Day care chemotherapy - Details of operational workflow and challenges

The workflow

When a patient is scheduled to receive chemotherapy, a predefined workflow is desired to make their day care journey smooth. It starts with an appointment, which should be fixed beforehand and adjusted for the availability of a bed slot in the day care ward. Appointment and bed allotment need proper handling. Many commercially available software programs are available which can be of help.^[3,4] It is equally useful to have a display of patient flow at a prominent place to guide subsequent visits.

Next on this journey, a patient arrived at the reception of the daycare facility. A trained first contact nurse will greet patients and conduct a comprehensive baseline survey, gathering detailed information about their health status and relevant reports. The fitness for receiving scheduled chemotherapy is not according to a fixed criterion, and acceptability varies from case-to-case basis and chemotherapy agents as well. This primary survey is being concluded with the remark categorized as “fit,” “review awaited,” and “probably unfit,” and sent to the medical officer. All cases will be reviewed by the medical officer and finalized in one of the categories. Once the patient is accepted for chemotherapy, a bed allotment, which is made provisional at the time of appointment, is given to him. This step of the first assessment has been noted to be a bottleneck, significantly contributing to prolonged stay in the day care unit. Aziz et al evaluated the time-consuming steps in chemotherapy day care and noted that the first assessment took more time, which was rectified by simply breaking it into two parts, segregating it into the first assessment, such as height, weight, and later assessment at the bedside, which includes checking vitals.^[5] That study also highlighted that increasing the number of nurses at the first assessment desk alone was not useful in reducing time.^[5] Similarly, interventions done at an ambulatory treatment center in the form of clubbing of vascular access and first assessment, rapid communication portal for confirmation of protocol, and pharmacy pre-intimation for medicines have shown a 15% reduction in waiting time.^[6] The bottleneck for the early disposal is different for every center, and it must be audited and rectified.^[7,8]

The next step involves making a chemotherapy protocol and the procurement of medicines. This step has been the most time-consuming. In a survey of day care patients, delays have been noticed in a subset of patients who are pre-scheduled without protocol details provided.^[6] In-house/nearby pharmacy is one of the options for reducing the delay, while pre-stocking chemotherapy based on appointments is also a feasible option. In a study from Kerala, India, major dissatisfaction was noted among patients for delays in pharmacy services and laboratory work. Pediatric sections showed poor ratings while oncologist consultation showed no dissatisfaction, probably related to bias by the patient or putting a higher value on consultation.^[9] The modern pharmacy, using updated informatics and storing medicines as per anticipated demands, is the need of the unit.^[10]

Chemotherapy mixing stations are an important place that needs special attention. As per recommendations, an isolated area with a laminar flow system is necessary.^[11] However, with the increasing cost of medicines and anecdotal reports of infringement, as a policy, keeping a glass partition so that attendants can see the mixing is a valid requirement.

The administration of chemotherapy needs well-trained staff and all the necessary equipment and medications (crash cart) to manage hypersensitivity reactions and immediate infusion-related adverse events. Although it is the most vital part and core of all the exercises being done in a daycare ward, it is also the simplest step to follow. Even though trained nurses are assigned to administer chemotherapy, a substantial gap persists in their knowledge and practice. An audit of nurses highlighted this gap, and the nurses expressed willingness to improve their skills.^[12] In a survey conducted in Turkey, nursing noncompliance with the drug order has been noted to be as high as 50.5%.^[13] After the chemotherapy administration, a relief check is conducted by the medical officer, and a discharge card is prepared. The discharge card should have a plan for the next visit date. A prior appointment can be made for his/her next visit at the time of discharge.

A follow-up call is an important part of running a busy day care. A pre-appointment call is being made by the coordinators to confirm patients’ attendance on the scheduled date. A WhatsApp (please mention that it’s an application used for communication) review of blood report done a day prior to the scheduled chemotherapy works like a screening measure, and it can reduce the delay as well. Two-day theory has been found to be effective in reducing the delay in day care functioning.^[14] A patient workflow has been a multi-prong exercise, as depicted in Figure 1.

