Discharge Process for Inpatient Hematology and Oncology Using Plan-Do-Study-Act Methodology Improves Follow-Up and Patient Hand-Off

Abstract

Background: Hematology and oncology patients represent a complex population that requires timely follow-up to prevent clinical decompensation and delays in treatment. Previous reports have demonstrated that follow-up within 14 days is associated with decreased 30-day readmissions, and the magnitude of this effect is greater for higher-risk patients. This project was designed to standardize the discharge process with the primary goal of reducing average time to hematology and oncology follow-up to < 14 days.Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team of hematology and oncology staff developed and implemented a standardized discharge process. Rotating resident physicians were trained through online and in-person education. Additional interventions included the development of a discharge checklist handout, and a clinical decision support tool including a note template and embedded order set. All patients discharged during the 2-month period before and after the implementation of the standardized process were evaluated. Follow-up appointment scheduling data and commu-nication between inpatient and outpatient providers were reviewed. Results: A total of 142 consecutive patients were reviewed. The primary endpoint of time to hematology and oncology follow-up appointment improved from a mean 17 days prior to intervention to 13 days in PDSA cycles 1 and 2 and 10 days in PDSA cycle 3. The target of 14-day average time to followup was achieved. Furthermore, the upper control limit decreased from 58 days at baseline to 21 days in PDSA cycle 3, demonstrating a decrease in variation. Electronic alerting of outpatient hematology and oncology providers to discharge summary increased from 20% before the intervention to 62% after the intervention (P = .01). Conclusions: This quality initiative to standardize the discharge process for the hematology and oncology service decreased time to hematology and oncology follow-up appointments, improved communication between inpatient and outpatient teams, and decreased process variation. Timelier follow-up for this complex patient population will prevent clinical decompensation and delays in treatment.

Predictors of Frequent Emergency Department Visits among Hospitalized Cancer Patients: A Comparative Cohort Study Using Integrated Clinical and Administrative Data to Improve Care Delivery

“…This nding might be related to the implementation of standardized care pathways that include discharge planning and better follow-up protocols. 49,50 Previous studies have found opioid dose to be associated with increased risk of long-term opioid use and its associated adverse events [51][52][53] While our ndings showed that initial doses of dispensed opioids did not exceed recommended thresholds and did not lead to increased risk of FED 54 , a longer follow-up window may be needed to accurately re ect the role of opioid dose on the risk of FED use. Over time patients may add several medications to maximize pain control, accumulating longer use over time [55][56][57] , which could consequently result in increased risk of opioid-related morbidity and healthcare utilization.…”

Predictors of frequent emergency department visits among hospitalized cancer patients: a comparative cohort study using integrated clinical and administrative data to improve care delivery

“…For example, we found that the receipt of any type of surgery, was associated with a decreased risk of FED use. This finding might be related to the implementation of standardized care pathways that include discharge planning and better follow-up protocols [ 52 , 53 ]. However, this finding may be a reflection of having patients in the study cohort that are at an early stage of their cancer disease and, thus, excluding the sickest population; the results should be replicated, in addition to investigating the effect measure modification of having surgery on the risk of FED, using larger cohorts within existent databases that link clinical information to administrative databases.…”

Improving Care Continuity in Oncology Settings: A Lean Management Approach to Minimize Discharges Without Follow-Up Appointments

“…The absence of a scheduled follow-up appointment can lead to various adverse consequences, underscoring the importance of post-discharge care coordination in oncology settings. Such deviations have the potential to cause treatment delays, thereby impacting the patient’s well-being [ 6 ]. Failure to conduct early medical evaluations and make necessary adjustments is associated with an increased risk of disease progression.…”

“…Failure to conduct early medical evaluations and make necessary adjustments is associated with an increased risk of disease progression. Non-compliance with the prescribed follow-up schedule may result in deviations from the established treatment plan, potentially compromising its efficacy [ 7 , 6 , 8 ].…”

“…Ensuring adherence to follow-up appointments and addressing missed appointments can be challenging, often due to factors such as high workload, unclear appointment systems, and inadequate coordination, particularly in newly established healthcare facilities. These challenges have the potential to disrupt the seamless provision of healthcare services, leading to possible gaps in the patient’s treatment course [ 7 , 6 , 8 ].…”