Redesign of Workflow Enhances Inpatient Chemotherapy Admissions

San Antonio, TX—A hematology unit at Memorial Sloan Kettering Cancer Center, NY, 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.

Her pilot study was conducted in patients with leukemia, multiple myeloma, or lymphoma, a group that receives 30% of all inpatient chemotherapy at Memorial Sloan Kettering. In 2014, this totaled 2653 treatments administered to 7 to 10 newly admitted patients daily, 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 designed a pilot program to address this.

Before 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,” explained Ms Lubimov.

She identified the following reasons for this approximately 10-hour delay:

• Electronic chemotherapy orders: only 12% were submitted 24 hours before admission
• Blood work: if tests taken within the previous 72 hours were not available
• Clearing for treatment: 46% of treatments were held, pending a “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 PM
• Drug delivery: time from drug preparation to delivery was 1 hour 47 minutes after it was obtained.

How the Workflow Became More Efficient

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

The new admission criteria were stringent:

• Chemotherapy orders had to be submitted and signed by the primary attending by 3:00 PM before 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 before admission
• All chemotherapy orders were verified before the day of admission
• A central access line, if required, was placed before 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 wastage of chemotherapy).

Notably, 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.

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 are also 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 that 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.