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Successful Development of a Hospital-Based Outpatient
Apheresis Program
Patricia Miles BSN, RN, OCN
Delight Joslyn MSN, RN, OCN, CRNI, CPHON
Shannon Jagger BSN, RN-BC
03/13/2019
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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.
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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 a variety of reasons. 03/1
3/19
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Historical Perspective…
• Dated Equipment• Training • Treatments limited to TPE and leukodepletion • Space/room availability
constraints• Per diem staffing model
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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
use COBE Spectra03/13/2019
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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
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Treatment Options
Treatment options were limited • Therapeutic plasma exchange • WBC depletion• Limited to dialysis/plasmapheresis dual lumen
short or long-term catheters
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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
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Development of Business Plan
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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
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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
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Review Process (BCOR-Business and Clinical Opportunity Review)
Business QUAD development• Opportunities• Justification• Schedule• Finances
Business Plan development• Business justification• Clinical justification• Financial assumptions• Exit Strategy
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Months of preparation (Weekly meetings with key stakeholders)
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Hematology/Oncology Specialty Treatment Services
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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.
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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 additional staff . 03/1
3/2019
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Financial Considerations
• Dedicated space/construction cost• Cost of machine• Cost of annual maintenance• Anticipated future volume• Staffing• Educational needs
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Exit Strategy
• Movement of outpatient services off-site • Impact on urgently needed inpatient
treatmento Equipment availabilityo Staff competency----”low volume, high
risk” • Contracted services• Transport to other facilities (i.e. out-of-
state) 03/13/2019
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Approval of Business Plan
• Dedicated room• Acquisition of new equipment• Daily staffing commitment• Staff Education and Training
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Space and Equipment
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Dedicated Space/New Equipment
• Patient-friendly environment
• Ease of access• Enhanced
availability of resources and supplies
• Infection Control Review/Risk Assessment
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Staffing Model
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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
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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
3/2019
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Scheduling/Calendar Development: Transition to new model
Starting February 2018 treatments were scheduled via outlook Calendar• Calendar was created via outlook
and Assistant Nurse Manager would enter all treatments and bill for all treatments
• Calendar was in read-only view for all apheresis nurses
• Printed version was placed in charge book every Friday
Scheduling calendar current state: • Apheresis nurses have read/write
access to scheduling calendar• Daily apheresis nurse will update
calendar and schedule appointments
• Apheresis nurses bill for each treatment same day and update “billing complete” on the calendar
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Staff Development/Competency
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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
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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
• Apheresis Resource Manual created03/13/2019
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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
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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
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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!!! 03/13/2019
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On the horizon…
GROWTH
• Trained 3 additional RN’s in November bringing total number of nurses on our Apheresis Team to 8!
• Training expanded treatment options to include WBC depletion on the Spectra Optia Machine
PATIENT SATISFACTION
• Gaming/entertainment system installed• New treatment recliners (vs. bed) • Increased vascular access options
STAFF SATISFACTION
• Professional development• Monthly team meetings
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Many new and exciting things continue to happen with the NL EMMC Apheresis Program…
TECHNOLOGY• CPOE
QUALITY• CLABSI Prevention/Vascular
Options • “Time-Out”
METRICS• In progress---for consideration: patient
experience, AABB standards, adverse event rates
“BEST PRACTICE” GUIDELINES• American Society for Apheresis
(ASFA)-”Choose Wisely”
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Leadership Impact
• Nurse Manager:• Recognition of importance of collaborative
multidisciplinary team for program development• All nurses are leaders – everyone has something
to offer and it takes a village• Formal title doesn’t make a leader
• Assistant Nurse Manager:• Empowerment of apheresis nursing team• Organizational skills • Ensuring the staffing model met program
demands• Communication is key
• Staff Nurse I:• Accelerated “learning curve”---novice to
expert• Coordinator responsibilities/leading a
“team”• Collaboration among disciplines regarding
patient care• Networking/establishment of a resource
base • Navigating change
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FINAL THOUGHTS
• Management of a therapeutic apheresis program “requires balancing multiple resources and talents in a coordinated effort to support patient care in a highly specialized area of medicine”.1
• Limited resources/references are available to consult in the management of a successful apheresis program.
• Key management strategies for the successful development of a hospital-based outpatient apheresis program include executive leadership support, effective management of daily operations, development of highly trained apheresis staff, multidisciplinary collaboration, balancing of resources, and ensuring excellence in patient care.
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References
1. Linz, W. et al. (2017). Principles of Apheresis Technology (6th ed.). Vancouver, British Columbia: ASFA
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QUESTIONS???
10/24/2018
