies to see if the ideal outcome was achieved (See Appendix A, Tables A1,
and A2). The level of evidence varied slightly between studies, with the average level of
evidence being four (See Appendix A, Table A3). The sample characteristics of the studies
included were relatively similar, with the majority being oncology nurses with varying
experience levels. Three studies included physicians, patients, and other healthcare professionals
in the sample (See Appendix A, Table A3).
All studies included educational sessions as the primary intervention to assess staff
members' knowledge, management strategies, and confidence levels in treating neurotoxic
effects or clinical deterioration of patients (See Appendix A, Table A3). Approximately half of
the studies highlighted interprofessional education sessions and saw reduced medical errors and
quicker management strategies to improve patient outcomes. The results of these studies showed
an increase in knowledge and confidence in the management of patient conditions. The Jensen
(2020) study was the only one to utilize healthcare professionals working in the adult oncology
population rather than pediatrics. However, the overall design utilizing a questionnaire and
education session regarding standardized questionnaires applies to the research question in this
project.
Discussion
There is evidence in the literature reviewed that healthcare professional education
sessions lead to an increase in knowledge and confidence in terms of patient management. In

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addition, interprofessional education sessions showed reduced medication errors and quicker
medical decision-making in patient decline. Overall, the literature supports that education
sessions make a difference in more confident and proper assessment or scoring based on patient
clinical appearance, leading to more optimal management of disease process and better outcomes
overall.
Specific to the oncology population, nurses who received education about the neurotoxic
effects of chemotherapy or other cellular therapies are more confident in recognition, reporting,
and early initiation of management in patient decline. A standardized tool used to assess patient
adverse effects that both nurses and other healthcare providers understand results in less error
and better management of the patient to avoid poor patient outcomes. Although there are many
variations of the scale to assess neurotoxic effects, the literature concludes that a healthcare
system should educate staff on a one standardized grading scale and base interventions on those
scores to improve early recognition and treatment of neurotoxic effects.
Theoretical Framework Application
The Lippitt theory of change model, an expanded version of Lewin's theory of change,
applies to this project's goals and desired outcomes. Lippitt's theory outlines the process of
creating, implementing, and sustaining change through seven phases that correlate with the three
phases of Lewin's theory (see Appendix B, Figure 1). The core concepts of Lippitt's theory of
change are identifying the issue that needs to be changed, developing a relationship with the
organization, establishing routes to change, implementing change, and sustaining the change
(Lippitt et al., 1958).
The concepts of this theory provide a framework to guide this quality improvement
project. The identification is that nurses need to accurately score and document the standardized

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CIN grading scales to initiate appropriate interventions. In addition, a relationship has been
established with the organization through a previous quality improvement project with the same
stakeholders. Relationships with the hem/onc nurses and stakeholders allow the expansion of
education sessions to include all hem/onc nursing staff on a new pathway to recognize
neurotoxicity in high-risk patients. The new education and compliance of pathway use through
documentation align with Lippitt's (1958) implementation of change and sustaining of change.
The new CIN pathway used by nurses will allow for ongoing feedback and data collection to
evaluate how documentation compliance is maintained. Consideration of feedback and
adjustment of interventions will allow the change to be sustainable within the target population
of nurses. Once the education and pathway are adequate, termination, the last phase of Lippitt's
theory, can occur.
Implementation Framework
The plan, do, check, or study, act (PDCA or PDSA) method developed by William
Deming in the 1950s is a well-known method utilized to guide healthcare quality improvement
projects (Taylor et al., 2014). The PDCA method is often used for quality improvement because
the application begins on a small scale and adapts to feedback while implementing changes that
result in favorable outcomes for a particular patient population (See Appendix B, Figure 2). The
PDCA will guide the steps of implementation of this project.
This framework builds upon each other and continues to adapt and change as feedback is
gathered during the intervention. This framework's cycle begins with a plan to identify a need for
change and establishes a team of qualified individuals to investigate current practices and
brainstorm ideas for improvement (See Appendix B, Figure 2). As a team is assembled and
current practices are reviewed, the next step is to create evidence-based interventions with

