August 2016 VOL 7, NO 7

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Oncology Nursing Society

Redesign of Workflow Facilitates Inpatient Chemotherapy Admissions

A hematology unit at Memorial Sloan Kettering Cancer Center, New York City, succeeded in greatly reducing chemotherapy wait time and increasing satisfaction among inpatients, as described by Elena Lubimov, RN, BSN, OCN, at the Oncology Nursing Society 41st Annual Congress.

With more efficient workflow, chemotherapy can be delivered faster, which reduces hospital length of stay and “bed crunch” and increases patient satisfaction, Ms Lubimov said.

The pilot study was conducted with leukemia, multiple myeloma, and lymphoma inpatients, a group that makes up 53% of the hospital’s chemotherapy admissions. In 2014, this totaled 2653 treatments administered to 7 to 10 newly admitted patients per day and 45 patients already admitted.

During their interdisciplinary Leadership Safety Rounds—sessions that focus on patient safety and the patient experience—Ms Lubimov and her team found chemotherapy wait time to be a primary concern, and they designed a pilot program to address this.

Prior to the pilot, the daily workflow started with receipt of the chemotherapy order and its verification before admission. Patients were then admitted and assessed, after which the drugs were mixed, delivered, and administered.

The average time from patient arrival to the first dose of chemotherapy was 9.7 hours, and most chemotherapy was not delivered until 8:00 PM or so, “which is not an ideal time for patients or for nurses, who are just coming on shift, so there is room for error,” she said.

Ms Lubimov identified the following reasons for this nearly 10-hour delay:

  • Electronic chemotherapy orders: only 12% were submitted 24 hours prior to admission
  • Blood work: not available if tests taken within the previous 72 hours
  • Clearing for treatment: 46% of treatments were held, pending “proceed to treat” order
  • Peripherally inserted central catheter line placement: ordered on day of admission, not before
  • Bed availability: only 30% of patients were discharged by 2:00 AM
  • Drug delivery: time from drug preparation to delivery was 1 hour 47 minutes

How Workflow Became More Efficient

They designed a new, more efficient workflow process and evaluated it in a pilot study on a leukemia/lymphoma/multiple myeloma unit. It was staffed with 3 clinical nurses and 1 unit assistant and was equipped with 4 recliners. Data were collected for February through March, 2015, on 192 chemotherapy admissions.

The new admission criteria were stringent:

  • Chemotherapy orders had to be submitted and signed by the primary attending physician by 3:00 PM prior to the day of admission
  • Blood work had to be obtained and the results reported within 72 hours of admission
  • For women aged 11 to 50 years, a pregnancy test was administered prior to admission
  • All chemotherapy orders were verified before the day of admission
  • A central access line, if required, was placed prior to the day of admission or prescheduled early on the day of admission
  • All chemotherapy was to be delivered to nurses by 8:00 AM on the day of admission (a practice that has not resulted in undue waste of chemotherapy)

Importantly, the new chemotherapy admission screening process enabled the nurses to eliminate the “proceed to treat” order by the physician or practitioner, “which was the best improvement,” she noted.

Multiple Outcomes Improved

Improvements were observed in multiple outcomes after implementation of the new workflow and admissions screening tool (Table).

ONS-tableJONSAugust2016

 

On an average day, if the patient arrived by 10:00 AM, and if chemotherapy was ordered and blood work was performed, the first chemotherapy was administered by 12:26 PM. If the chemotherapy was ordered but the blood work was not completed, the patient was treated by 5:28 PM. If the chemotherapy had not been ordered by the time the patient arrived, treatment occurred at 7:07 PM.

The improved efficiency has been a great time-saver. Overall, the process saved 18 inpatient days, Ms Lubimov reported.

Patients, as well, are much more satisfied. In a survey of 71 patients in the pilot study, 38% perceived their time in admissions to be “shorter than expected,” 55% said the time was as they had expected, and only 7% indicated it was longer than they anticipated. Before the pilot, only 39% of patients were satisfied with the speed of the admissions process; this rose to 81% after the pilot.

“After achieving our goal on the hematology unit, we expanded our program to the neuro[oncology] service and now are in the process of expanding to the solid tumor service,” she said.

Reference

Lubimov E, Srikumar C, Rojas C, et al. Chemotherapy admissions: an opportunity to improve the patient experience. Presented at: Oncology Nursing Society 41st Annual Congress; April 28-May 1, 2016; San Antonio, TX.

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