Using patient flow analysis with real-time patient tracking to optimize radiation oncology consultation visits.

PURPOSE: Clinical efficiency is a key component of the value-based care model and a driver of patient satisfaction. The purpose of this study was to identify and address inefficiencies at a high-volume radiation oncology clinic. METHODS AND MATERIALS: Patient flow analysis (PFA) was used to create process maps and optimize the workflow of consultation visits in a gastrointestinal radiation oncology clinic at a large academic cancer center. Metrics such as cycle times, waiting times, and rooming times were assessed by using a real-time patient status function in the electronic medical record for 556 consults and compared between before vs after implementation of the PFA recommendations. RESULTS: The initial PFA revealed four inefficiencies: (1) protracted rooming time, (2) inefficient communications, (3) duplicated tasks, and (4) ambiguous clinical roles. We analyzed 485 consult-visits before the PFA and 71 after the PFA. The PFA recommendations led to reductions in overall median cycle time by 21% (91 min vs 72 min, p < 0.001), in cumulative waiting times by 64% (45 min vs 16 min; p < 0.001), which included waiting room time (14 min vs 5 min; p < 0.001) and wait for physician (20 min vs. 6 min; p < 0.001). Slightly less than one-quarter (22%) of consult visits before the PFA lasted > 2 h vs. 0% after implementation of the recommendations (p < 0.001). Similarly, the proportion of visits requiring < 1 h was 16% before PFA vs 34% afterward (p < 0.001). CONCLUSIONS: PFA can be used to identify clinical inefficiencies and optimize workflows in radiation oncology consultation clinics, and implementing their findings can significantly improve cycle times and waiting times. Potential downstream effects of these interventions include improved patient experience, decreased staff burnout, financial savings, and opportunities for expanding clinical capacity.

Continuous Quality Improvement Measured With Time-Driven Activity-Based Costing in an Outpatient Cancer Surgery Center.

PURPOSE: As health care costs rise, continuous quality improvement and increased efficiency are crucial to reduce costs while providing high-quality care. Time-driven activity-based costing (TDABC) can help identify inefficiencies in processes of cancer care delivery. This study measured the process performance of Port-a-Cath placement in an outpatient cancer surgery center by using TDABC to evaluate patient care process. METHODS: Data were collected from the Anesthesia Information Management System database and OneConnect electronic health record (EHR) for Port-a-Cath cases performed throughout four phases: preintervention (phase I), postintervention, stabilization, and pre-new EHR (phases II and III), and post-new EHR (phase IV). TDABC methods were used to map and calculate process times and costs. RESULTS: Comparing all phases, as measured with TDABC methodology, a decrease in post-anesthesia care unit (PACU) length of stay (LOS) was identified (83 minutes v 67 minutes; P < .05). The decrease in PACU LOS correlated with increased efficiency and decreasing process costs and PACU nurse resource use by fast tracking patients for Port-a-Cath placement. Port-a-Cath placement success and the functionality of ports remained the same as patient experience improved. CONCLUSION: TDABC can be used to evaluate processes of care delivery to patients with cancer and to quantify changes made to those processes. Patients' PACU LOS decreased on the basis of the 2013 Port-a-Cath process improvement initiative and after implementation of a new EHR, over the course of 3 years, as quantified by TDABC. TDABC use can lead to improved efficiencies in patient care delivery that are quantifiable and measurable.

New Cancer Therapies: Implications for the Perioperative Period.