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measurable outcomes (Taylor et al., 2014). The intervention is selected by the team and initiated
within a specific population, data is collected, and unexpected challenges with the intervention
are recorded during this period. After collecting data throughout the “do” stage of the PDCA, the
data is analyzed to evaluate the outcomes of the implemented change (See Appendix B, Figure
2). Through the interpretation of findings, plans on improving the initial intervention and ideas
on how to carry the intervention out on a larger scale are developed, thus repeating the PDCA
cycle (Taylor et al., 2014).
Implications for Practice Change
The evidence has shown that nursing education about neurotoxicity and using a
standardized scale to evaluate for toxicity has led to increased recognition and management of
this disorder. In a previous project, nursing education regarding neurotoxicity assessment and
grading scales was conducted with pediatric BMT nurses on the unit, excluding nursing staff that
are not oriented to BMT care yet. The education provided was regarding which patients are at
high risk of neurotoxicity development and how to add neurotoxicity scoring the electronic
medical record on these patients.
Since that initial education was completed, a new pathway was developed to be utilized
by both providers and nurses to standardize the assessment and scoring of chemotherapy-induced
neurotoxicity. Education sessions need to be conducted with all hem/onc nurses on the unit to
ensure understanding of the new pathway, accurate documentation, and initiation of appropriate
interventions.
The literature analyzed shows that interprofessional education sessions have been proven
to increase confidence, knowledge, and management of patient conditions (See Appendix A,
Table A3). This intervention is within the “Do” phase using the PDCA framework for

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implementation. A review of charts and assessment confidence levels post previous education
sessions will be reviewed before the new pathway education. Education regarding the pathway
will be introduced to the nurses during mandated education sessions. The new neurotoxicity
grading scale will be added to patients deemed high-risk electronic medical records. Posteducation regarding this new CIN pathway will be assessed for compliance via chart review on
identified high-risk patients. The ideal outcome is improving nursing compliance and appropriate
use of the CIN pathway after expanded education sessions and protocol rollout on the unit.
Methods
Setting and Stakeholders
The project site is a standalone children’s hospital system in the southwestern United
States. The hospital system consists of a main campus, multiple outpatient clinics, and two
smaller satellite campuses. The project will take place within the inpatient pediatric
hematology/oncology/bone marrow transplant unit (hem/onc/BMT) located on the main campus.
The unit has 46 inpatient beds that are utilized by numerous patients for the treatment and
management of hematologic or oncologic disorders. The stakeholders for this project include the
hem/onc/BMT inpatient nurses, the unit educator, the unit manager, hem/onc/BMT providers,
neurocritical care providers, and patients who receive one of the identified medications that place
them at a greater risk for neurotoxicity.
Recruitment Participation
The participants of this project include inpatient hem/onc/BMT patients being cared for
by the chemotherapy service receiving one of the identified medications that increase the risk of
neurotoxicity or patients that experience posterior reversible encephalopathy syndrome (PRES)
during the hospital stay. The high-risk medications include Cytarabine, Methotrexate,

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Blinatumomab, Ifosfamide, Peg Asparaginase, Nelarabine, or CAR-T cell therapy. Patients who
are under 28 days of age, patients who did not receive identified high-risk neurotoxic
medications or develop PRES, and patients re-admitted after discharge for treatment
complications are to be excluded from this project. Recruitment of these participants will occur
by identifying admitted patients who meet inclusion criteria during this project timeframe. The
consent to participate in this project is obtained through assuring each patient has a completed
HIPPA release form documented in the electronic medical record.
Intervention Plan
The evaluation question for this project is: will the implementation of a standardized
chemotherapy-induced neurotoxicity protocol lead to at least 50% of pediatric oncology patients
receiving high-risk chemotherapy having a documented neurotoxicity score in the electronic
medical record? Education regarding neurotoxicity and associated scoring has been done with
the hem/onc/BMT nursing staff within the first stage of the project. This evaluation question was
developed by discussing the timeline and need for a standardization of evaluating interventions
associated with neurotoxicity by the project stakeholders. Institutional board review (IRB)
approval was obtained through Arizona State University and the project site IRB waiver was
obtained before chart audits were conducted.
The presentation of the standardized chemotherapy-induced neurotoxicity (CIN) pathway
occurred at multiple mandatory hem/onc/BMT staff education meetings throughout
August/September 2023. The pathway will be implemented for use by the chemotherapy service
in December 2023. Data gathered via chart auditing will evaluate the primary outcome of
adherence to nursing administration and documentation of neurotoxicity screening scores. The
data was gathered between December 2023 and February 2024. Additional outcomes are

