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Cara Henderson, RN, BSN, CMSRN, patient service manager of surgical oncology at Smilow Cancer Hospital in New Haven, CT; Elizabeth Rodriguez, DNP, RN, OCN®, nurse leader of outpatient services at Memorial Sloan Kettering Cancer Center in New York, NY, Amanda Choflet, DNP, RN, OCN®, director of nursing in radiation oncology at Johns Hopkins Health System in Baltimore, MD, and Megan Howe, MSN, RN, OCN®, nurse manager of Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center in Lebanon, NH, discussed the factors that relate to improving outcomes, the multidisciplinary approaches to the process change strategy, and the results and future direction of chosen pathways during a session at the 43rd Annual Congress in Washington, DC.
Multidisciplinary Approach to Head and Neck Cancer Care
In her presentation, Henderson discussed the process of using free flaps for cancer of the head and neck. Patients undergoing free tissue flaps generally had an immediate postoperative 24- to 48-hour surgical intensive care unit (SICU) stay. The SICU stay was required for many patients specifically because of the frequency of the flap assessments and vital sign monitoring; the length of the stay was approximately 10 days, with tracheostomy decannulation on the seventh postoperative day.
Henderson noted that head and neck reconstruction requires a highly specialized surgical team consisting of:
- Head and neck reconstructive surgeon
- Dental surgeon
Postoperative care of head and neck reconstruction takes a significant amount of time with hourly vital sign assessment, thrombosis prevention, hourly assessment of perfusion, proper head positioning, and tracheostomy care. With all of these essential steps, Henderson posed the question of how the length of stay for patients can be reduced, in addition to reducing postoperative complications and readmission rates of patients with head and neck cancer undergoing free flap surgery.
Her answer is to engage a multidisciplinary team to develop a strategy for process change. Once the work group is convened, a review of feasibility can be done to examine the current practices including the postoperative care in the SICU. Here are the steps her team took:
- Nurses from surgical oncology observed the nursing care provided in the SICU.
- Assessed feasibility of patients going from the operating room to the postanesthesia care unit (PACU) to surgical oncology.
- Assessed staff competency in the PACU and surgical oncology.
Henderson stressed the importance of making sure your core group of staff has experience with head and neck reconstruction, excellent communication skills, and good leadership skills. Room readiness is also important in reducing postoperative time and improving patient outcomes; this can also help with streamlining patient handoff and transfer.
By expanding the quality of care, outcomes will improve, including:
- Reduction in length of stay (e.g., a reduction in overall cost)
- Elimination of SICU stay (e.g., a reduction in direct care cost)
- Reduction in complications (e.g., hospital acquired infections, flap failure)
- Reduction in rate of readmission
Reduction in length of stay improves patient outcomes and has a large impact on the institution, Henderson said. By maximizing resources and building competency among a team, permanent changes in practice can reduce surgical complications and readmission rates.
Improving Vaccination Rates
Rodriguez’s presentation focused on how to improve vaccination rates of influenza and pneumococcus through a nurse-driven protocol. The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommended that all people with high-risk conditions (including malignancy) receive influenza and pneumococcal vaccines.
In data reported from 1991–2012 on patients presenting with pneumococcal disease at Memorial Sloan Kettering (MSK), 98% of patients diagnosed with invasive pneumococcal disease at MSK had not received any vaccine,and 17.4% of patients who had not received a vaccine had a 30-day mortality.
The old way of receiving vaccinations, Rodriquez noted, began with the patient asking for (or a medical professional offering) a vaccination. After the request, the licensed independent practitioner or physicians assistant would order the vaccine and the RN would administer it. In the enhanced, new process, the RN verifies eligibility in patient notes, the order is automatically generated, and the RN administers the vaccine. The RN can assess vaccine eligibility by reviewing the last documented influenza and previous vaccination from electronic medication administration record (eMAR); duplicate orders would automatically be detected and prevented.
Once patient assessment is finished, the information can be saved as incomplete or complete, orders are placed on hold, the pharmacy verifies the order, the vaccine is administered, and the process is then documented in the eMAR.
Better Benchmarks for Oncology Practices
In her presentation, Choflet discussed internal evaluations and how using benchmarking to confirm optimal staffing can improve outcomes in radiation oncology practices.
No concrete standards currently exist related to staffing levels, she said. The American Society for Radiation Oncology recommends one RN per office and the American College of Radiation Oncology recommends one RN per 200–300 new patients per year, but no standards exist for daily workload volumes or special procedures and acuity.
RN staffing standardization can be improved by:
- Identifying the current model: Examine the current primary nursing model, and compare the current workload with the suggested workload
- Comparing to benchmarks (e.g., internal and external): Choflet’s facility’s primary nurses were operating at 105% productivity on average, and this benchmark did not account for daily clinic work.
- Quantifying daily and weekly work: Retrospective analysis is helpful, but not enough. Can the data be used to help prospectively?
By quantifying the work, you can better understand how much time activities require, the real versus ideal time to complete, and role specificity. Daily work staffing spreadsheets can be created to better coordinate work, leading to a standardized staffing structure and protected RN time.
Scheduling Infusion Limits
In her presentation, Howe discussed scheduling ALL infusion limits using the DMAIC process (Define, Measure, Analyze, Improve, and Control), which can help stabilize business processes and designs.
Define: What was the problem? According to Howe, hematology/oncology infusion scheduling was guided by three capacities: chairs, pharmacy, and nurses. Frequently, one or more of those capacities was reached and hindered the ability to appropriately schedule additional patients. Patient wait times increased between the provider and infusion visit, and provider frustration grew as well. Increased patient wait times can lead to an inability to adhere to clinically indicated treatment schedules, treatment initiation delays, and an inability to accept new patients for chemotherapy treatment.
Measure: How big was the problem? Howe said her facility experienced continued difficulty in scheduling patients for treatment.
Analyze: Through Howe’s analysis, she determined the nursing capacity and how much time it took for each treatment step (i.e., researching patients, giving premedication, documentation and billing, and discharging patients).
Improve: Using a PDSA cycle (plan, do, study, and act), Howe presented some scheduling pilots, including increasing pharmacy doses in the morning, offering morning appointments first, expanding the options for morning appointments, coordinating nurse staffing with busier mornings, and not increasing overall staffing hours. Through this plan, her facility experienced fewer long gaps between appointments, and more patients were able to finish their treatment on time or earlier than expected.
Control: Gains have now been established—but how are they maintained? Ongoing system monitoring is an important key to improving patient and staff experience, Howe said.