Ambulatory care (AC) at a London teaching hospital is a nurse-led service that requires the support from a multidisciplinary team (MDT) comprising medical teams (junior doctors and consultants), pharmacists, healthcare assistants (HCAs), administrators, and clinical nurse specialists (CNS) to champion the service so it flourishes. A team of specialist nurses and a collaborative MDT are needed to promote communication for fostering safety, continuity and efficiency within the service and for patients (Jain et al, 2016). Nurses and the MDT are therefore vital in the set-up and running of AC to identify challenges, develop plans to address them and achieve common goals (Jain, 2016).
In an AC service, the job roles of nurses, pharmacists and doctors/specialty registrars (SpRs) are similar to their traditional inpatient equivalents. However, there is a diversification in responsibilities, leading to better and more autonomous decision-making in patient care.
This article is based on the first author's experience of managing an AC service. It will explain the nurses' roles and the importance of team collaboration within the service at this London teaching hospital and examine the maintenance of safety in a nurse-led service, making comparisons with inpatient wards. To conclude, there is a case study of a clinical scenario to illustrate the importance of the MDT and its effects on safety.
The nurse's role
AC at this hospital is led by registered nurses, HCAs and a lead nurse/charge nurse. The team does not consist of advanced nurse practitioners, but the nurses are empowered to be independent in daily patient assessments to manage chemotherapy toxicities and symptoms using Common Terminology Criteria for Adverse Events assessment (CTCAE, v4.03) (National Cancer Institute, 2010). Nurses need to be able to understand symptom control to prevent inpatient admission for as long as possible. They also make key decisions about admitting patients to the inpatient ward (Wang-Romjue, 2018). Furthermore, the AC nurses facilitate collaboration with the MDT to provide holistic care (Furlong and Smith, 2005).
Through daily work with patients, nurses learn each patient's individual ability to self-care and monitor their capacity to remain in AC safely, while ensuring that the patient's experience is at the core of their decision-making. Therefore, their understanding of each patient can be used when evaluating whether AC remains safe and suitable for patients. Nurses need to educate patients about the service, provide daily guidance to help those managing their own care and be able to identify non-compliant patients (Sive et al, 2012; Ingram, 2017). AC SpRs rotate every 3 months, so it is the nursing team's responsibility to support new SpRs working in the service.
Having a nurse-led service supports healthcare workforce challenges while meeting patient needs. Patients are assessed by a nurse on a daily basis who highlights any changes that need review to the medical team. This frees time for doctors to attend to unwell and complex patients (Hoare et al, 2012). Measuring AC workload is difficult because a patient's condition can be unpredictable and individual needs fluctuate. Therefore, a safe nurse to workload ratio and appropriate medical and administrative support should be key considerations if nurses are to work effectively and have time to communicate with patients (Schroeder et al, 2000; Cusack, et al 2004).
Within the AC service, the lead/charge nurse:
The role is also that of an educator, and includes training nurses in skills such as using portable infusion pumps, infusing stem cells and understanding the AC environment.
Team collaboration
Within this AC service, the administrator is the key liaison between the CNS and the AC team, who coordinates patient referrals and hotel bookings, while making sure the nursing workload remains manageable. The administrator and lead nurse work closely together to maximise AC space, balancing the acuity and number of patients, and predicting potential discharges and admissions to inpatients.
AC nurses, SpRs, the pharmacy team and the administrator collaborate to provide an efficient pathway into AC through advanced planning in order to identify issues that need to be resolved before a patient is admitted, such as following up test results, confirming treatment plans, and booking procedures that are part of the chemotherapy protocol (Prades et al, 2015). This helps ensure that patients are treated in a timely manner, which reduces waiting times and improves patients' experiences.
The AC SpR works autonomously alongside the nurses and the HCAs, with support from the attending consultant. The AC SpR attends multidisciplinary meetings and liaises with the inpatient team about patients transferred across services to maintain continuity of care. Consultants review their patients in AC twice a week, as they do for inpatients, to maintain continuity of care. Patients who have received an allograft are reviewed daily by a transplant SpR.
Pharmacists also support AC service expansion by identifying suitable AC regimens. Knowing whether chemotherapy drugs are stable at room temperature or high concentration is vital when identifying whether a drug can be delivered via a portable infusion device. In addition, viscosity and precipitation can affect the suitability of drugs for portable infusion devices (Prabha, 2017). The pharmacists work within the outpatient clinics with the MDT, so they understand the treatment pathways and issues that can arise in AC. This gives them an opportunity to identify suitable patients for AC, educating the wider MDT, including doctors and the CNSs, regarding AC regimens, as well as championing the use of the service.
