Integrative Approach Successfully Improves Safety of in-Patient Chemotherapy and Reduces Health Care Costs
Authors: Preis Meir , Abu-Salah Ziad , Melberger Ravit , Zack Leah , Mohilever Judith , Cohen Limor , Shwartz Judith , Cohen Shai , Lavon Ophir , Musai Yamit , Alroy Preis Sharon 
Published: October 2019

Abstract
Introduction
Patients with hematological malignancies often require inpatient chemotherapy treatment to administer continuous infusion of chemotherapy drugs and allow better monitoring. Inpatient setting includes multiple caregivers with different level of expertise - physicians, nursing staff, pharmacy and administrators. Many patients are seen by their hematologist in an outpatient clinic where the chemotherapy plan is written. The patient is then admitted to the inpatient floor for therapy. However in many hospitals there are 2 different electronic medical record systems that don't necessarily communicate properly. In addition, the inpatient setting utilizes more health care resources and is undoubtedly more expensive than the ambulatory care. In this paper we describe an integrative process of establishing safer and better care to hematological patients admitted for inpatient chemotherapy.
Methods
A multidisciplinary team was established incorporating physicians, nurses, pharmacists and IT. We conducted focused observations and mapped the process. Failure Mode Effect Analysis (FMEA) was preformed to identify the most important issues needing intervention. An integrated electronic medical record interface was generated to enable online streaming of communication between different entities in the hospital - inpatient floor, outpatient clinic and pharmacy. We established a dedicated time out of the process. To assess the impact of our work we reviewed charts of randomly selected 18 patients who received inpatient chemotherapy prior to the interventions and continued to monitor records post intervention for the following indicators: 1. Percent of patients who received pre-chemo medications and fluids as prescribed by the hematologist; 2. The difference between a patient's weight on the chemotherapy orders and the actual patient weight as measured on admission; 3. The time difference variability between the planned administration time and the actual administration time of chemotherapy drugs.
Results
Prior to intervention, 20% of the pre-chemotherapy orders such as anti-emetics or fluids were not done according to the hematologist's request. Following the intervention, 100% of pre-chemotherapy orders were preformed accurately and timely. In 24% of patients' cases there was more than 10% difference between the weight used for chemotherapy orders and weight on admission. No significant difference was noted following intervention. In 50% of cases there was more than 2 hrs delay in chemotherapy administration on the following day. Following intervention there was no incidence of more than 2 hrs delay in chemotherapy administration. These interventions resulted in a significant decrease in hospital stay (7.4 vs. 4.7 days).
Conclusions
The Multidisciplinary team's approach is critical in a complex process as inpatient chemotherapy administration. FMEA is an essential tool to assess the severity of different failures of a complex process to prioritize interventions. Integrated electronic medical records interface helps improving communication between different providers and results in a better and safer patient care as well as reduces health care costs.

Disclosures
No relevant conflicts of interest to declare.