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Nursing

DEPARTMENT  OF  NURSING    

Kim  P.  Holt,  BSN,  RN,  CPN Nurse  Manager

Ambulatory  Infusion  Center

Developing a Successful Pediatric Ambulatory Infusion Center:

From Concept to Expansion & Beyond

Objectives  1.  Identify essential elements to consider when

developing a pediatric Ambulatory Infusion Center

2.  Describe unique considerations for daily operations of a pediatric Ambulatory Infusion Center

3.  Identify strategies to enhance operations & promote success in a pediatric Ambulatory Infusion Center

Infusion Centers are a subspecialty in Ambulatory that offer accessible, cost-effective care for patient’s with acute illness or chronic disease. By implementing key strategies, Infusion Centers can provide safe, efficient, high-quality, evidence-based care that results in positive outcomes.

Ambulatory Infusion Center Background •  Patient throughput project

•  >900 outpatient infusions occurred in an inpatient setting

•  300 outpatient infusions occurred in a surgery/procedural area

•  >1200 missed opportunities for inpatient admit or procedure

•  Consolidate infusion services into one outpatient location

ü Allergy/  Immunology  ü Bariatric  Surgery  ü Dermatology  ü Endocrine  ü Gene8cs  ü Gynecology  ü Nutri8on/  GI    

ü Neurology  ü Pulmonary  ü Renal  ü Rheumatology  ü Transplant  services  ü Infec8ous  Disease  

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Ambulatory Infusion Center History

•  October 2006: opened with 8 chairs + 1 private room in the hospital (2500 sq ft/ capacity= 9). Minor renovations to existing space

•  May 2010: relocated to the outpatient building & expanded to 10 chairs + 1 private room (3300 sq ft/ capacity= 11). Major renovations to existing space

•  March 2011: opened 2nd center with 4 chairs, 2 private rooms & an open area (living room) with capacity for 6 at TCH West Campus (3900 sq ft/ capacity= 12). New construction

•  FY2013: Pavilion for Women Infusion Center to open with 5 chairs New construction

Measurable Outcomes

•  Throughput optimized ð  Better use of existing capacity

•  Financial opportunities maximized ð  Lower costs/ increased revenue

ð  Increased billing compliance & denials minimized

•  Operations enhanced ð  Increased efficiency & staffing effectiveness

ð  Decreased length of stay

•  Consistent standard of care ð  Positive outcomes for patients & the organization

ð  Improved risk management

•  Increased patient satisfaction ð  Timely, efficient infusion therapy

Essential Elements v  Strategic assessment

•  Current infusion process

•  Organizational priorities

•  Expansion opportunity/ combination of services

•  Resources/ experts

•  Reimbursement issues/ concerns

•  Market assessment

•  Existence of “competitors”; range of services available

•  Recent changes

•  Potential challenges/ advantages

•  Risks/ benefits (quantify)

Internal

External

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Essential Elements  

v Project Implementation

•  Objectives/ Goals/ Priorities

•  Organizational structure

•  Project members

•  Project plan

•  Timeline & budget

•  Marketing plan

•  Scope of Services

ð Services offered

ð Capacity/ volume projections

ð Limitations/ exclusions

ð Staffing mix/ plan

ð Referral/ scheduling process  

Essential Elements  

v Space/ Design

•  Desired capacity •  Renovations or new construction •  Best-practice design standards •  Proximity to ancillary services •  Type/ layout of environment •  Workflow •  Non-patient care areas

•  Regulations/ Accreditation ð Federal/ State/ Local ð CMS (Medicare/ Medicaid) ð The Joint Commission ð OSHA/ United States

Pharmacopeia (USP) ð Internal: Facilities, Compliance,

Legal, Safety/ Infection Control

Essential Elements

v Human Resources •  Complexity of services

•  State board requirements

•  Qualifications/ experience

•  Training/ competency

•  Physician supervision (“incident to”)

•  Management (typically nurse managed)

•  Resources/ Technology

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Considerations for Daily Operations

v Staffing •  Staff mix

•  Volume/ Acuity/ workload

•  Emergency needs

•  Manager staffing expectations

•  Physician supervision (availability)

•  Physical layout/ workflow (direct observation vs closed-door)

Considerations for Daily Operations  

v Appointment Scheduling •  Patient initiated or limited to referring provider

•  Treatment versus chair time

•  Difficult to master scheduling of chairs

•  Mismanaged schedule à delays

•  10%- 20% urgent walk-in appointments

•  Benefits requirements (precert/ prior authorization)

