ACE in the Hole: Reducing Patient Wait Times in the Infusion Room

As presented at the 2017 Oncology Nursing Society Annual Congress, nurses at Johns Hopkins Hospital developed a plan to reduce the patient's waiting time in the infusion chair.

Mary Beth Collins, MSN, RN

Along with the many challenges that come with cancer treatment, having to wait a long time in the infusion chair before receiving chemotherapy or other anticancer IV medications should not be one of them. A team of nurses at Johns Hopkins Hospital stepped up to the challenge and developed an action plan to address the problem with a focus on mixing standard chemotherapy doses ahead of time and prescreening patients before their infusions to make sure they’re appropriate to treat the next day.

And vital to this effort, according to participants, is the expert guidance on workflow provided by an “ACE” interprofessional team of experienced nursing and pharmacy staff.

Mary Beth Collins, MSN, RN, presented the findings of the ACE (Ambulatory Clinical Evaluation) project during a podium presentation entitled “Improving Patient Outcomes—It’s All About Teamwork” at the 42nd ONS Congress held May 4-7 in Denver.

The project is an outgrowth of Hopkins nursing staff’s longstanding interest in improving the patient experience in the ambulatory setting and especially on reducing patient infusion wait times to no more than 30 minutes beyond the patient's scheduled appointment.

When nurses had begun closely examining the problem during the period November 2014 to October 2015, they found a range of wait times, from 0 to a maximum of 525 minutes, and a mean wait time of 48 minutes.

In addition, they discovered that preparation for next-day patient visits was inconsistently performed by the patients’ primary nurses, and in the absence of a structured process for prescreening patients for their infusion, pharmacy staff was reluctant to prepare the drugs ahead of time.

Primary nurses at Hopkins took a number of steps to improve the process with the help of the 4-member ACE team of veteran nurses and pharmacists to facilitate care coordination, including:

  • A requirement that treatment orders and notes are submitted 48 hours in advance of the patient’s appointment
  • The ACE team also reviews the patients’ treatment orders and notes, as well their laboratory values.
  • Patients are telephoned at home 1 day before their scheduled appointment, using a standardized, checklist specific to the drug to find out if the patient is fit for the planned treatment.

For example, a patient scheduled for an adriamycin/cytoxan infusion would be asked questions about symptoms like shortness of breath, abnormal heart rate, ringing in the ears, any falls, swelling, or rashes, and their eating and drinking.

If this review is successful, chemotherapy mixing orders are sent to the ACE pharmacy team for a second safety review. This enables some drugs to be prepared the evening before the patients’ scheduled infusion appointments the next day.

Staff also has developed a list of ACE drug eligibility with a timetable for how long certain drugs can be prepared in advance. This is based on whether they are extended stability (eg, bendamustine [can be mixed the evening before with overnight storage in a refrigerator]), or short stability (eg, bortezomib, for compounding 2 hours before the drug is due to be administered and has an expiration of 4 hours).

"The ACE program has changed the treatment experience for providers, nurses, and most importantly our patients,” reported Collins. “It has significantly reduced patient wait time from a baseline of 49.7 minutes to 32.7 minutes post the ACE intervention."

Other benefits of the program include "ensuring quality, value, and a patient-centered experience," and Collins credits this to the ACE's standardized approachfor evaluating patients before treatment.

She added that these improvements were achieved without the addition of full-time equivalent staff.

"Interprofessional collaboration promotes trust, communication, and teamwork, confirming safe handoffs and preventing errors," Collins concluded, stressing, “it is important not to underestimate the value of collaboration with our pharmacy colleagues.”