Initiatives Can Contain Costs and Increase Quality of Nursing Care

By taking the initiative and addressing concerns about patientcare and conservation of health-care resources, nursing staffat five cancer treatment facilities across the nation have hada positive impact on their environment, to the mutual benefitof staff, patients, and the bottom line.

The initiatives, ranging from methods to prevent patient fallsto 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 consumean estimated 2 billion health-care dollars nationwide each year,"said Laura Fennimore, MSN, RN, of the Pittsburgh Cancer Institute'sOncology Unit.

At her institution, intervention and prevention programs reducedpatient falls from an average of six a month to zero in November,1994. She said most literature on fall prevention points to raisingstaff awareness.

The initiative first identified high-risk patients. "Glioblastomapatients have an altered mental status, potential motor problems,and 3 days of continuous infusion with three pumps, which meansmany cords to trip over," Ms. Fennimore said. Also at riskare the elderly and those on narcotics and diuretics.

A number of methods (Table 1) were used to decrease the risk offalls by changing the patient's environment and by helping raisestaff, patient, and family awareness.

Preadmission Patient Education

At Westmoreland Regional Hospital, Greensburg, Pennsylvania, theCancer Care Services has developed a unique preadmission patienteducation program that conserves nursing staff time and inpatienthospital bed/outpatient treatment chair utilization.

"Education committee members and a rotation of interestedstaff members have budgeted time for the education program, andshare responsibility with the teaching RNs," Mary Lou Ferguson,RN, said. "Therefore, we can provide uninterrupted, qualityeducation 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 forthat time. "With its couches, TV, VCR, refrigerator, andcoffee pot, the lounge provides a relaxed, nonthreatening atmosphere,"said Pam Kiral, RN.

Each patient receives a file containing standard information onchemotherapy, equipment, home care aids, and support services,as well as specific information on disease treatment and drugregimens, all thoroughly reviewed by the RN. Patients also viewan informational video; and receives a tour of the facility.

Preventing Antibiotic Delays

The timely administration of antibiotics to febrile, neutropenicpatients became a multidisciplinary quality improvement initiativeat 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 initiatingantibiotics in accordance with standards of care. Analysis revealedthat physician noncompliance to those standards resulted fromlack of knowledge of departmental standards, and delays in patientassessment, writing orders, and notifying nursing staff of assessment.

Nursing noncompliance included omissions/delays in informing thephysician of temperature elevation, failure to intervene whena physician or house officer did not respond in a timely fashion,misunderstanding of the chain of command, unawareness on the partof nonprofessional staff as to what constitutes a fever or delayby 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 poorcommunication between physicians and nurses."

Faster Chemo Administration

At Lakeland Regional Medical Center, Florida, identifying avoidabledelays in initiating chemotherapy, and developing a multidisciplinaryquality management initiative for its administration, led to increasedproductivity and revenue, and decreased patient time, expense,and dissatisfaction.

Glenda Kaminski, RN, said that raising physician awareness, combinedwith uniformly spreading admissions through- out the week, improvedthe average time between patient examination and written chemotherapyorders arriving at the pharmacy from 1.8 to 1.5 hours.

Adding a fax machine and a clinical pharmacist dedicated to theunit reduced pharmacy delivery time from 2.9 to 0.9 hours, whilenurse awareness reduced the time between arrival of the chemotherapyat the unit and initiation of chemotherapy administration from1.4 to 0.7 hours.

According to the unit's new chemotherapy guidelines, most patientssee their doctor and have blood work done 2 days prior to treatment.The unit begins treatment and if lab work done that day comesback outside limits or drastically changed, the nurses are notifiedand receive appropriate instructions.

"We also initiated more protocols during the day shift toavoid shift-change delays and delays created by fewer eveningstaff," Ms. Kaminski said. "These and other protocolshave reduced the average time from patient admission to initiationof chemotherapy from 4.9 to 2.7 hours," she said.

Clinical Pathways

Clinical pathways designed and implemented at the Pittsburgh CancerInstitute for primary brain tumor patients receiving carmustine(BiCNU)/cisplatin (Platinol) are expected to result in an annualcost savings of $240,000 across 210 patient admissions, JoyceTokarsky, RN, MSN, said at the conference.

She recommends that institutions interested in developing clinicalpathways focus on high volume/high cost diagnoses or procedureswith poor outcomes.

At Pittsburgh, a multidisciplinary task force collected information,performed a critical analysis, and mapped out the care and resourcesrequired to manage a typical patient with a brain cancer diagnosis.

"When developing clinical pathways, determine what resourcesare absolutely necessary, and eliminate those that are not clinicallyappropriate 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. Dischargesmay also be held up by escort service delays and poor coordinationof physical therapy, radiation, and diagnostic studies. Communicationbetween departments is also important. "ICU and recoveryroom fees are a high price to pay for an occupied bed," shesaid.