PURPOSE OF REVIEW: Cancer is on the rise. Standing on verge of exciting discoveries, research is being translated into therapies that are being widely administered to patients. Providing a hope for cure, where none existed before. This new body of knowledge has come from a better understanding of cancer genetics, molecular and sub molecular behavior, and understanding of cancer-generated cellular environments. These have led to development of immunotherapy and its many sub-genres, improvement and introduction of new radiation technologies, and decreasing toxicities of existing chemotherapies. RECENT FINDINGS: The purpose of this review is to have a summary look at this huge landscape of cancer therapy. Specially looking at toxicities that an anesthesiologist should be familiar with while providing perioperative care for these patients, complications like tumor lysis syndrome, cytokine release syndromes, Kounis syndrome, myocarditis, encephalopathies, and pituitary failure need to be kept in mind. SUMMARY: One should be knowledgeable about these therapies and approach these patients with a high index of suspicion. Anesthesiologists will need to refine preoperative assessment with appropriate testing and intraoperative and postoperative management in collaboration with oncologists, while involving the expertise of internists, cardiologist, and endocrinologists in helping assess and manage these patients in the perioperative period.

Value based care and bundled payments: Anesthesia care costs for outpatient oncology surgery using time-driven activity-based costing.

BACKGROUND: With the movement towards bundled payments, stakeholders should know the true cost of the care they deliver. Time-driven activity-based costing (TDABC) can be used to estimate costs for each episode of care. In this analysis, TDABC is used to both estimate the costs of anesthesia care and identify the primary drivers of those costs of 11 common oncologic outpatient surgical procedures. METHODS: Personnel cost were calculated by determining the hourly cost of each provider and the associated process time of the 11 surgical procedures. Using the anesthesia record, drugs, supplies and equipment costs were identified and calculated. The current staffing model was used to determine baseline personnel costs for each procedure. Using the costs identified through TDABC analysis, the effect of different staffing ratios on anesthesia costs could be predicted. RESULTS: Costs for each of the procedures were determined. Process time and costs are linearly related. Personnel represented 79% of overall cost while drugs, supplies and equipment represented the remaining 21%. Changing staffing ratios shows potential savings between 13% and 28% across the 11 procedures. CONCLUSIONS: TDABC can be used to estimate the costs of anesthesia care. This costing information is critical to assessing the anesthesiology component in a bundled payment. It can also be used to identify areas of cost savings and model costs of anesthesia care. CRNA to anesthesiologist staffing ratios profoundly influence the cost of care. This methodology could be applied to other medical specialties to help determine costs in the setting of bundled payments.

Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire.

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m(2) (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

Measuring the value of process improvement initiatives in a preoperative assessment center using time-driven activity-based costing.

BACKGROUND: The value and impact of process improvement initiatives are difficult to quantify. We describe the use of time-driven activity-based costing (TDABC) in a clinical setting to quantify the value of process improvements in terms of cost, time and personnel resources. PROBLEM: Difficulty in identifying and measuring the cost savings of process improvement initiatives in a Preoperative Assessment Center (PAC). GOALS: Use TDABC to measure the value of process improvement initiatives that reduce the costs of performing a preoperative assessment while maintaining the quality of the assessment. STRATEGY: Apply the principles of TDABC in a PAC to measure the value, from baseline, of two phases of performance improvement initiatives and determine the impact of each implementation in terms of cost, time and efficiency. RESULTS: Through two rounds of performance improvements, we quantified an overall reduction in time spent by patient and personnel of 33% that resulted in a 46% reduction in the costs of providing care in the center. The performance improvements resulted in a 17% decrease in the total number of full time equivalents (FTE's) needed to staff the center and a 19% increase in the numbers of patients assessed in the center. Quality of care, as assessed by the rate of cancellations on the day of surgery, was not adversely impacted by the process improvements.

A case series of thoracic paravertebral blocks using a combination of ropivacaine, clonidine, epinephrine, and dexamethasone.

Five patients who underwent surgery for breast cancer were followed for 6 days after placement of a multiple-injection, one-time paravertebral block. Data were collected on patient satisfaction, analgesic consumption, side effects, and complications. Ropivacaine as a sole agent in paravertebral blocks has a clinical duration of up to 6 hours. The addition of epinephrine, clonidine, and dexamethasone prolonged the clinical duration considerably.