Considerations for Daily Operations

v Orders/ Protocols/ Documentation •  Various therapies/ services

•  Reoccurring treatment

•  Order process (requesting/ receiving/ storage)

•  Billing/ reimbursement requirements

•  Nursing documentation

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Considerations for Daily Operations

v Billing issues/ concerns •  Frequent changing codes & guidelines (CPT, HCPCS)

•  COMPLICATED rules with specific criteria/ requirements

•  Payer practices & reimbursement policies

•  Capturing/ recording all services provided

•  Urgent medically necessary visits

Considerations for Daily Operations  

v Miscellaneous •  New technology

•  New drugs

•  Pharmacy

o  Inventory management (lead time to order/ storage)

o  Expensive, hard to obtain drugs/ Non-formulary

o  Preparation requirements/ time

o  Payer practices (specialty pharmacy)

Strategy  to  Improve  Efficiency  v  Space Design/ Layout

•  Incorporate best-practice/ evidence-based design standards ü Open layout

–  Timely detection of problems / diversion of untoward events

–  90% of drugs require frequent / continuous monitoring

ü Research shows patients prefer an open layout

–  Study revealed 97% prefer direct observation

•  Integrate workflow in the design

•  EMR workstations throughout space &/or on wheels

•  Identify services to consolidate (space redundancies eliminated & â costs)

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Space/  Square  Footage  Initial Space/ Capacity= 9

New space

Blank canvas

Supply/ equip/ med storage

utility

Weigh/ measure

Nurse

Offi

ce

Private room

8 open infusion bays

Entrance Pharmacy 5 floors up (9th floor)

Pharmacy

= P-tube

Ini8al  Space  Capacity=  9  

                                     

       

                                 

 Nurses Station

 

       

New  Space/  Capacity=  11    Open  Concept    10  infusion  bays  +  1  Private  Room  

Patient Restroom

Staff Restroom

Waiting area Manager Office

Lounge

Supply/ Equiq Med storage Soiled

Utility

Nourishments

Private Room

Entrance

= P-tube = Pass-through

window

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Open  Infusion  Bay  

Workspace  between  Infusion  Bays  

Central  Nurses  Sta8on  

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Mixed  Concept  Infusion  Center  TCH  West  Campus  

                     

                 

         Open    Living  Room  (6)        

   Closed    Private  Rooms  (2)  

                       

                 Open    

 Infusion  Bays  (4)    

Nurses    StaFon  

     

Restroom

Restroom

Storage

Waiting Room

Work area

Open  Concept-­‐  Living  Room  

Open  Concept-­‐  Infusion  Bay  

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Closed-­‐  Private  Infusion  Rooms  

Strategy to Improve Efficiency

v Scheduling Process •  Centralize scheduling/ benefits process

•  Schedule chairs based on ordered treatment

•  Standardize visit types ü Identify length of each visit by drug (chair time)

ü Include preparation, treatment and post observation time

ü Assign visit types based on drug/ length of visit (IV3, IV4, etc)

•  Dedicated person to review medical necessity

•  Create resources for schedulers & update regularly

•  Review orders 24-48 hours in advance

•  Track length of stay & turnaround time/ delays

Visit  type  resource  for  Schedulers  

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Visit  type  resource  for  Schedulers  

Coding  Resource  for  Schedulers  

Drug  Resource  

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Turnaround  8me/  Delays  

Turnaround  Time/  Delays  

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

FY07- FY10 Patient Experience- treatment started within 1 hr

Performance Goal

Exclusion criteria identified

First full month of stims

Satellite renovations

Strategy to Improve Efficiency

v Staffing •  Conduct time-study

•  Identify workload per treatment

•  Assign acuity based on workload

•  Create custom staffing/ acuity tool

•  Test/ validate tool and adjust as needed

•  Incorporate occupancy (chair time) to identify trends

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Customized daily staffing/ acuity tool

