Click icon to add picture Click icon to add picture Successful Development of a Hospital-Based Outpatient Apheresis Program 03/13/2019 Patricia Miles BSN, RN, OCN | Delight Joslyn MSN, RN, OCN, CRNI, CPHON Shannon Jagger BSN, RN-BC
Therapeutic Apheresis • Therapeutic apheresis is a treatment that cycles patient blood to remove an offending substance from the body. • Apheresis is used to treat many different autoimmune, neurologic, and blood-related diseases • Having the ability to perform emergent apheresis can save lives. | 03/1
Therapeutic Apheresis • Apheresis is a service that has proudly been performed at Northern Light Eastern Maine Medical Center (NL EMMC) for many years. • Over the last several years, use of this intensive treatment option has rapidly increased at the hospital. • Despite the increasing numbers, in 2017 the service was on the brink of collapse for | 03/1 a variety of reasons.
Historical Perspective… • Dated Equipment • Training • Treatments limited to TPE and leukodepletion • Space/room availability constraints • Per diem staffing model | 03/1
Equipment Impacts Prior to 2018, COBE Spectra was the machine of choice for apheresis treatments. EMMC had 2 COBE Spectra machines. 1 Spectra Optia machine was in use. New staff were being trained to Spectra Optia. • In 2017, learned that COBE Spectra being “sun- downed” by company in 2018 • Needed to get FDA approval for WBC depletion on Spectra Optia • Staff turnover influenced pool of people able to | 03/1
Training Impacts New staff were being trained to Spectra Optia “on- the-job” • No formal training process or documentation of competency • Voluntary participation • Relied on staff report “feel” ready | 03/1
Treatment Options Treatment options were limited • Therapeutic plasma exchange • WBC depletion • Limited to dialysis/plasmapheresis dual lumen short or long-term catheters | 10/2
Space Constraints Limited availability of bed • Day to day challenges of bed management • • Frequently moved around • Not patient conducive • Limited resources and supplies available to staff performing treatment | 03/1
Development of Business Plan | 03/1
Business Plan Leadership Sponsor: Deborah Sanford MBA, MSN, RN, Vice President of Nursing and Patient Care Services Leadership Team: Tina Scott MSN, RN, Medical-Surgical Service Line Director • Kael Mikesell DO, Director of Blood Management • Patricia Miles BSN, RN, OCN, Nurse Manager • Shannon Jagger BSN, RN-BC, Assistant Nurse Manager • Delight Joslyn MSN, RN, OCN, CRNI, CPHON, Staff Nurse I • Cheryl Levesque CPA, Director of Nursing and Clinical Finance • Laurie Damon PMP, Process Improvement Specialist • | 03/1
Business Plan Leadership Apheresis Team: Angela Stanoch BSN RN OCN Staff Nurse I G6 • Sandy White BSN RN OCN Staff Nurse I G6 • Ashley Bradley BSN RN Staff Nurse G6 • Meghan Pardy BSN RN Staff Nurse G6 • Rebecca Julian BSN RN Staff Nurse G6 • Brianna Speed BSN RN Staff Nurse G6 • Victoria Hill BSN RN Staff Nurse G6 • Delight Joslyn MSN RN OCN, CRNI, CPHON BSN RN Staff Nurse I/Apheresis Coordinator G6 • | 03/1
Review Process (BCOR-Business and Clinical Opportunity Review) Months of preparation (Weekly meetings with key stakeholders) Business QUAD development Business Plan development Opportunities Business justification • • Justification Clinical justification • • Schedule Financial assumptions • • Finances Exit Strategy • • | 03/1
Hematology/Oncology Specialty Treatment Services | 03/1
Business Justification Pediatric and Adult Apheresis treatments have increased at • EMMC over the last several years. Lack of dedicated space resulted in decreased bed availability for • inpatient admissions during the time of an outpatient treatment. It is important for EMMC to maintain a hospital run apheresis • program as it is the only hospital in central and northern Maine doing so. Maintaining a program in this geographic region enhances • alignment and continuity of care with the primary care community closer to home for patient and their families. | 03/1
Clinical Justification Apheresis is used to treat many different potentially life- • threatening pediatric and adult diseases. Having the ability to perform emergent apheresis can, and does, save lives. Reliance on “off duty” staffing model put the urgency of • treatment at risk, affecting patient satisfaction, safety, and quality of care for patients. 2/3 apheresis machines at EMMC were retiring by June 1, 2018. • An additional apheresis machine was needed to continue treatments. Structured program for annual competency of nurses and • providers needed to be reviewed/developed. Increased demands and types of treatment required training of • | 03/1 additional staff .
