Bone marrow path saves up to $100,000 per case

Length of stay slashed by 8.6 days

The bone marrow transplantation pathway at Richland Memorial Hospital in Columbia, SC, has slashed length of stay by 8.6 days and cut costs per case by as much as $100,000, says Regina McKnight, RN, BSN, OCN, administrative manager for the fifth floor and the cancer center at Richland Memorial.

The pathway, which is 44 days long, includes 10 days of pre-transplantation conditioning therapy, the day of the procedure, and 33 days of recovery. Most of the cost savings and reduction in length of stay have come from changes made to the recovery phase, McKnight notes.

Implemented in February 1995, the pathway is for bone marrow transplant patients for whom a related, partially matched donor has been identified. The cancer center’s biggest pathway, it was also the first to be developed in the center under the hospital’s pathway-focused plan to reduce LOS. "It’s also the one that most of our patients fall under," McKnight says.

Physician buy-in for the pathway wasn’t a problem, McKnight says, because they recognized the importance of standardizing care for bone marrow transplantation patients given the extreme length of time they spend in the acute care setting. "The pathway helped to clean out our protocol and redefine it," she says. "And it also helps with cost-containment issues. It helps the whole multidisciplinary team focus on those things, so overall everyone was happy with the idea of actually getting it going."

Among the disciplines represented on the pathway are attending physicians, nurse practitioners, staff nurses, protocol and research nurses, social workers, registered dietitians, psychiatrists, and the blood transfusion coordinator. The pathway committee also included representatives from ancillary departments, such as the clinical and bone marrow transplantation laboratories, the managed care coordinator, and the insurance specialist.

In addition to 44 days of inpatient care, patients undergo four days of pre-transplantation evaluation, conducted on an outpatient basis. During the evaluation, patients undergo rigorous testing to determine the health of their lungs, kidneys, liver, and cardiac function. "Because we’re going to give extremely high doses of chemotherapy and radiation, we have to make sure that, other than the condition we’re treating, they’re in relatively good shape," McKnight says.

Patients could literally die from a cavity

During the evaluation, clinicians also perform a psychological work-up and a dental examination. "Any cavities have to be repaired before they can come in for transplant," McKnight says. "That’s for infection purposes. Once we completely wipe out their immune system [with chemotherapy], they could actually die from a cavity. All those things have to be looked at beforehand."

The pre-transplant evaluation is conducted on the bone marrow floor of the cancer center in an area designed for outpatients. When patients come in for their evaluation, they’re assessed by an attending physician, have lab work drawn by clinic nurses, and receive a pre-written schedule informing them of what tests they’ll have and where to go for them. Because the cancer center is a freestanding building attached to the main hospital, patients have easy access to services.

In order to decrease LOS, the pathway incorporated three major changes into the bone marrow transplantation pathway:

Changing the admission date.

Before the pathway, patients were admitted one to three days prior to conditioning therapy for preliminary procedures such as radiation therapy set-ups, central catheter placement, and a formal consent conference. Now, the consent conference is held in the outpatient clinic, and patients are admitted when conditioning begins.

Deleting some routine laboratory tests and rescheduling the collection frequency of others.

In the past, a complete blood count was drawn on every patient daily. Changing that to every other day, with an S-Profile drawn on the days in between, resulted in savings of $517 per patient. Also, nurses previously took cultures every Monday and Thursday. Stopping the Thursday collection of cultures resulted in "big savings" without compromising the patient, McKnight says. "When we looked back over what we were doing and why were doing it, we found that we weren’t getting much information from the routine cultures."

Giving medications orally rather than intravenously whenever possible.

Following the recovery stage of the pathway, patients are discharged on a weekday and scheduled for a follow-up visit the next day. "We don’t want to discharge someone on a Saturday and not be able to see them again until Monday," McKnight says. "So we try to discharge them during the week so we can make sure everything went well for them over the night."

Patients usually are scheduled for about three visits per week. Over time, that’s tapered down to two and then one visit per week. During these visits, patients receive routine tests and are asked about their side effects from chemotherapy and radiation therapy. Infections are also monitored. "Although they have enough of an immune system to be discharged from the hospital, it’s still very immature," McKnight says. "So the patient could die of an infection very quickly."

On day 100 following the transplant, the patient receives another work-up, generally including a bone marrow aspiration biopsy and additional laboratory work. If everything checks out, patients — who typically are from out of state or even out of the country — are sent home to their referring physician.

McKnight says staff have benefited from the pathway by gaining a better understanding of transplantation protocols. Because it’s used as an audit tool, the pathway has also helped to improve documentation. "We use it to check to see if something was or wasn’t done," McKnight says. "Once people understood that we were looking for that documentation, it dramatically improved."

For more information about the bone marrow transplantation pathway, contact Regina McKnight, RN, BSN, OCN, administrative manager, Center for Cancer Treatment and Research, Richland Memorial Hospital, 7 Richland Medical Park, Columbia, SC 29203. Telephone: (803) 434-3554.