By: Sarah Garrigues
Team Members: Anisia Dugala, Jennifer Hansen, Jillian Settlemire, Mohana Roy, Debbie Bergman, Michael Conte, Sarah Garrigues
Team Sponsor(s): Roni Brar, Vasu Divi
Patients with acute leukemia are some of our most vulnerable patients, especially shortly after discharge from the hospital when they are at risk of critically low blood counts. When these patients do not have outpatient follow-up scheduled shortly after discharge, they are at increased likelihood for poor outcomes, many which require rehospitalization if not addressed in a timely manner. Upon review of our patients’ discharge plans, we found many patients did not have a scheduled follow-up clinic or infusion appointments before they were discharged.
Primary Problem Causes:
Due to the pandemic and the fact that acute leukemia patients may be critically ill, Gemba walks were limited to two team members. We supplemented Gemba with zoom interviews that revealed many contributing issues. We found that there was neither a standard process nor an expectation to schedule prior to discharge an outpatient appointment in the Infusion Treatment Area (ITA) or the hematology clinic. Access to ITA appointments is limited, and team members trying to coordinate patients’ post-discharge care didn’t have direct phone lines to the schedulers. Outdated Epic pools and incomplete communication explaining a patient’s post-discharge needs contributed to messages being sent to the wrong people or requiring multiple back-and-forth messages to clarify scheduling requests. One notable example revealed that discharge coordination took 34 inbasket messages before the patient’s appointment was scheduled in the desired manner. Since the hematology service is run by housestaff who rotate frequently between services, if discharge care wasn’t successfully coordinated in the days leading up to a patient’s discharge, the scheduling of follow-up appointments slipped through the cracks and did not occur, leaving many patients vulnerable to clinical decline.
After our analysis we settled on a handful of key drivers including:
- Standard process for discharge communication between in- & out-patient teams
- Direct access to infusion treatment area (ITA) schedulers to secure appointments
- Escalation pathways when no appointment slots appeared to be available
- Education for the constantly changing trainees
The most impactful intervention was a customization of Epic’s discharge navigator to identify follow-up appointment needs and facilitate communication to the appropriate ITA and clinic pools to schedule post-discharge appointments. This Epic navigator can be viewed by multiple care team members and sends an auto-inbasket message with specific instructions to reduce back and forth messaging.
We also implemented new contact lists for each outpatient clinical team (sustained by a plan for continuous updates) and incorporated all new standard work into the resident and fellow training materials.
As a result of our interventions, we witnessed an increase in the percentage of acute leukemia patients who had outpatient follow-up within 5 days of discharge from 65% to 94%, and we have sustained this rate for 3 months.
Though our key intervention did not launch until right after the CELT program concluded, we continued to collect data for 3 months to monitor the proportion of patients who had timely post-discharge care scheduled in clinic or the ITA. We have witnessed sustained improvement far greater than the goal we set at the beginning of our project, which we credit to having implemented standard work and a technical solution that reduces EMR burden. Since the discharge navigator intervention lives in Epic, no additional IT support is required to adapt this intervention for the four other hematology-oncology inpatient services. The Cancer Quality Council has accepted the task of disseminating this intervention so that oncology patients on any of our services will have greater likelihood of timely outpatient follow-up.
In reflecting on our experience, here are our main takeaways:
- There is no one solution to a complex problem: we identified inconsistent processes, incorrect contact lists, and limited ITA and clinic access. Our solution had to be multifaceted.
- Inpatient teams often rely on rotating key players, who are often not connected to the outpatient teams (working in silos). Workflow standardization was one way we reduced variability in practice across all players.
- Interventions that reduce EMR burden are most likely to succeed.