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recorded in the chart audit form that pertains to the use of the CIN pathway. The chart audit tool
(See Appendix C, Figure 1) developed by a group of hem/onc/BMT and neurology providers is
utilized to evaluate the documentation of neurotoxicity scoring and if interventions were
implemented per protocol. Chart auditing has been proven to be beneficial in evaluating patient
care, improving quality of care, and continuous improvement of clinical practice (Azzolini et al.,
2019).
Results
Descriptive Statistics
Introduction
The project included n=55 patient charts audited within the two-month time frame. The
patient charts that were included were followed by the chemotherapy service providers and
received an identified neurotoxic medication. Descriptive statistics and comparison between
variables are used to describe the results of this project as the chart audit form is not validated.
Table 1 lists the six medications/combinations administered to patients within the chart
auditing period. The most frequently administered medication is Methotrexate (n=22).
In evaluating the primary outcome of this project, nursing adherence to documentation of
CIN grading scores greater than 50% of the time, scores were documented 80% of the time
overall (n=44). Approximately 16% (n= 9) of patients had incomplete scores documented, which
means that one or more shifts did not have a score documented during the seven days after
chemotherapy administration. Thus, overall exceeding the original goal of 50% adherence by the
nursing staff.
As the adherence was well beyond what was expected, Table 2 shows that four instances
of neurotoxicity were identified via screening. Two were related to the developmental level of
the patients in which nurses were variable in scoring depending on the patients’ actions each

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shift, but two did require interventions per the CIN pathway. The two instances of true
neurotoxicity did not require transfer to the ICU.
As this is a multidisciplinary effort, the chart audit tool included secondary
outcomes that evaluated the provider's orders and interventions. Orders were placed by providers
on 89% of the patients, but baseline assessments were done only 50% of the time by the nursing
staff. A trend in the data collection that was not recorded directly in the chart audit form is that
the orders were placed the day after starting chemotherapy in some cases, this could have
impacted the baseline assessment amount.
Table 1
Medication Distribution
Variable
n
%
Medication
High Dose Methotrexate
22 40.00
Ifosfamide
17 30.91
Cytarabine
6 10.91
High Dose Methotrexate, Cytarabine 3 5.45
Blinatumomab
6 10.91
Peg- aspariginase
1 1.82
Table 2
Outcome frequencies
Variable
Baseline Assessment (before chemotherapy)
Yes
No
Neurotoxicity Order Placed
Yes
No
Nursing documented CIN grade (every shift x7 days or d/c)
Yes
Incomplete
No
Supportive measure initiated (if a change in neuro status)

n

%

28
27

50.91
49.09

49
6

89.09
10.91

44
9
2

80.00
16.36
3.64

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Yes
No
No change

2
2
51

3.64
3.64
90.91

Limitations
Limitations occurring through the implementation phase of this project include
inconsistency in screening scores, order placement by providers, and documentation of both
scores and associated grades of toxicity. Although orders were placed on 89% of patients
receiving neurotoxic medications, some orders were placed the day after medication
administration, thus nursing forgot to document a baseline screening score, which unless caught
on the following shift, resulted in incomplete screening documentation. Also, without a baseline
score, there were variations in scoring by nurses. The variable scores represent a neurotoxicity
grade change, but in most cases, the score reflected the patients’ developmental levels that would
have been reflected on the baseline assessment.
Another barrier is that nurses not only had to add in the parameter to document screening
scores but after calculating the total score, had to separately document a neurotoxicity grade. The
providers look at the neurotoxicity grade changes to introduce interventions per the CIN clinical
pathway. Nurses received reminders via email and flyers to document the grade as well. The
information technology (IT) team is going to be contacted to see if grades can be automatically
calculated to avoid this limitation.
Summary and Future Recommendations
The goal of 50% adherence to screening score documentation and administration by
nurses was exceeded. After the education sessions and CIN pathway rollout, the data gathered
reflected that 80% of patients had scores properly documented, reaching 100% adherence in the
last two weeks of data collection. The two cases of CIN recognized did not require emergent

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intensive care unit transfer, therefore adherence to screening ensures that CIN is caught
promptly. The education sessions regarding neurotoxicity recognition are aimed at being
sustainable and available for use in future pediatric oncology nurses.
Due to the success of the project, it is recommended to expand the CIN pathway and
screening requirements to the other services on the hem/onc/BMT unit. It is recommended that
the IT department assists in automatically calculating grades and adding the neurotoxicity order
to the high-risk chemotherapy order sets, to avoid a delay in order. Continue to use the PDSA
model to evaluate the implementation of the other services and revise education as updates are
presented.

