Initiatives Can Contain Costs and Increase Quality of Nursing Care

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 Oncology Unit.

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 staff awareness.

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, Bronx, NY.

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, and dissatisfaction.

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

Clinical pathways designed and implemented at the Pittsburgh Cancer Institute for primary brain tumor patients receiving carmustine(Drug information on 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 said.