Quality Improvement: Decreasing Length of Stay, TPN and Filgrastim Usage in Autologous Stem Cell Transplant Patients

Abstract

We used the Plan-Do-Study-Act quality improvement methodology to reduce the length of stay (LOS) for autologous stem cell transplant (ASCT) patients. Baseline data were collected from the electronic medical records of patients admitted for ASCT from January – April 2014 to serve as the control population. Changes in care were implemented during April 2014. The post implementation comparison intervals were phase I from May – October 2014 and phase II from November 2014 – April 2015 after re-education of staff. Changes in workflow included changing filgrastim administration post-stem cell infusion from day +6 to day +9. The utilization of TPN was changed from individual provider preferences to protocol based with a nutritional team member rounding with the inpatient hematology team. Criteria for starting TPN included patients with less than 50% required calories for >7 days, severe mucositis, or weight loss (>10%) from the time of hospital admission. TPN was not used within the first week of hospital admission unless clinically required. Time to neutrophil engraftment and LOS were monitored continuously during the study period. The pre-implementation median LOS was 17 days (n=16, range: 14-22 days) with a median neutrophil engraftment day of +12 (n=22, range: 10-13). Post-implementation with 3 days less of filgrastim, the median neutrophil engraftment day remained +12 (n=45, range: 10-14). Overall there was a decrease in the median LOS to 16 days (n=46, range: 14-29 days). The cost savings was approximately $1500 per patient due to the reduced filgrastim use and administration and approximately $8500 per patient for the decreased LOS. TPN use was 10% (n=20) at baseline. Post-implementation TPN use decreased to 8.33% (n=24) during phase I and 0% (n=23) during phase II. For the patients receiving TPN during phase I the start day went from +7.5 (pre-implementation) to day +11 and the average number of days on TPN decreased from 4.5 to 3 days. The cost savings was approximately $1000 per patient not requiring TPN. The implementation of protocol driven quality improvement parameters decreased our ASCT patients LOS by one day, decreased TPN use to 0% and decreased the need and cost associated with 3 days of filgrastim use. Re-education of providers at the beginning of phase II contributed to this continued improvement. These practice improvements have important clinical implications. Reduced LOS decreases infection risks and improves the quality of life (QOL) for patients and caregivers. Limiting TPN use also reduces the risks of infection and hepatic dysfunction. Decreased use of filgrastim decreases the risk of side effects including injection site reactions and bone pain, further improving patient QOL. Decreased LOS, TPN and filgrastim use, are all economically preferred and beneficial. An ongoing study is evaluating the same parameters in allogenic BMT patients.