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24
Appendix A

Table A1
Evaluation Table for Qualitative Studies

Evaluation and Synthesis Tables

Citation

Theory/
Conceptual
Framework

Design/
Method/
Sampling

Sample/
Setting

Major Themes
Studied/ Definitions

Measurement/
Instrumentation

Data Analysis

Findings/
Themes

Harden et al.,
(2020), CARTEAM: A
SimulationBased
Interprofessional
Education
Intervention for
Management of
CAR Toxicities

Not stated

Design:
Retrospective
Study

Sample: (n=
70). 47/70
responses to the
pre- and postsurvey were
obtained.
Demographics:
Various health
care roles and
areas of
oncologic
specialty. 41%
were staff
nurses.
Setting:
57% inpatient
faculty; the
other portion is
either outpatient
or unknown
Attrition: Not
all members
responded to the
pre/post
questionnaire

•

Do interprofessional
education
sessions
improve
knowledge and
confidence
regarding CART therapy
adverse effects?
Authors:
Hypothesis that
education
sessions would
assist in:
Assessment of
NT
Interprofessional
Collaboration
Management of
CRS

Data Collection:
Pre and posteducational
module
confidence
assessment tools.
Data
Dependability:
Data is
dependable as
this study could
be repeated and
the guidelines
discovered can
be followed.

No statistical
analysis was
stated, but it can
be inferred that
the pre-post test
results were
analyzed using a
paired sample ttest to compare
pre and post
education
answers.

(1) Improved
knowledge: 90
days after
education 22/24
respondents
expressed that
the education
sessions
improved
knowledge and
clinical practice
of CAR-T
therapy CRS

Country:
United States
Funding:
Jazz
Pharmaceuticals
grant
Bias:
None stated by
authors.

Method:
Interprofessional
members were
chosen at
random and
looked at cases
of NT along
with didactic
lectures
Purpose:
Development
and
implementation
of an
educational
module to
address
evidence-based
management
and recognition
of CRS.

•

•
•
•

Definitions:
CRS: Cytokine
Release Syndrome

Pre and post
confidence and
knowledge
assessments after
education
modules,
simulations, and
didactic content.

(2) CRS
recognition: over
90% of the
respondents
expressed more
confidence in
CRS clinical
recognition and
interventions

Level/ Quality of
Evidence;
Decision for/
Application to
practice;
Generalization
LOE: 6
Strengths:
Interprofessional
communication,
QR code at the
beginning and end
of educational
sessions, various
modalities of
education
Weakness: Not all
members
completed the
survey, lower level
of evidence
Application:
Interprofessional
education improves
recognition of CRS

(3) Use of
ICANS grading
for CRS
management: >

Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Citation

Theory/
Conceptual
Framework

Design/
Method/
Sampling

25
Sample/
Setting

Major Themes
Studied/ Definitions

Measurement/
Instrumentation

Data Analysis

90% of
respondents
expressed
comfortability in
interpreting
ICANS scores
and how that
relates to CRS
management

Car-T: Cellular
infusion therapy
utilized to treat
malignant disease

Knoerl, R.
(2023)
Exploring
Clinicians’
Perspectives of
Barriers to
ChemotherapyInduced
Peripheral
Neuropathy
Assessment and
Management in
Oncology
Practice: A
Qualitative
Analysis of
Semi-structured
Interviews.

None Stated

Design:
Qualitative
longitudinal
study

Sample: 15
eligible doctors
interviewed
(oncology unit)

Method:

Attrition: 24
physicians due
to lack of time
or responses to
the initial email

30-minute
structured
interviews with
clinicians
involved in the
study
Purpose:
explore clinician
perspectives on
CIPN
assessment,
management,
and the use of a

What are the barriers
to recognition,
assessment, and
management of
CIPN in oncology
patients?
Healthcare providers
were interviewed to
recognize:
-Neurotoxic
medications
-Personal barriers
to screening for
CIPN
-Management of
neurologic-related
side effects

Findings/
Themes

Data Collection:
Audio-recorded
interviews with
the participants
of this study

Statistical
Analysis: No tool
is stated in the
study; It is stated
that an inductive
content analysis is
utilized to identify
and code themes
within the
interviews.
Due to the coding
of themes,
multiple statistical
tools can be
applied to this
data.
Interviews were
coded into a

CIPN
Management
Practice Patterns
and Barriers were
identified and
addressed
through the
interviews.
Physicians
differed in their
approach to
assessing and
managing CIPN.
Utilization of the
CIPN Clinician
Decision Support
Tool was
reported to not
support the

Level/ Quality of
Evidence;
Decision for/
Application to
practice;
Generalization

LOE: 5
Strengths:
Interview structure
and barrier
identification for
proper neuro
assessment
Weakness:
Lack of
communication
about neurotoxicity
(peripheral
neuropathy)
between providers
and patients

Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Citation

Country: United
States
Funding:
CARTOX
program at MD
Anderson
Bias: No
conflict of
interest reported

Theory/
Conceptual
Framework

Design/
Method/
Sampling

CIPN decision
tool

26
Sample/
Setting

Major Themes
Studied/ Definitions

Measurement/
Instrumentation

Data Analysis

Findings/
Themes

codebook by
research assistants
summarized in a
framework matrix
with themes and
sub-themes with
subsequent quotes
from the
interviews

physician’s
current practice
as the utilization
of the tool did
not alter the
course of
treatment for
CIPN. If used,
the physicians
recommended
that the tool be
integrated into
the electronic
medical record
with
recommendations
that correlated
with a score on
the tool.