Staffing  Tool  

Monthly  Summary  

Daily  Infusion  Chair  Occupancy  

0%

21%

41%

62%

82%

103%

123%

144%

165%

8/1/

2011

8/

2/20

11

8/3/

2011

8/

4/20

11

8/5/

2011

8/

6/20

11

8/7/

2011

8/

8/20

11

8/9/

2011

8/

10/2

011

8/11

/201

1 8/

12/2

011

8/13

/201

1 8/

14/2

011

8/15

/201

1 8/

16/2

011

8/17

/201

1 8/

18/2

011

8/19

/201

1 8/

20/2

011

8/21

/201

1 8/

22/2

011

8/23

/201

1 8/

24/2

011

8/25

/201

1 8/

26/2

011

8/27

/201

1 8/

28/2

011

8/29

/201

1 8/

30/2

011

8/31

/201

1

Daily occupancy rate Goal

*average industry standard is 80% productive time per chair

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Strategy  to  Improve  Efficiency  v  Standardize Orders/ Documentation

•  Establish an acceptable timeframe for reoccurring orders

•  Incorporate common orders (procedural pain prevention, flushes, pre-meds)

•  Create protocols for adverse event management

•  Standardize documentation per billing requirements

Standardized  Orders    (currently  43  protocols)  

Infusion/  Injec8on  Documenta8on  &  Billing  

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Strategy to Improve Efficiency

v  Standardize Patient Education

•  Develop process for creating handouts/ resources

•  Involve staff in creation of patient education

•  Develop a standard curriculum for pt education (injection teaching)

•  Standardize documentation of patient education

Standardized  Pa8ent  Educa8on      37  drugs  1  generic  infusion    1  generic  injec1on            

Standard  Curriculum  for  Injec8on  Teaching  

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Strategy to Improve Efficiency

v Technology •  Venous access assistive devices

•  Vein Illumination Device

ü  Improved first attempt success rate

ü  Decreased number of attempts

ü  Decreased costs and nursing time

Vein  Illumina8on  Study  Results  

Primary  Outcomes:  ü 1st  a^empt  success  rate  increased  by  5%  (85%  to  90%)  ü Number  of  a^empts/pa8ent  reduced  from  1.27  to  1.14  

Secondary  Outcomes:  ü  3  or  >  a^empts  decreased  by  4%  (6.3%  to  2.3%)  ü  Reduced  costs  of  labor  &  supplies  by  $4.25  per  paFent  (>

$19,000  annual  savings)    ü  Anecdotal  reports  of  increased  sa8sfac8on  

3 or > attempts

(with device)

Experimental

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PURPOSE: assess impact of a vein illumination device on first attempt success rate & number of attempts required for insertion of a peripheral intravenous (IV) catheter in pediatric patients

Vein illumination: •  Improves 1st attempt success •  Decreases number of attempts •  Preserves veins •  Increases efficiency &

proficiency •  Ensures proper & efficient use of

resources •  Decreases unnecessary &

costly procedures •  Improves satisfaction

Study  Implica8ons  

•  Decreases costs

•  Enhances the IV experience

•  Promotes building of trust, cooperation & confidence

•  Supports high-quality care & outcomes

•  Complies with practice standards

Summary of Strategies for Success

v Evidence-based concepts •  Space design

•  Technology v Standardize / Customize

•  Visit types •  Scheduling/ Benefits verification

•  Billing

•  Identifying staffing needs (acuity tool)

•  Orders

•  Documentation (critical for reimbursement)

•  Patient education

Additional Strategies for Success v Recruit the “right” staff

•  Maximize experience

v Facilitate development of experts •  Designate staff to specific tasks

v Market your services •  If you build it they will come, BUT only if they know about it •  Remain alert to changing needs

v Develop collaborative partnerships •  Pharmacy •  Referring services/ physicians •  Home Health

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1243   1454  1923  

2259  

3024  164  

349  

258  

210  

221  

156  

378  

441  

471  

567  

50  

550  

1050  

1550  

2050  

2550  

3050  

3550  

FY07   FY08   FY09   FY10   FY11  

Infusions   Blood  Transfusions   S8mula8on  Test  

20.2%  á  

30%  á  

1563  visits   2181  visits   2622  visits   2940  visits   *3813  visits  

Top  3  infusion  visits:  1.  Steroids  2.  Biologics  (MoAbs;  IVIG)  3.  Enzyme  Replacement  Therapy  

*full  year  in  expanded  space  

39.5%  á  

12%  á  

FY2012  acFvity=  4,581  visits:    (25%  á)  v  Infusions=  3,917  v  Blood  Transfusions=  127  v  S8mula8on  Tests=  537  

System-­‐wide  Infusion  Services  Growth  

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