The London teaching hospital (LTH) discussed in this article started an ambulatory care (AC) service in 2005. The patient experience of the service and the role of nurses and the multidisciplinary team and safety were discussed in parts 1 and 2 of this three-part series (Comerford and Shah, 2018; 2019).
Initially, two side rooms within the LTH's day care unit were used, plus one ring-fenced inpatient bed for every five patients. Two band 7 nurses joined the service on secondment. Thus this service was taken on as a cost pressure to the cancer service initially, owing to the increase in staffing. This had a minor impact on the clinical area. There was capacity for seven patients at this time. In 2012 the service moved to another building and gained its own area, comprising six chair spaces and six side rooms. The impact on other existing cancer services, such as the day care unit, was not measured because the whole cancer division was expanding. Figure 1 shows the trajectory of inpatient beds saved daily on average per financial year from 2006 to 2017 through the increase in capacity of the AC service since its inception.
One of the benefits of AC is the flexibility and turnover in the number of patients being treated. Each chair or bed space can treat approximately 1.5 to 2 patients per day when considering average capacity.
Starting an ambulatory care service
For staff interested in introducing an AC service, a pilot can take place on an inpatient or outpatient ward by converting a four-bed inpatient bay to one with approximately four chairs and a bed, or using side rooms. Owing to the similarity in functionality between AC and inpatients, an inpatient oncology ward is particularly suitable for running an AC service. Piloting a new AC service on an inpatient ward is an efficient arrangement because emergency equipment and outreach services are already in place, and will also negate the need to ringfence an inpatient bed within the division. Treatments provided depend on the opening hours and arrangement of facilities.
If the area is without side-rooms, this will cause problems when making provisions for allograft patients (Foundation for the Accreditation of Cellular Therapy and the Joint Accreditation Committee—ISCT and EBMT, 2018), or isolating infectious patients and this should be taken into consideration. If piloting a new service without accommodation being readily available, recruiting patients who are able to travel from home is an option. At this LTH, the criterion for a patient staying at home while in AC is that it takes them a maximum of 60 minutes to drive from their home to the hospital. Timings may vary depending on the type of area in which a hospital is situated. Box 1 describes criteria information for patients used by some hospitals providing AC services in the UK.
| Hospital | AC at home criteria set out in patient information booklets |
|---|---|
| Oxford University Hospitals NHS Trust | Patient suitability for AC will depend on: |
| The Leeds Teaching Hospital NHS Trust | Patients suitable for AC will: |
| University College London Hospital Foundation Trust) | Patient suitable for AC will: |
Starting any new service will raise challenges. A SWOT analysis (strengths, weaknesses, opportunities, threats) of an AC service can be found in Box 2. A ‘change champion’ who can gain support from their peers and communicate their vision for developing the service is needed (Urquhart et al, 2013). Furthermore, the change champion can ensure that all members of the multidisciplinary team (MDT) understand what AC is, clarify how it differs from day care and communicate the patient eligibility criteria (Comerford and Shah, 2018). Members of the MDT can help to identify suitable medication regimens and help manage safety aspects of chemotherapy delivery in an AC setting. Without the support of the wider MDT (this includes all nurses, including inpatient nurses, bed managers, administrators, consultants, specialty registrars, pharmacists, dietitians and clinical nurse specialists), service leaders may struggle to implement changes (Urquhart et al, 2013). The MDT drives the service as they identify and refer suitable patients from outpatient clinics and inpatient wards. Their understanding of each patient's ability to cope in an AC setting and their ongoing needs is paramount to assessing suitability.
| Strengths | Weaknesses |
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| Opportunities | Threats |
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Issues may arise according to the location of the service. If the AC service is located on an inpatient ward, there might be pressure to accept non-AC patients for the day when there are no hospital beds available, or to use the area as a discharge/admission waiting area. If it is based in an outpatient setting, it may be seen as an area that will accept other outpatient work, especially at the weekends. Nurses within the service should have a clear understanding of the type of patients who can be admitted to AC. The priority of the AC nurses should be the wellbeing and safety of the current patients being treated under the AC service. Furthermore, limiting the AC nurses' workload to appropriate patients maintains the service's capacity to continue to accept suitable patients.
Treating patients requiring regimens such as melphalan autologous stem cell transplantation (ASCT) can be an ideal starting point for a new AC service since expensive portable infusion machines are not required for them. The AC service at this LTH treats approximately 85% of the trusts' patients receiving ASCT (Sive et al, 2012) and there is available evidence on its feasibility, safety and cost effectiveness in an AC setting (Holbro et al, 2013; Reid et al, 2016). There are other regimens that do not require portable infusion pumps (Comerford and Shah, 2018).
Some of the challenges that may arise in starting AC services include:
Maintaining the AC service
Nurses are key to maintaining an AC service. AC nursing staff at this LTH are haemato-oncology nurses covering AC, chemotherapy day care, supportive care and apheresis. Four nurses and one healthcare assistant work in AC. Based on verbal feedback from the nurses in 2015, it was found that they enjoy AC working because skills learned from the ward were utilised, and they found daytime-only working appealing. In addition, the nurses enjoyed the continuity of care and developing a working relationship with patients. However, those who only worked in AC at the weekend found the experience daunting because the regimens were complex, and patient needs were different to day care and supportive care. Before 2015, there was a core group of AC-dedicated nurses who worked only in the AC service, which was beneficial for patient continuity and team structure. However, as the service grew, skill-mix issues arose when nurses resigned.