Level/ Quality of
Evidence;
Decision for/
Application to
practice;
Generalization
Limitations in
which interviews
only involved
physicians
Application:
Continue to utilize
a standardized
screening approach
in patients at risk
for neuro-related
side effects.

Jensen et al.,
Phenomenological Design:
Sample: (n=23) Screening tool
Data Collection: Phenomenological The tool is useful LOE: 5
(2020),
hermeneutic
applicability
hermeneutic
in assessing
Qualitative
15 patients, 8
Strengths:
Involving
approach
Semi-structured
approach:
urgent versus
•
Application
to
exploitative
oncology nurses
patients and
interviews
describe
the
non-urgent
levels
practice
study
Continued
nurses in
translation of
of peripheral NT
Demographics: • The usefulness
interviews and
choosing
Data
quotes. General
and how this
Method:
of tools in
All nurses
follow-up
between two
Dependability:
concepts from
impacts nursing
Interviews with
practice from a
female with a
throughout the
Dependable data, interviews coded
validated
care
cancer patients
healthcare and
mean years of
study process
the
interviews
questionnaires
into
themes/suband two focus
patient
(2)
Need
for
a
were
recorded
to identify
themes
for
groups of nurses experience of
perspective
Weakness:
6.5 years,
precise
and the study
chemotherapyinterpretation of
interpretation of
patients
were
description of
could be
induced
participants'
Purpose:
quotes from a
receiving
peripheral
repeated in the
answers
NT—tool
Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Citation

Theory/
Conceptual
Framework

neuropathy
before
implementing in
clinical
practice—A
qualitative
study.
Country:
Denmark

27

Design/
Method/
Sampling

Sample/
Setting

Major Themes
Studied/ Definitions

Measurement/
Instrumentation

To evaluate
from nurse and
patient
perspectives
which tool is
better to assess
peripheral NT to
guide treatment

chemotherapy—
those with
cognitive
impairments
excluded
Setting:
Oncology
outpatient clinic
Attrition:
One nurse
unable to
participate due
to illness

Definitions:

future following
the same format,

Design:
Utilizing class
evaluations (pre
and post lecture)
to evaluate
nursing
knowledge

N= 100

Themes:
Nursing knowledge
around cellular
therapy toxicity
recognition

Funding:
Novo Nordic
Fund

Peripheral NT:
neuropathy
developing due to
chemotherapy
infusions

Data Analysis

Findings/
Themes

provides more
clarity and
guidance

Level/ Quality of
Evidence;
Decision for/
Application to
practice;
Generalization
research consumer
perspective or
researcher
reviewing
information
Feasibility:
Application:
involving the users
of the tool (nurses
and patients) is
essential for proper
treatment to be
initiated

Bias: None
stated.
Winacoo et al.,
2019
Implementing
Immune
Effector Cell
Education for
Nursing Staff
Country: USA
Funding: None
reported

NA

Method: Review
underpinnings
of toxicities
associated with
IECT through

Demographics:
Inpatient,
outpatient, and
triage nurses

Definitions:
IECT: Immune
effector cell therapy

Data Collection:
Post education
session survey
filled out by the
participants of
the course.

No specific
analysis tool was
stated. Can infer
that a form of a ttest would be
utilized to
compare pre and
post intervention
questionnaires

Majority of the
nurses reported
an increase in
knowledge of
CAR-T cell
treatment and
common
toxicities

LOE: 5
Strengths:
Large sample size
with good
participation rates
Applicable to
current nursing
practice
Increased
knowledge

Bias: None
reported
Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Citation

Theory/
Conceptual
Framework

Design/
Method/
Sampling

classes and
modules
Purpose:
Oncology nurses
play a crucial
role in the
identification of
cellular therapy
toxicity, thus the
need for
education for
early
intervention and
treatment

28
Sample/
Setting

Major Themes
Studied/ Definitions

Measurement/
Instrumentation

Data Analysis

Findings/
Themes

Level/ Quality of
Evidence;
Decision for/
Application to
practice;
Generalization
Course content met
participant's needs
Weaknesses:
Time constraint
All nurses may not
have replied to post
survey
Applicability: The
study applies to
hem/onc nursing
practice and could
be recreated with
the same
information

Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON

29

Table A2:
Evaluation Table for Quantitative Studies
Citation

Theory/
Conceptual
Framework

Design/ Method/
Purpose

Sample/ Setting

Variables

Measurement/
Instrumentation

Data Analysis

Results/Findings

Crowe et al., (2018).
The impact of
simulation-based
education on nursing
confidence,
knowledge and patient
outcomes in general
medicine units

Not stated

Design: Pre and
post-analytic study
with survey given
at three separate
points in time

N= 161 nurses
completing the
pre and postsurvey

IV1: Simulation
Course for
clinically
declining patient
DV1: Nursing
self-report of
confidence

Statistical
analysis: Paired
t-tests for
evaluating
knowledge and
confidence
questionnaires

DV1: Increased
self-reporting of
confidence

Inpatient
hospital: all
nurses of
various genders
and experience
levels are
invited to attend
an education
session on
patient
decompensation.

Pre and post
analytic survey
after the 4-hour
simulation
education
session

Attrition: only
79/161 nurses
completed the 3month follow-up
survey
N= 30

Definitions: N/A.

Demographics:
30 inpatient
oncology
nurses; 78%

DV1:
Chemotherapy
medication
errors

Funding: University of
British Columbia
Country: Canada
Bias: None

Fisher et al., 2017
Impact of a
Pharmacist-Led
Chemotherapy
Education Program on
the Knowledge of
Pediatric

Purpose:
Implementation of
simulation to
improve nurse
knowledge,
confidence, and
communication
with a focus on
clinically declining
patients

Design: 3-session
educational
program with a
pre-test before the
first session and a
post test after each

Knowledge
retention
evaluated by the
survey given 3
months post
intervention

DV2: Nursing
recognition of
patient
deterioration
DV3: Nursing
knowledge

IV1: Educational
Sessions

Increased
recognition of
patient decline

Tools: Pre and
post multiple
choice tests with
a final
cumulative post
education
program test

Paired t-test

Statistically
significant
improvement in
knowledge (P
<0.0001) as
evidenced by a
14.1% score

Level of Evidence;
Application to
practice;
Generalization
LOE: 4
Strengths: Large
sample
Weakness: Not all
completed surveys
at 3 months. Only
given to nurses at
one facility;
questionnaire not
used in other
studies.
Application:
Education sessions
with pre & post
tests increase
confidence
&assessment all
skill levels.
LOE: 4
Strengths:
Knowledge gained
through education

Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Citation

Theory/
Conceptual
Framework

30

Design/ Method/
Purpose

Sample/ Setting

Variables

Hematology/Oncology
Nurses

educational
session.

Country: USA

Purpose: Do
education sessions
by a chemotherapy
pharmacist
increase nurses’
knowledge and
confidence in
identifying adverse
effects and safe
administration of
chemo?

with a bachelor
of nursing
degree; mean of
7.8 years
experience; 21
with APHON
credentials

DV2: Nursing
chemotherapy
knowledge

Funding: Children’s
Colorado
Bias: None to disclose

Setting: one
inpatient
oncology unit

Definitions:
APHON:
Association of
pediatric hem/onc
nurses

Measurement/
Instrumentation

Data Analysis

improvement on
posttests overall;
individual
sessions were
6%, 22%, and
16%
respectively.

Validity/
Reliability: This
study could be
repeated utilizing
the same format.

Reduction in
medication errors
from 8 per month
to 4 per month
post education
session
attendance by
nurses

Exclusion:
None
Attrition: Not
reported

Gallegos et al. (2019).
Chemotherapy
Education
An interprofessional
approach to
standardizing
processes and
improving nurse and
patient satisfaction.

None stated.

Design: Pre and
post intervention
questionnaire
Purpose:
Evaluating the
utilization of a
standardized
educational tool
regarding chemo
and side effects

Sample: N=55
Demographics:
Nurses who are
chemotherapycertified
Setting:
Outpatient
cancer infusion
clinic

IV1:
Standardized
education tool
DV1: Nursing
knowledge
DV2: Nursing
Satisfaction

Results/Findings

Data Collection:
Pre and post
questionnaire
before utilizing a
standardized
education tool
regarding
chemotherapy
and side effects.

Paired t-tests to
evaluate the
difference in
mean between
the pre and post
tests of both
nurses and
patients.

Level of Evidence;
Application to
practice;
Generalization
Good rate of survey
completion
Error reduction was
measured
Weaknesses:
Attendance not
required
Application:
Could be applicable
to practice if
attendance and
participation were
mandated. The
same questions and
information could
be valuable to be
presented and
gauge nursing
knowledge.

