Reducing Wait Time Between Admission and Chemotherapy Initiation

Improving Utilization of the Chemotherapy Unit through Implementing the Medication Early Release Project

Introduction

The outpatient oncology infusion unit is very busy, serving 60 to 70 patients per day. Due to a limited number of nurses, treatment chairs, only one pharmacy hood for bio-hazardous drug preparation, and other factors, patients wait a long time before starting their treatment, which affects the patient experience negatively. We conducted a quality improvement project to reduce the waiting time before starting the treatment, improve the patients' experience, and allow the unit to work more effectively through better resource utilization and accommodating more patients.

Methods

A committee was formed with representatives from oncology nursing and the quality specialist, chemotherapy pharmacy supervisor, data manager, and a medical consultant (team leader). We studied baseline data of patient waiting times from January to March 2019 and the factors that contributed to delays before starting the treatment. The charge nurse identified patients who could safely have their medication released early in the morning at 7 am, enabling the pharmacy to dispense at 8 am without their actual presence being required in the infusion suite (i.e., medication early release program or MERP). Multiple plan-do-study-act (PDSA) cycles were implemented to achieve a wait time from check-in to medication administration of less than 60 minutes. Data collected included check-in time, chair time, vital signs time, administration time, and discharge time. Additionally, reasons for drug wastage were assessed for patients who did not receive the prepared medication. A patient satisfaction survey was conducted with the patients before and after being enrolled in the program.

Results

At baseline, average waiting time for patients receiving similar medications in the MERP was 2 hours and 27 minutes. After the first intervention, average waiting time was reduced to 1 hour and 24 minutes, and small improvements were observed after each PDSA cycl. A major breakthrough occurred after an intensive patient education program and enforcement of strict compliance with the criteria in selecting the patients appropriate for theMERP. Average waiting time wasreduced to ≤ 60 minutes, and in November 2022, it was 30 minutes on average. Drug wastage was identified as a balancing measure. We were successful in reducing drug wastage by implementing several changes and patient education measures and achieved zero wastage. The patient satisfaction survey showed better satisfaction with the new changes.

Conclusion

A positive impact was achieved in this quality improvement project, with a significant reduction in the average waiting time for patients to start receiving chemotherapy. The outcome of this project has been maintained for 4 years and is still ongoing.

Utilization of an Outpatient Integrated Infusion Suite to Decrease Length of Stay, Increase Revenue, and Improve Patient Experience for Elective Chemotherapy Admissions

PURPOSE

Reduction of chemotherapy start times (CST) and length of stay (LOS) for elective chemotherapy admissions is a priority. The aim of this project was to improve efficiency of patient care while simultaneously increasing revenue by reducing LOS and transitioning high-cost chemotherapy to the outpatient setting.

METHODS

A multidisciplinary quality improvement team proposed building a new outpatient infusion suite in close proximity to the inpatient unit. This suite was then integrated into the flow of elective inpatient chemotherapy admissions and discharges for etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R). Quality measures such as CST, LOS, and revenue were used to evaluate the new infusion suite.

RESULTS

In the pilot phase of the study, the average CST improved by approximately 1 hour 45 minutes (P = .0218). The mean LOS was reduced from 4.3 to 4.1 midnights (P = .0214). In terms of hours, LOS was reduced from 105.8 to 95.5 hours (P < .0001). A mean quarterly revenue of $309,410 US dollars was noted during the pilot that had not been previously billed. These improvements were sustained throughout the control phase.

CONCLUSION

Delays in CST and prolonged LOS lead to patient dissatisfaction and increased cost to the health care system. Focus groups and patient feedback are important when designing and implementing new workflows. The creation of an outpatient integrated infusion suite allows medical centers to meet patients' expectations of reducing number of visits while also reducing LOS and capturing new revenue. Adherence to scheduling guidelines further reduces the CST for elective chemotherapy administration.

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis

OBJECTIVES

To systematically review the evidence base for a systems approach to healthcare design, delivery or improvement.

DESIGN

Systematic review with meta-analyses.

METHODS

Included were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs-heterogeneity was assessed using I2 statistics.

RESULTS

Of 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%).

CONCLUSIONS

This study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.

Reducing chemotherapy administration time on an inpatient oncology unit

PURPOSE

Due to the multifaceted chemotherapy workflow within the hospital, many patients often experience delays in receiving their treatment. This study aims to evaluate the causes for chemotherapy administration delays and implement new methods to reduce delays from order release to chemotherapy administration on an inpatient oncology unit at a community-focused academic medical center.

