By taking the initiative and addressing concerns about patient
care and conservation of health-care resources, nursing staff
at five cancer treatment facilities across the nation have had
a positive impact on their environment, to the mutual benefit
of staff, patients, and the bottom line.
The initiatives, ranging from methods to prevent patient falls
to improvements in the administration of antibiotics and chemotherapy,
were presented at the Fifth Annual Pittsburgh Cancer Conference.
"Patient falls, a major threat to quality of care, also consume
an estimated 2 billion health-care dollars nationwide each year,"
said Laura Fennimore, MSN, RN, of the Pittsburgh Cancer Institute's
At her institution, intervention and prevention programs reduced
patient falls from an average of six a month to zero in November,
1994. She said most literature on fall prevention points to raising
The initiative first identified high-risk patients. "Glioblastoma
patients have an altered mental status, potential motor problems,
and 3 days of continuous infusion with three pumps, which means
many cords to trip over," Ms. Fennimore said. Also at risk
are the elderly and those on narcotics and diuretics.
A number of methods (Table 1) were used to decrease the risk of
falls by changing the patient's environment and by helping raise
staff, patient, and family awareness.
Preadmission Patient Education
At Westmoreland Regional Hospital, Greensburg, Pennsylvania, the
Cancer Care Services has developed a unique preadmission patient
education program that conserves nursing staff time and inpatient
hospital bed/outpatient treatment chair utilization.
"Education committee members and a rotation of interested
staff members have budgeted time for the education program, and
share responsibility with the teaching RNs," Mary Lou Ferguson,
RN, said. "Therefore, we can provide uninterrupted, quality
education at no extra cost to hospital or patient."
Patients' physicians provide the unit with pertinent information.
An RN schedules the patient and, if possible, a family member,
for a 1- to 2-hour session, and reserves the patient lounge for
that time. "With its couches, TV, VCR, refrigerator, and
coffee pot, the lounge provides a relaxed, nonthreatening atmosphere,"
said Pam Kiral, RN.
Each patient receives a file containing standard information on
chemotherapy, equipment, home care aids, and support services,
as well as specific information on disease treatment and drug
regimens, all thoroughly reviewed by the RN. Patients also view
an informational video; and receives a tour of the facility.
Preventing Antibiotic Delays
The timely administration of antibiotics to febrile, neutropenic
patients became a multidisciplinary quality improvement initiative
at the Albert Einstein Cancer Center, Montefiore Medical Center,
A threshold of 95% compliance to standard of care was established,
and initiatives raised the rate of compliance from 60% in February,
1994, to 100% in September, 1994, Carol Sheridan, RN, MSN, OCN,
said at the meeting.
Infection control nurses recorded data regarding delays in initiating
antibiotics in accordance with standards of care. Analysis revealed
that physician noncompliance to those standards resulted from
lack of knowledge of departmental standards, and delays in patient
assessment, writing orders, and notifying nursing staff of assessment.
Nursing noncompliance included omissions/delays in informing the
physician of temperature elevation, failure to intervene when
a physician or house officer did not respond in a timely fashion,
misunderstanding of the chain of command, unawareness on the part
of nonprofessional staff as to what constitutes a fever or delay
by nonprofessionals in notifying a professional of febrile conditions,
and inexperience of new nurses in antibiotic administration.
"We have successfully addressed many of these problems,"
Ms. Sheridan said. "However, over and over, we find poor
communication between physicians and nurses."
Faster Chemo Administration
At Lakeland Regional Medical Center, Florida, identifying avoidable
delays in initiating chemotherapy, and developing a multidisciplinary
quality management initiative for its administration, led to increased
productivity and revenue, and decreased patient time, expense,
Glenda Kaminski, RN, said that raising physician awareness, combined
with uniformly spreading admissions through- out the week, improved
the average time between patient examination and written chemotherapy
orders arriving at the pharmacy from 1.8 to 1.5 hours.
Adding a fax machine and a clinical pharmacist dedicated to the
unit reduced pharmacy delivery time from 2.9 to 0.9 hours, while
nurse awareness reduced the time between arrival of the chemotherapy
at the unit and initiation of chemotherapy administration from
1.4 to 0.7 hours.
According to the unit's new chemotherapy guidelines, most patients
see their doctor and have blood work done 2 days prior to treatment.
The unit begins treatment and if lab work done that day comes
back outside limits or drastically changed, the nurses are notified
and receive appropriate instructions.
"We also initiated more protocols during the day shift to
avoid shift-change delays and delays created by fewer evening
staff," Ms. Kaminski said. "These and other protocols
have reduced the average time from patient admission to initiation
of chemotherapy from 4.9 to 2.7 hours," she said.
Clinical pathways designed and implemented at the Pittsburgh Cancer
Institute for primary brain tumor patients receiving carmustine
(BiCNU)/cisplatin (Platinol) are expected to result in an annual
cost savings of $240,000 across 210 patient admissions, Joyce
Tokarsky, RN, MSN, said at the conference.
She recommends that institutions interested in developing clinical
pathways focus on high volume/high cost diagnoses or procedures
with poor outcomes.
At Pittsburgh, a multidisciplinary task force collected information,
performed a critical analysis, and mapped out the care and resources
required to manage a typical patient with a brain cancer diagnosis.
"When developing clinical pathways, determine what resources
are absolutely necessary, and eliminate those that are not clinically
appropriate or do not contribute to enhancing clinical outcomes,"
Ms. Tokarsky said.
She also advised reviewing system procedures; a late discharge,
for example, increases costs and delays admissions. Discharges
may also be held up by escort service delays and poor coordination
of physical therapy, radiation, and diagnostic studies. Communication
between departments is also important. "ICU and recovery
room fees are a high price to pay for an occupied bed," she