Improvement in
nursing and
patient
knowledge
regarding
medication and
side effects

LOE: 4

Improved
nursing

Weakness: Small
hospital, outpatient

Strength: ability to
measure both
patient and nurse
satisfaction and
confidence due to
setting

Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Citation

Theory/
Conceptual
Framework

Country: United States
Funding: none
reported

31

Design/ Method/
Purpose

Sample/ Setting

Variables

Measurement/
Instrumentation

(such as NT)
increases nurse
knowledge and
overall patient
satisfaction.

Exclusion:

DV3: Patient
satisfaction

Data Validity:
The study could
be repeated using
the same
standardized
education tool
and survey.

Design: Pre and
post test in the
form of
questionnaires
before and after the
course curriculum
was completed

N= 36

Attrition:

Definitions:
None to report.

Bias: none reported

Moreira et al. (2021).
Creation of a
successful
multidisciplinary
course in pediatric
neuro-oncology with a
systematic approach to
curriculum
development
Country:
USA/International
Funding: American
Lebanese Syrian
Associated Charities
Disclosures: No
conflicts of interest or

Not Stated

Purpose: Create
educational
modules to
improve healthcare
provider
knowledge on
central nervous
system tumors

Demographics:
Various
healthcare roles
in 8-9 different
medical
institutions
Setting:
Online course
and in-person
course

IV1: Course
curriculum
DV1:
Comprehension
of central nervous
system tumors
and adverse
effects

Data Collection:
Pre and post
questionnaire
regarding new
knowledge,
management,
and recognition
of central
nervous system
tumors and
adverse effects
Data Validity:
The study could
be repeated using
the same
educational
curriculum in the
healthcare
worker
community.

Data Analysis

Results/Findings

satisfaction with
increased
confidence and
knowledge of
chemo and side
effects

Wilcoxon
single-rank
tests. Analysis
of results
performed with
GraphPad
computer
software.

DV1: Clinical
outcomes of
patients with
central nervous
system tumors
are improved

Level of Evidence;
Application to
practice;
Generalization
facility,
standardized tool
not utilized in other
studies
Application:
education and
utilization of
standardized
screening tools
increase nursing
confidence and
satisfaction
LOE: 4
Strengths:
Interdisciplinary
and international
outreach.
Participants were
satisfied with the
program.
Clinical outcomes
of patients are
improved.
Weakness:
Limited to
budgeting
constraints.

Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Citation

Theory/
Conceptual
Framework

Design/ Method/
Purpose

32
Sample/ Setting

Variables

Measurement/
Instrumentation

Data Analysis

Results/Findings

disclosures were
reported.

Level of Evidence;
Application to
practice;
Generalization
Complexities of a
multidisciplinary
team with answers
to questionnaire
Tailoring of content
(too specific to
area)
Feasibility:
Application:
This study is
applicable to
practice as it
outlines how
education can be
utilized across
professions and
countries.

Pergert et al. (2015)
Confidence and
authority through new
knowledge: An
evaluation of the
national educational
programme in
paediatric oncology
nursing
in Sweden
Country: Sweden

Design: Study
specific
questionnaire with
open and closed
questions
(both quantitative
and qualitative
elements)
Purpose: Evaluate
a national pediatric
oncology nurse
education program
to enhance the

N= 66
Demographics:
Pediatric
Oncology
inpatient
Nurses; Ages
24-77; 3 Male;
Mean
experience
(years): 11-20

IV1: Education
Program
DV1: Working
situation after the
program
DV2: Nurse
perception of
educational
program
influence on
practice

Study specific
questionnaires
with open and
close-ended
questions.

Descriptive
statistics for the
structured
portion of the
questionnaire.
Open-ended
questions were
abstracted into
codes and a
comparative
analysis was
performed.

DV1: 65% of
nurses changed
into a higher
level of work
(manager, charge
nurse, educator)
DV2: 98%
shared
information with
coworkers and
67% reported
utilizing the new

LOE: 4
Strengths:
Network across the
country
Consensus reached
that there is a need
for educational
programs
Weaknesses:

Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Citation

Funding: Swedish
Childhood Cancer
Foundation

Theory/
Conceptual
Framework

Design/ Method/
Purpose

33
Sample/ Setting

quality of care in
the pediatric
oncology units

Country: USA
Funding: American
Cancer Society
Doctoral Degree
Scholarship

Prospective,
longitudinal study
Purpose: to
evaluate the effect
of educational
sessions on
improving nursing
knowledge and
core competence

Measurement/
Instrumentation

Data Analysis

DV3: Nursing
confidence in
caring for
clinically ill
oncology patients

Bias: No disclosures
or conflict of interest
reported

Peterson et al. (2017)
An Online
Educational Program
Improves Pediatric
Oncology Nurses’
Knowledge, Attitudes,
and Spiritual Care
Competence