METHODS

In this prospective quality improvement study, we developed a process map to track baseline time stamps and utilized performance improvement tools to identify causes for chemotherapy delays. Based on recognized areas for improvement, the Plan-Do-Study-Act (PDSA) model was used to implement one cycle of interventions. Chemotherapy orders were collected, and benchmark time stamps were documented from the electronic medical record.

RESULTS

The primary outcome for the number of chemotherapy delays, based on compliance rate, was reduced from 63/100 (63.0%) to 48/100 (48.0%), a 15% reduction (p = 0.046). Our primary outcome of chemotherapy delays, based on our institutional benchmark of <3 hours, did not show statistical significance. Median time from chemotherapy order release to administration decreased from 7.08 hours at baseline to 6.10 hours post-intervention, a 13.8% reduction (p < 0.0001). Median verification, preparation, and delivery times were all reduced post-intervention by 13.0% (p < 0.0001), 3.9% (p = 0.024), and 14.8% (p < 0.0001) respectively.

CONCLUSIONS

This study allowed our institution to evaluate our current practice and reformulate the chemotherapy administration process. With the continuing education on the chemotherapy administration process and additional PDSA cycle interventions, it will help standardize our process and ultimately continue to reduce chemotherapy delays.

Decreasing Time to Initiation of Chemotherapy for Patients Electively Admitted to a Hematologic Malignancy Service

PURPOSE

Delays in initiating elective inpatient chemotherapy can decrease patient satisfaction and increase length of stay. At our institution, we observed that 86% of patients who were admitted for elective chemotherapy experienced a delay-more than 6 hours-with a median time to chemotherapy of 18.9 hours. We developed a process improvement initiative to improve time to chemotherapy for elective chemotherapy admissions.

METHODS

Our outcome measure was the time from admission to chemotherapy administration in patients who were admitted for elective chemotherapy. Process measures were identified and monitored. We collected baseline data and used performance improvement tools to identify key drivers. We focused on these key drivers to develop multiple plan-do-study-act cycles to improve our outcome measure. Once we started an intervention, we collected data every 2 weeks to assess our intervention.

RESULTS

At the time of interim analysis, we observed a median decrease in time to chemotherapy administration from 18.9 hours to 8.85 hours (P = .005). Median time to laboratory results resulted decreased from 3.17 hours to 0.00 hours. There was no change in time from signing chemotherapy to nurse releasing the chemotherapy. We noted that more providers were signing the chemotherapy before patient admission.

CONCLUSION

By implementing new admission workflows, optimizing our use of the electronic medical record to communicate among providers, and improving preadmission planning we were able to reduce our median time to chemotherapy for elective admissions by 53.2%. Improvement is still needed to meet our goals and to ensure the sustainability of these ongoing efforts.

Multidisciplinary Effort to Decrease Time From Admission to Chemotherapy on an Inpatient Oncology Unit

There are no national standards for time between patient arrival and the initiation of scheduled chemotherapy (time to chemotherapy [TTC]). Delays in this process have a negative impact on patient care and the use of health care resources. At the University of Virginia Cancer Center, mean TTC in 2015 was 12.1 hours and mean length of stay (LOS) was 5.45 days at baseline. We formed a multidisciplinary team that participated in ASCO's Quality Training Program. We aimed to improve TTC by 10% over 6 months. We used Plan-Do-Study-Act (PDSA) cycles as quality improvement (QI) models and used XmR charts to evaluate the interventions. The first PDSA cycle involved amending the chemotherapy consent process; mean TTC and LOS improved to 9.3 hours and 4.65 days, respectively. The second PDSA cycle involved shifting pharmacist review of chemotherapy orders to before admission rather than after patient arrival. Mean TTC remained at 9.4 hours (net 22% improvement from baseline) and LOS improved to 4.33 days (net 21% improvement). Our team surpassed the 10% improvement goal for TTC. This QI project faced a few limitations. Our baseline data set was a retrospective cohort review. In addition, oncology patients have a wide range of individual clinical needs that may have an impact on TTC. Delays in TTC have an impact on oncologic care at many medical centers. Our project highlights the need for guidance on this issue. We recommend that other institutions form multidisciplinary teams and also use QI tools to assess delays and implement changes.