Denver, CO—A growing number of patients treated at the infusion center, coupled with a fixed number of infusion chairs, helped to create a logjam at the National Cancer Institute–designated New York University Langone Medical Center. Laura Loninger, RN, MA, OCN, and colleagues tackled this problem by redesigning scheduling and addressing other challenges, and were able to streamline efficiency and demonstrate dramatically improved infusion chair use with very little downtime.
“We were able to better distribute activity throughout the day to accommodate increased patient volume. Our project decreased patient wait times and improved patient and staff satisfaction,” Ms Loninger told listeners at the 42nd annual meeting of the Oncology Nursing Society.
Before implementing the streamlining project, patient scheduling for infusions was clustered around peak times during the day, while the infusion center was empty at other times, including at the end of the day and on weekends. This led to increased wait times for patients, and frustration for patients and staff.
“We decided we needed to better distribute infusion chair use throughout the day to accommodate our increased patient volume. There were 4 main challenges: location, tradition, space versus volume, and scheduling,” Ms Loninger explained.
Challenges to the Streamlining Project
The infusion center at Langone is located in midtown Manhattan, and the majority of patients travel there from the outer boroughs of Manhattan, Long Island, upstate New York, New Jersey, and Connecticut.
“We have to consider city traffic, rush hour times, and costs for our patients,” she noted.
Tradition was the second challenge. Scheduling was being done by the office practice, with infusions scheduled around the physician’s appointment, which patients can come to at any time throughout the day. Ideally, patients would like to have all their visits scheduled for 1 day, including laboratory tests, blood draws, imaging, and x-rays.
“Infusion is usually the last stop. Delays at any of the previous stops create delays in the infusion center. We decided to provide all the infusion-related care in the infusion site,” Ms Loninger said.
Space versus volume was the third challenge. Outpatient volume had increased at Langone with the hiring of new physicians, whereas the space for the infusion center remained the same. In the past 3 years, patient volume increased by 29% to encompass 31,000 patients. The projected number of patients at the end of 2017 is 41,000, she said.
“Scheduling is the fourth challenge, and this is the key to all the other challenges,” Ms Loninger told the audience.
A review of scheduling showed that peak use of infusion chairs was between 10 am and 2 pm. The chairs were underused between 8 am and 10 am, and after 5 pm, as well as on the weekends.
“Our goal was to even this out and use all of our variable chair hours,” Ms Loninger said.
Nursing, administrative, and physician team leaders met to identify patients who could be safely treated without a coordinated physician’s visit on the same day. The next step was to create a fast track unit to accommodate short visits and to provide vascular device access and blood draws, injections, infusion pump disconnects, and dressing changes.
The third intervention was educating the infusion schedulers to identify uncoordinated physician visits and schedule infusions at off-peak times, including before 10 am, after 3 pm, and during weekend hours. Schedulers were provided with scripted answers to explain the new process to patients.
Progress to Date
As a result of these interventions, the number of patients seen before 10 am increased by 92%.
“We redistributed 48 hours of chair time per week to nonpeak hours by moving infusions that were not linked to the visit to the doctor. We opened a fast track infusion unit, resulting in a 12 hours per day reduction of lab draws, injections, and pump disconnects off of the 5th and 6th floors. We now accommodate 17% more patients. By August of 2016, we saw upwards of 500 patients, whereas we had only seen 415 the year before,” she stated.
In 2015, 54 patients were seen per week before 10 am, whereas now 106 patients are seen. After 2 pm, the average number of patients was 52 in 2015, and now it is 79.
“This project opened up other opportunities where improvements could be made. We require all orders to be signed prior to arrival at the infusion center. We have structured the scheduling process to place infusions of ≤2 hours after 2 pm for both coordinated and noncoordinated visits with the doctor. We hired a new infusion practice monitor and plan to increase fast track availability to 5 days per week from 4 days. And we added weekend staff,” Ms Loninger said.
“This is a work in progress. We are constantly tracking data with the goal to continue to provide world class care in the most efficient way possible,” she stated.