Use of Ambulatory Pumps Prevents Long Patient Waits in Infusion Unit

BOSTON—Outpatient infusion units around the country have experienced soaring numbers of patients due to changes in reimbursement as well as increasingly complex cancer treatments. In a move that contributed to this growth, oncologists at the Massachusetts General Hospital (MGH), supported by the literature, began giving 2-hour infusions of pamidronate (Aredia^®) for prevention of skeletal complications from several malignancies.

At the MGH Cancer Center Infusion Unit, where the number of patient visits increased by an average of 22% in 4 years, Joanne Perri-LaFrancesca, RN, MN, nurse manager, and her staff came up with one solution to deal with the long patient waits that resulted from this growth: ambulatory pumps for cancer patients receiving pamidronate.

Ms. LaFrancesca, Joan M. Agretelis, PhD, RN, and Susan Sheehan, RN, presented a description of the ambulatory infusion program at a poster session of the Oncology Nursing Society’s 26th Annual Congress.

Patient waits for infusion occurred for many reasons other than increased volume, Ms. LaFrancesca noted. "Because we are a large city hospital, we have issues with parking and transportation in and out of the city," she said. "Patients prefer midday appointments to avoid Boston’s notorious traffic and transportation problems."

In addition, she said, the physicians have commitments early and late in the day requiring that patient care activities take place in the middle of the day. "This all added up to a midday crunch," Ms. LaFrancesca said in an interview with ONI.

The infusion unit, with 10 beds and 14 chairs, has approximately 2,000 visits monthly and continues to grow. "We had all these patients coming in at the same time, and we were seeing horrifically long waits. I didn’t know what to do about it," she said.

Since the patients receiving pamidronate were occupying chairs for 2 hours, Ms. LaFrancesca and her staff came up with an idea: If the first dose of pamidronate was tolerated without difficulty, then on subsequent visits, patients could opt to have an ambulatory infusion pump and leave the infusion unit. In this way, the space could be used for another patient who required chemotherapy.

Patients getting pamidronate were good candidates for this idea for several reasons, she said. Approximately 140 patients each month were being treated with 2-hour infusions of pamidronate (280 infusion hours).

Many of these patients were asymptomatic. "They don’t feel sick, and they don’t want to sit in the infusion unit where they are exposed to patients who are sicker. It makes many of them unhappy," she said.

In terms of safety, she noted, patients tolerate the drug with little toxicity, and it does not have vesicant properties.

The infusion unit had already tried decreasing the infusion time of pamidronate from 2 hours to 1 hour, but found that the incidence of constitutional side effects and phlebitis increased with 1-hour infusions.

"We didn’t want to continue that practice. We felt uncomfortable about it. We wanted to continue the 2-hour practice, and so did the physicians. So we decided to try using a small ambulatory infusion pump in selected patients," she said.

Now, some of the patients who used to spend hours waiting for an infusion are going to their doctor’s appointment visit, having lunch, or taking a walk along the nearby Charles River with a 7-inch, 3-lb pump in their fanny pack or backpack, Ms. LaFrancesca told ONI.

"One of my patients would come in after work at 5 pm on a Friday evening. She’d get hooked up to her pamidronate infusion, and by the time she would arrive home, her infusion was finished. She learned how to flush her catheter and disconnect her pump, and would then mail the pump back to us."

At the beginning, some of the nurses in the unit resisted the idea, Ms. LaFrancesca said. "Some nurses thought that the hospital should just give us more space to treat our patients. The thought of an ambulatory pump did not feel patient focused," she said. However, she noted, other programs at the Massachusetts General Hospital, such as obstetrics and cardiology, are also growing and competing for the same limited space.

Fortunately, once the staff nurses who liked the idea involved their patients and spoke positively about it, "they converted the others," she said.

In the initial pilot study, Ms. LaFrancesca and her colleagues calculated that the ambulatory infusion pump was used by 38% of patients, reserving 136 hours of infusion time/space for other patients. Today, that percentage is much larger. "Now, the staff have acclimated to the program because it has improved patient flow through the infusion unit and, more importantly, has resulted in increased patient satisfaction," she said.