This project was reviewed by the QI committee of the University of Pittsburgh Medical Center (UPMC) and deemed not to be human subjects research, but to be a QI initiative, according to review of the common rule (45 CFR 46.102(d)). SQUIRE 2.0 guidelines were followed [13]. So that we could build on the learnings of this QI project, we aligned the methods and measures used with the approaches promoted by the science of implementation, especially as noted in the cancer prevention and control field [14]. Through this initiative, our goals were to generate practice-based evidence to inform future research and practice-changing activities.

The EPIS framework guided this QI initiative. The EPIS framework highlights key phases that guide and describe the implementation process and clarifies common and unique factors within and across levels of system and organizational context across phases, factors that bridge the variety of contexts specific to implementation, and the nature of the innovation being implemented, as well as the role of the innovators [11]. There are four phases to the EPIS Framework: Exploration, Preparation, Implementation, and Sustainment. In this project, we accomplished three of these phases; sustainment remains to be studied. After 5 months, we expanded our program to the 3rd floor of the Hillman Cancer Center. All implementation strategies were repeated for this expansion.

We chose to use the EXCEEDS tool [9] for our triage and referral program. EXCEEDS has 23 questions, in 3 sections, including a section regarding difficulty completing daily activities (positive responses lead to rehabilitation services referrals); a section about recent falls, recent cancer treatments, and recent symptoms (e.g., fatigue, neuropathy, memory, dizziness, nausea, lymphedema), and a section about catheters, current exercise, and confidence with exercise. It was developed with the help of a multidisciplinary team of experts and has been documented to be acceptable to oncology clinicians [10]. The EXCEEDS tool is intended to result in referral to four possible levels of intervention: unsupervised exercise, supervised cancer-specific community-based exercise, clinically supervised exercise, and cancer rehabilitation. EXCEEDS was designed to be adaptable to the needs of local systems. As such, based on available programming at our site, we collapsed into three levels of intervention: community-based exercise oncology programming, clinically supervised exercise, and cancer rehabilitation. The instrument was loaded into a RedCAP® database and delivered to patients on a computer tablet.

A rehabilitation navigator identified patients coming in for their second chemotherapy infusion visit at Hillman Cancer Center. The clinical encounters reported on herein occurred between March 21 and October 6, 2023. A list of patients was provided to the medical assistants. At the point of seating the patient in their chemotherapy chair, the medical assistants provided an iPad to the patient and asked that they complete the survey, which was provided in RedCAP® [15], [16]. It took between 2 and 5 min per patient for medical assistants to complete the task of providing the iPad and explaining the survey. Upon completion, the scored results became immediately available to the rehabilitation navigator, who approached the patient for a brief counseling session to discuss the results and provide the referral. These counseling sessions were usually 5 to 10 min long but could be as long as 90 min. Patients had the option to accept or deny any recommendation made.

The Moving Through Cancer Triage Program staff includes a licensed physical therapist with specialty training in Exercise Oncology (the rehabilitation navigator) and five Medical Assistants, who provided the iPads to the patients at the start of the second infusion visit.

When a patient was identified as having the symptom and disease profile consistent with referral to community-based exercise programming (e.g., minimal symptoms or comorbidities), we offered those who were UPMC health plan members the option to connect with the UPMC Prescription for Wellness (https://www.upmcmyhealthmatters.com/prescription-for-wellness-for-upmc-health-plan-members/) a customized care management system for healthy lifestyle changes. Other options offered included local cancer exercise offerings (Cancer Bridges: https://cancerbridges.org/), or a link to online programming available through the Moving Through Cancer Directory (https://www.exerciseismedicine.org/eim-in-action/moving-through-cancer/). After 4 months during which acceptance of these options was close to zero, we began to offer these patients the option for a few sessions of clinically supervised exercise with the rehabilitation navigator. These sessions provided instruction that could be carried out within unsupervised home-based exercise sessions. There are ongoing and completed exercise oncology interventions that have offered brief in person counseling that have documented benefits [17,18,19]. Patients had the option to refuse this offering as well.

When patients had sufficient symptoms to warrant more attention, but insufficient for referral to outpatient rehabilitation, the rehabilitation navigator offered clinically supervised exercise sessions. These sessions could occur prior to the infusion visit or at a separate time, and could occur chair side, in the chemotherapy infusion center, in the 200 square-foot gym on the second floor of Hillman Cancer Center, or virtually.

If a patient identified sufficient impairments that the EXCEEDS triage tool suggested referral to outpatient rehabilitation, the rehabilitation navigator offered this referral. If the referral was accepted by the patient, the rehabilitation navigator facilitated the referral by providing supporting materials to the appropriate nursing staff. If patients refused the referral, they were offered clinically supervised exercise sessions with the rehabilitation navigator.

All analyses were conducted in R (version 4.3.2). Descriptive statistics were developed for tables. Acceptability was defined as the percentage of patients who were willing to engage in the triage process. Feasibility was defined as the percentage of triaged patients who accepted a referral. Our a priori threshold for establishing feasibility was 30% (double the published background rate) [4]. Differences between those who accepted the triage process and those who did not were examined using t-tests and chi-square tests. Differences in exercise confidence across EXCEEDS triage tool levels were examined using a chi-square test.