Financial Considerations • Dedicated space/construction cost • Cost of machine • Cost of annual maintenance • Anticipated future volume • Staffing • Educational needs | 03/1
Exit Strategy • Movement of outpatient services off-site • Impact on urgently needed inpatient treatment o Equipment availability o Staff competency----”low volume, high risk” • Contracted services • Transport to other facilities (i.e. out-of- | 03/1 state)
Approval of Business Plan • Dedicated room • Acquisition of new equipment • Daily staffing commitment • Staff Education and Training | 03/1
Space and Equipment | 03/1
Dedicated Space/New Equipment Patient-friendly • environment Ease of access • Enhanced • availability of resources and supplies Infection Control • Review/Risk | 10/2 Assessment
Staffing Model | 03/1
Staffing Model Prior to 2018, staffing for apheresis was done on a per diem/on call basis. • Relied on staff to respond to text/calls to come in as needed any day, any night • Weekend scheduling challenging • Difficult to coordinate with line placement • Staff turnover influenced pool of people to be available | 03/1
Staffing Model: Current state Apheresis nurse is assigned to treatment room 620 on a daily basis: An apheresis trained nurse is always assigned to room 620 – 7 • days a week, 12 hours a day. The assigned Apheresis nurse is a staff nurse, and has the ability • to flex back into direct patient care staffing in the event no apheresis treatments are scheduled that day. This has allowed us to more quickly and efficiently schedule • patients. Provider awareness that if a patient needs treatment a nurse will • always be available Increase in staff desire to become apheresis trained • Retention of apheresis nurses | • 03/1
Scheduling/Calendar Development: Transition to new model Starting February 2018 treatments Scheduling calendar current state: were scheduled via outlook Apheresis nurses have read/write • Calendar access to scheduling calendar Calendar was created via outlook • Daily apheresis nurse will update • and Assistant Nurse Manager calendar and schedule would enter all treatments and bill appointments for all treatments Apheresis nurses bill for each • Calendar was in read-only view for • treatment same day and update all apheresis nurses “billing complete” on the calendar Printed version was placed in • charge book every Friday | 03/1
Staff Development/Competency | 03/1
Staff Development to support the new model • On-site formal training of additional staff during the fall of 2017 by Terumo • Developed competency for documentation of performed treatments/transition to independence • Training provided by Terumo to perform RBC Exchange on the Spectra Optia • Staff trained to perform apheresis via Vortex and PowerFlow Apheresis ports or peripheral access | 03/1
Staff Development to support the new model • On-site staff training on apheresis adverse reactions by the Medical Director • Skype training for leuko-reduction in November 2018 • Policy development/revisions with staff input regarding care and management of the patient undergoing apheresis treatment • Development/documentation of SOP’s for each type of treatment | 03/1 Apheresis Resource Manual created
Staff Development Impact Expanded treatment options Red blood cell exchanges • Expanded options to provide • service to patients with port access Treatment also provided to • patient with triglycerides>5000 | 03/1
Community Outreach Enhanced collaboration with • Neurology, Adult Hematology and Oncology, Pediatric Hematology and Oncology EMMC Apheresis Program • “In the News” Website Development • Dedicated Phone/Fax line • | 03/1
Outcomes What does it all mean? • Increased patient satisfaction • Increased efficiency • Increased treatment options • Increased availability of scheduling • Increased volume • FY 2019-Q1 | 102 Treatments!!! 03/1
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