Variables

N= 112
Demographics:
Oncology
Nurses, 29% of
participants with
11-20 years of
experience

IV1: Education
Sessions
DV1: Nursing
knowledge

Results/Findings

education in their
personal practice
as a nurse
DV3: Reported
that nurses felt
better equipped
to care for
pediatric
oncology patients

Three
questionnaires
were
administered to
participants as a
baseline,
immediately
after the
program, and
three months
post education

RM- ANOVA

DV1:
Increased nursing
knowledge about
the use of scale
and shows that
education
sessions do work
to increase and
retain knowledge
on patient care
topics

Level of Evidence;
Application to
practice;
Generalization
Targeted oncology
nurses with a lot of
experience, need to
include newer
nurses
Applicability:
This study applies
to practice in that it
can be recreated in
any pediatric
hem/onc nursing
unit
LOE: 3
Strengths:
Strong sample size
Online educational
program success
Weakness:
Self-report bias
Lack of control
group

Bias: No conflicts of
interest to report
Key: CRS: Cytokine Release Syndrome, CAR-T: Chimeric antigen receptor T-cell therapy, CIPN: Chemo-induced peripheral neuropathy EDU: Education ICE/ICANS: Immune
effector cell neurotoxicity, LOE: Level of Evidence NT Neurotoxicity

NEUROTOXICITY RECOGNITON
Table A3
Synthesis of Evidence Table
Study
(Author, year)
Design
LOE

34

Crowe et al.,
2018

Fisher et al.,
2017

Gallegos et
al., 2019

Pre and
post
analytic
study

3-session
educational
program
with a preand posttest

Pre and post
intervention
questionnaire

LOE: 4

Harden et al.,
2020
Retrospective
LOE: 6

Knoerl et al.,
2023

Jensen et al.,
2020

Moreira et al.,
2021

Pergert et al.,
2015

Qualitative
longitudinal
study

Qualitative
exploitative
study

Pre and
posttest in the
form of
questionnaires

Study
specific
questionnaire
with open
closed
questions

LOE: 5

LOE: 4

LOE: 5

LOE: 4

LOE: 4
Sample Demographics
Number of
161
Participants
Profession
Nurses
Mean Experience
Setting
Work Environment
INPT
Interventions
Educational Course
Pre and Post
Knowledge Test
Interprofessional
Collaboration
Outcomes/ Themes
Knowledge
Confidence
Management
Medication related

Standardized Scale
Use

X
X

Winacoo et al., 2019

Pre and post course evaluation
questionnaires
LOE: 5

LOE: 4

30

55

47

15

23

36

66

112

100

Nurses

Nurses

41% Nurses

Physicians

Nurses/Patients

VAR

Nurses
11-20 yrs

Nurses
11-20 yrs

Nurses

INPT

OPT

51% INPT
Other UNKN

INPT/OPT

OPT

INPT/OPT

INPT

INPT/OPT

INPT/OPT

X
X

X
X

X
X

X

X
X

X
X

X
X

X
X

X
X

X

X

+

+

X

+
+
+

Peterson et
al. 2016
Prospective
longitudinal
study
LOE: 3

+
+
+
-medication
errors

X

+
+

+
+
+ adverse
effect
recognition
+

+

+
+

+

+

+
+

+

+

Key: ED Education, LOE Level of Evidence Prof: profession, PPQ: Pre and post questionnaire, IP: Interprofessional, INPT: Inpatient, OPT: Outpatient, KNW: Knowledge, UNKN: unknown, VAR:
varies, + : increased, - : decreased

NEUROTOXICITY RECOGNITION

35
Appendix B

Models and Frameworks
Figure 1
Lippitt Change Theory (Expansion on Lewin’s Theory of Change in 1951)

(Lippitt, Watson, & Wesley, 1958)

NEUROTOXICITY RECOGNITION
Figure 2
Deming’s Plan, Do, Check, Act (PDCA) Model for Quality Improvement

(Taylor et al., 2014)

36

NEUROTOXICITY RECOGNITION

37
Appendix C

Chart Auditing Tool
Figure 1
Subject ID

Demographics
(Age in years,
ethnicity,
insurance)

Medication
Name

Date

Chemo
team

Neurotoxicity
Screening
order placed
(Y/N)

Ageappropriate
screening
tool selected
(ICE/CAPD)

Nursing
documented
neurotoxicity
grade X 7
days (Y/N)

Supportive
measures
initiated at
grade 3+

Neurology
consulted
(Y/N)

Neurology
recommendations

ICU transfer
(Y/N)