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Figure 1:

Patient workflow in chemotherapy day care unit.

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Human resources

Chemotherapy day care requires multiple strata of employees to do the integrated but distinct functions [Table 1]. The medical officer is responsible for the patient assessment, making the chemotherapy protocol, supervising the administration, and ensuring patient well-being during their stay in day care. Additionally, he conducts discharge counselling. Apart from the above-mentioned roles, he/she must oversee the functioning of the unit. That person must be experienced and qualified to conduct all functions. There exists a necessity to specify the minimum academic qualification for this role, which remains poorly defined and shows considerable variation from one location to another. The chances of medication error have been noted to be as high as 283.5% [4253 errors in 1500 prescriptions] if we include errors of short form, brand names, and patient details, but 11.7% errors were noted to be of serious consequences.^[15] This error frequency is variable and under-reported.^[16,17] Usually, the oncologist takes the clinical round and takes charge of supervision of the unit. However, the appointed medical officer must be versed in oncology, chemotherapeutics, and management of its complications. MBBS is the minimum desired degree for such a post in India; however, years of experience are often sought while selecting for the post. A continuous medical education (CME) credit arrangement seems more reasonable to keep them updated and help in reducing errors.^[18]

Nurses are the main functionary in day care. The concept of team leader commanding and supervising the group of nurses is very useful and productive. Good teamwork is essential and has been found to be more efficient for patient care.^[19] Role and bed assignment make their duty perimeter clear and easy. Chemotherapy nurses are certified after completing certain training hours and several months of shadowing, with duration varying from center to center. Also, an adequate number of nurses is required not only to run the day care unit smoothly but also to prevent burnout. Prolonged duty hours are common in day care units, which in the long run, reduce individual and cumulative productivity and increase burnout.^[20] The standard operating system should include two shifts of nurses or extra perks of extended duty hours.

Pharmacists are equally important and vital to this unit. A trained pharmacist who has adequate training and experience in onco-therapeutics should be appointed in the daycare unit pharmacy and the mixing section. Drug mixing competency should be pre-defined as any error will make the administration faulty and hazardous. The role of pharmacists in day care units is expanding, and it has encompassed pre-treatment evaluation and post-treatment counselling as well.^[21] It opens new professional dimensions for pharmacists, but with the burden of shouldering more responsibilities. A software-based double-check mechanism and a clear standard operating procedure (SOP) for commonly used chemotherapeutics should be in place.

The daycare unit needs participation of staff at various levels, like housekeeping staff and pantry staff. Gatekeepers and security personnel are essential to manage the rush while coordinators streamline the daycare journey. The same importance lies with the billing staff and assistants/ward boys. A nurse team leader, a senior patient coordinator, and a support staff team leader should be responsible for the smooth functioning of their respective duties. To manage such large and variable staffing, supervisors at different levels are required.

All staff working at the day care unit need regular knowledge updates, daily operational meetings, feedback sessions, and an improvement agenda. It is useful to apply fish-bone analysis and the plan-do-study-act cycle for improvement in performance; other available tools can be used as well, based on the personal preference of the center.^[22] Self-appraisal has been proven to be effective for improvement. A proposed staffing and reporting algorithm has been depicted in Figure 2, which can be used as the guide.

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Figure 2:

Operational workflow and reporting system model in day care unit.

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Day care unit setup

Setting up a day care unit is of paramount importance, and it must be planned professionally. It can be broadly divided into patient care areas and caregiver stations. The patient care area includes the designated bed, side table, medication stand, and infusion pumps. A bedside monitor is desired, ideally for all beds, or must be available for at least 2 beds where the patient can be closely monitored in case of anaphylactic reaction or some emergent issue occurring during his/her stay in the day care. There is no standard recommendation for spacing between beds; however, overcrowding is neither aesthetically good nor acceptable as per infection control needs. Beds can be replaced by recliners, which utilize less space. Partition between beds can be secured by curtains or walls, while curtains are preferred by our unit as they take up less space and are functionally equal. A tentative design for a 12-bedded daycare chemotherapy unit has been proposed [Figure 3].