Finally, the role of the CNS in the patient's treatment is instrumental in facilitating continuity and advocating for patient concerns (Ling et al, 2017). At this London teaching hospital trust, CNSs understand the patients' experiences outside hospital and the pathway that patients follow from clinic to AC. The education provided to CNSs during the set-up of the service ensures that they are instrumental in promoting the service, ensuring that patients understand what AC is, and advocating for patients to be admitted to the service. CNSs' understanding of AC and involvement in clinics will help the wider MDT understand the intricacies of the service and help improve pathways and patient care. Ultimately, working as an MDT ensures that communication between health professionals is effective, which leads to a positive patient experience (Tremblay et al, 2017).
Safety
The overriding theme of enquiries made to the AC team from other hospitals centres on the maintenance of patient safety when delivering intensive treatment outside an inpatient setting, and when the patient is staying on their own at the hotel or at home. Collaboratively, patients, nurses/AC lead, doctors and the wider MDT take many steps to safeguard patients by taking responsibility for specific aspects of care (Box 1) and by adhering to the AC eligibility criteria (Box 2).
Patients should be encouraged to participate in their care by reporting symptoms in the first instance to avoid delays in care (Vincent and Coulter, 2002). Under-reporting of symptoms such as nausea, vomiting, diarrhoea, dehydration and sepsis can lead to a patient's condition becoming more complex as a result of delayed nursing intervention (Basch et al, 2005).
The lack of reporting can put patients at risk if they require support and do not seek help. It is important for nurses to understand that care should not be delivered outside the AC department; otherwise, nurses may find themselves in a precarious situation helping a patient at a hotel. Patient participation in their care is vital for maintaining safety, and can also assist in helping patients cope through their treatment (Vincent and Coulter, 2002).
Although the MDT has a role in caring for and maintaining patient safety, patients also have responsibility for aspects of their care (Box 3). Lazzara et al (2016) explored trust, stating that studies have found that trust between patients and practitioners enables adherence to treatment and improves continuity of care and patient satisfaction. AC requires a communication rapport between the nurse, the wider MDT and the patient in order to foster a foundation for trust. This is vital in nurturing patients to self-manage, and being open and honest, which are necessary if patients are to report their concerns and symptoms. The AC model of care builds on good communication and trust to foster safe patient outcomes (Lazzara et al, 2016).
Many studies have examined the safety and feasibility of autologous stem-cell transplantation (ASCT) in an outpatient setting (Holbro et al, 2013; Reid et al, 2016). Holbro et al (2013) and Reid et al (2016) demonstrate that performing ASCT is safe in an outpatient environment.
Two local audits took place at the London teaching hospital pertaining to reduced intensity allografts. In 2013, the audit compared inpatients with those receiving ambulatory care, and found that patient outcomes and length of stay were not affected. Another audit, started in 2018, showed that overall length of stay for patients who started treatment in AC was shorter by an average of 4 days compared with inpatients.
The audit showed that the most common reason for inpatient admission from AC (Table 1) is pyrexia, which is inevitable for both inpatients and outpatients (Reid et al, 2016). The second most common reason for hospital admission was related to gastrointestinal (GI) toxicities, which are commonplace with chemotherapy (Boussios et al, 2012). Although there is no comparable data to the inpatient setting at this teaching hospital for these toxicities, Reid et al (2016) found fewer GI toxicities in the outpatient (AC) group compared with the inpatient group, and demonstrated that the types of toxicities were similar.
| Temperature of 38°C or above, or sepsis | 288 |
| Gastrointestinal toxicity (nausea/vomiting/diarrhoea/mucositis/poor oral intake) | 206 |
| Monitoring/anxiety/fatigue/patient choice | 26 |
| Generally unwell | 4 |
| Drug/blood product reaction | 2 |
| Venous access issues | 1 |
| Other (i.e. risk of bed pressure ulcers/tachycardic/low blood pressure) | 22 |
| N/a (patient went home without an inpatient admission) | 14 |
| Total number of patients | 563 |
These symptoms can apply to other regimens as toxicities are similar across chemotherapy regimens (National Cancer Institute, 2010). Nothing suggests that outpatient settings are less safe than an inpatient ward.
Because having a high temperature is the most common reason for admission, measures to improve safety and efficiency in receiving immediate care were initiated. Working with the London Ambulance Service, the AC service at this hospital arranged a red flag system to ensure an immediate response to patients with suspected neutropenic sepsis at the hotel where the majority of AC patients stay.