In 2016, when the chemotherapy day care staff had spent one year rotating to AC for 2 weeks at a time, a staff questionnaire was issued (n=22). This assessed whether 2-week rotations were helpful for non-regular AC nurses. Overall, it was found that the rotation was helpful for increasing confidence in working in AC at the weekend. However, nurses commented that one 2-week rotation was not enough, and felt 6-month rotations would be more beneficial. Nurses said they felt supported during their 2-week rotation but wanted more support in training, predominately in using portable pumps.
Since then, regular rotation has been promoted. One or two nurses have worked there for at least a year to maintain patient safety, continuity and support newer staff. There is a further mix of nurses who rotate to the AC service more frequently, anywhere between every 2 weeks to every few months, in order to increase exposure to AC while not compromising staffing in other areas. Rotating nursing staff provides nurses with experience of the service and ensures that appropriate skill mix is maintained during weekends, sickness and annual leave.
Adequate staffing and skill mix are vital for delivering quality care (Twigg and McCullough, 2014; Davidson and Everett, 2016) and complex chemotherapy regimens. Nurses experienced in working in cancer inpatients are likely to adapt easily to an AC setting due to its similarity to working in a haemato-oncology ward. Addressing turnover using rotation of staff to maintain patient safety and staff morale needs to be considered for future-proofing the service. In particular, if two AC-service nurses leave for another post, this equates to 50% of the workforce.
Inpatient and outpatient nurses will require education in working in the AC service. For patient continuity, patients are often transferred between inpatient wards and AC, and this requires inpatient teams to understand how AC functions. Training helps inpatient nurses and doctors in identifying patients who are suitable for the AC service and managing AC patients when the service is closed at night. Thus the standards of care should remain the same across inpatients and AC. Education includes skills such as stem cell return or the use of portable pumps because the inpatient team will need to be able to deal with AC patients overnight. Specific pathways from inpatient to AC exist in this LTH for an efficient transfer. As the AC discussed in this article is a teaching hospital, there are also frequent rotations of doctors and pharmacists. Therefore, education and constant updates are needed in order for the MDT to understand the services being offered and the AC guidelines.
Associated costs, savings and benefits
The important costs to consider are:
In recent years, staff at many hospitals have enquired about the cost of running an AC service and the savings compared to an inpatient ward. However, there is not a direct comparison for savings because a ward and an AC service have different needs, including drug expenditure. For example, antiemetic use may be higher in AC to avoid patients being admitted for nausea and vomiting and a portable infusion pump may be used for administering chemotherapy.
Holbro et al (2013) cited savings of Can$19 522 (around £12 000) per myeloma ASCT patient, based on clinical research at a Canadian facility. Reid et al (2016) and Mahadeo et al (2010) outlined the cost-effectiveness of an ‘outpatient’ cycle compared to hospital admission. However, it is difficult to apply these figures to the UK as they are based on inpatient stays within private care facilities in the USA.
Due to the sensitivity of commercial data, hotel costs cannot be published. Tariffs of a cost per bed day will vary, depending on Healthcare Resource Groups and the trajectory of a patient's care during an admission (National Institute for Health and Care Excellence (NICE), 2015; NHS Improvement, 2016). The finance department at this LTH states that an average hospital bed day costs approximately £300. The AC at this LTH currently treats an average of 16 patients per day: £300 x 16 beds at 365 days per year is£1 752 000 saved on inpatient beds per year. This does not take into consideration the income generated from increasing the capacity of a cancer division without requiring more inpatient beds. Sive et al (2012) calculated a saving of £61.40 per patient day for an AC nursing care episode compared to inpatient nursing care.
In this AC service up to 25 patients per day are treated in AC, using four nurses and one band 4 healthcare assistant with potentially one extra nurse, depending on patient acuity. This equates to fewer nurses being used to care for the same or higher number of patients on an inpatient ward, without having to pay for unsociable hours. The ability to fluctuate patient numbers depending on workload and moving patients around is an added flexibility for a cancer division.
Having an AC service frees up acute inpatient beds, as not all patients require an inpatient overnight stay for their treatment and 24/7 nursing care (Ganzel and Rowe, 2012; NICE, 2016). AC at this LTH allows patients to be treated more quickly and with a guaranteed start date, as there is no reliance on another patient being discharged before the next patient can be admitted. Treating patients in AC reduces the demand on inpatient beds, allowing patients who require inpatient treatment to be admitted sooner as the waiting list should be shorter. As a result, this also improves overall patient waiting times for treatment and avoids breaching treatment target times. Thus the flexibility of AC is beneficial if there is a high demand on inpatient beds. Furthermore, patients are not restricted to one service only; they can be transferred between AC and inpatient care. This allows the cancer division the flexibility to transfer patients to AC before discharge, which opens up inpatient beds and uses fewer outlier beds. Essentially, this increases the beds available within cancer services as a whole, using a smaller space and fewer nurses.
Equally important are the benefits of an AC service for nurses. A day-care setting would provide daytime shift working patterns on Monday to Friday with occasional weekends to supplement unsociable hours' pay. Nurses can continue to work with patients receiving intensive treatment traditionally administered in inpatients and build on their existing skills. The service allows nurses to build continuous relationships with patients and work autonomously. This supports nursing in providing quality nursing care, and improves staff morale and retention (Twigg and McCullough, 2014).
Conclusion
Financial savings and expenditures are justifiably the first consideration when contemplating opening a new service. The ability to be able to treat approximately 1.5-2 patients per chair in a converted four-bed bay shows the flexibility of an AC service. Being able to be flexible and maximise bed space is not quantifiable in monetary terms. The positive aspects of an AC service will be to the advantage of cancer services as a whole, including staff morale and retention. Apart from enhancing the flexibility of an entire division to maximise bed space, the real benefit is the patient experience—and the benefits to patients should remain the main priority when implementing such a service.