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Figure 3:

A model of 12 12-bedded day care chemotherapy unit. A= Toilet area, B=Storage area, C=First assessment area, D=Doctors station, E=Mixing and dispensing unit, F=Pharmacy, G=Isolation units, H=Crash cart area, I=Nursing stations, J=Waiting area, K=Pantry, P=patient’s bed.

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Caregiver stations typically include a front desk for patient welcome and initial assessments, a doctor’s desk, and a drug indenting computer site. Pharmacy and drug mixing stations should be in the vicinity, yet at some distance. Robust computer interlinking and a communication portal are crucial for seamless information flow and operational efficiency. The day care facility should have various components in the same unit setting, while many other facilities should be associated with it. Essential components have been represented in Figure 4.

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Figure 4:

Artistic impression of components of a chemotherapy day care.

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Daycare units should have separate areas for neutropenic cases. Hematological malignancy patients can have separate areas where neutropenic cases can be segregated. They must not be mixed with solid tumors, especially post-operative cases with wounds, fungating masses, or potentially infected cases. Similarly, pediatric cases need separate arrangements, for both infrastructure like weighing scale, sphygmomanometer, etc., as well as manpower, specially trained nurses for children’s vascular access. However, segregation is often not possible due to cost and other logistical limitations. Every attempt must be made to prevent the spread of infection by the daycare staff.

Nevertheless, essentials like exit safety, ventilation, fire safety, and building design should be as per the norms of the state. Discussion of those will not be covered in this manuscript.

Quality control and audit

No system is flawless, and sustained perfection is unrealistic. Quality control and audit are an essential part of the sustained functioning of a day care unit. Quality control is broadly divided into two areas, quality related to pharmacological services, like accuracy of drug dosing, administration, mixing error, and timing of infusion. While the other area is nonpharmacological quality, which includes time management in admission, indenting medicine, billing, discharge formalities, and counselling of discharge. Random case trial is an easy way to have an idea about quality control. Stratified sampling from the cases and their follow-up is another way. Quality checks based on the feedback are also practically easy and most practiced.^[23-25]

Audit of medicine and paperwork, billing amount, time on bed, time lag per case, and hours in hospital shed some light on the efficiency of the unit. Audit of a hematological day care noted administration delay due to institutional causes, like ordering a test or X-ray in between. Audit also identified improper documentation of reasons for dose modifications and proposed an automated granulocyte-colony stimulating factor administration protocol at a certain threshold, which could be beneficial.^[26] Weekly audit of one section of the day care unit is advisable, while monthly cumulative audit reporting has been practiced. Studies have shown significant improvement in functioning while doing stringent auditing and acting on it.^[27-29]

Vision for the future

The chemotherapy day care unit is a unique place of rapid transit for many patients and caregivers. Utilizing this as a relatively receptive area for health education seems a good approach. Cancer screening information, preventive approaches, good healthy habits, and education about care during and after chemotherapy can be easily implemented in a day care. A simple digital screen depicting smoking side effects and a request to quit smoking might change the individual’s perception of it.^[30] Similarly, dietary advice during chemotherapy can be displayed either digitally or by posters placed at various places. Information about preventive oncology, like the human papillomavirus vaccine for adolescent girls, is likely to receive more attention in a day care setting.

The other area of improvement is to apply think lean philosophy. This philosophy is a business model which insists on making operations simple, as simple as it could be by arranging the pharmacy, drug mixing facility, and billing desk near the day care unit. Centers, including ours, are already using the think lean philosophy; however, it can be further improved.^[31] Strict adherence to time slots and making sure the availability of drugs in advance is desirable.

Some situations are exceptional, such as elderly people finding it challenging to commute to the chemotherapy day care ward, particularly in the absence of family assistance. The question of home-based chemotherapy is a topic of debate, and probably the administration of simpler and shorter chemotherapy can be organized at home.^[32]