Within this AC, ‘in hours’ is the time during which the service is open (08:00–20:00 Monday to Friday, and 08:00–18:00 during weekends and bank holidays). Data recorded between 2011 and 2017 show that, of 549 patients receiving an ASCT, 440 (80%), were admitted in hours. Other haematology groups being treated in AC were also admitted in hours 80% of the time. This shows that nurses are efficient in their assessment skills in judging whether patients need to be admitted as an inpatient during AC opening hours; 80% in hours admission was recognised as a safe number by the trust's haematology governance. This can be paramount for the patient experience and safety because during working hours patients will have immediate medical support and help with transfer to the hospital.
Ganzel and Rowe (2012) suggested that it is mostly assumed but not proven that patients feel satisfied regarding their safety and care in an AC setting. An electronic survey of patients receiving AC at the London teaching hospital between March and August 2017 captured feedback on AC and safety. Overall feedback has been overwhelmingly positive, with 93% of patients stating that they feel safe.
Portable infusion pump safety
Chemotherapy administration errors can cause serious harm, so a number of safety considerations are in place to ensure safe administration practices (Markert et al, 2009). All nurses who work in AC will require support and training to program and set up portable infusion pumps, which are maintained yearly by the medical physics department. A record, which also guides users, is maintained to prevent set-up errors. These are checked daily against the patient's chemotherapy chart to recheck both set-up and that the correct doses have been administered (White et al, 2010). Chemotherapy is placed into a cassette by the cytotoxic productions unit to minimise exposure to the nurse and the patient.
Clinical scenario
The following scenario is a composition of potential events, and highlights the ambiguity that AC service providers can face when deciding patient suitability for safety within AC, and the importance of MDT communication.
The patient characteristics were as follows:
Mrs X is referred to AC by the CNS. She is due to have R-CODOX-M, a long chemotherapy treatment, with a potential admission to AC of 3 weeks or more. Mrs X recently started developing issues with her mobility, and is having difficulty walking for more than 5 minutes. Her husband is able to stay with her at night, but needs to work during the day. She is tearful and frightened.
This scenario requires a conversation between the medical team, CNS and AC team to discuss whether the patient is suitable for AC because of her emotional wellbeing and her risk of falling. Furthermore, planning is required with the administrator on the type of room that would be suitable for Mrs X because of her mobility issues. In an AC setting, scenarios such as this occur and the AC service should remain open-minded, but it is important to remember that eligibility rules (Box 2) are in place to protect the safety of patients, the service and staff. The wider picture must be considered for neither to be compromised.
Some would argue that Mrs X has a falls risk and is not therefore suitable for AC. A few actions can be taken to mitigate that risk. She could have a physiotherapy assessment through community referral if feasible before AC admission, or be admitted to inpatients to start treatment and have a physiotherapy assessment before being transferred to AC. The AC administrator would liaise with the bed manager to discuss progress and transfer the patient at a suitable time. Discussion with the medical teams needs to explore the reasons for her mobility issues and whether they are disease related and likely to worsen with treatment.
Mrs X could hire a wheelchair, depending on the severity of her mobility and provided that her husband would be able to assist her at the hotel. Mrs X could stay in AC during the day while her husband is at work to maintain her safety and ensure that her psychological support needs are met.
It is important for the AC nurses and the MDT to discuss Mrs X's emotional needs to assess whether she is willing to take on the responsibilities required of her while dealing with a new diagnosis as this will affect her aptitude to cope (Coulter et al, 2015). Her husband's capability to support her and be a carer/companion should be considered while he is working and adjusting to her diagnosis. Carer burden and support for carers/companions should be deliberated to meet the needs of both patient and carer/companion (Sklenarova et al, 2015).
This scenario illustrates that reviewing patients on a case-by-case basis personalises care. Collaboration between members of the MDT and the patient to set goals and decide on the management of a treatment can help empower patients. Furthermore, it can help patients cope with their situation and promote self-management (Coulter et al, 2015).
Conclusion
The AC nursing team at this London teaching hospital comprises four nurses and an HCA, and receives support from the wider MDT. This set-up promotes continuity of care and the ability to understand each individual patient's preferences through daily patient reviews. Every member of the MDT should understand the intricacies of how AC works so that resources are used appropriately and in order to maximise the number of patients who are treated.
Patients work with the MDT to plan their care and take responsibility for aspects of their safety. Together, MDT members contribute to starting, improving and expanding the AC service to improve overall patient experience and maintain safety. By knowing how the AC service works, collectively as an MDT we can understand the whole journey that patients experience, and reinforce patients' safety while they are being treated in the AC setting.