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Implementation of a Bone Marrow Biopsy Clinic: Effect on Wait Times for the Procedure, Diagnosis and Treatment Initiation
Clinical Situation
Bone marrow biopsies often need to be performed expeditiously in order to alleviate patient concerns and quickly determine a diagnosis and treatment plan. However, with increasing subspecialization there are fewer hematology/oncology providers available to perform this procedure.
Literature
Our VA previously addressed this issue by having all bone marrow biopsies performed through Interventional Radiology (IR). The average time from order to procedure, though, was 18.6 days (Arfons LM, AVAHO 2016).
Intervention
A weekly bone marrow biopsy clinic was formed, utilizing a small group (heme/onc physician, nurse practitioner and key nursing staff). In collaboration with pathology, interior design, pharmacy, facilities and environmental services, a standard operating procedure was developed, which included a staffing model, procedural checklist, documentation template, scheduling and ordering system.
Outcomes/Implications
Bone marrow biopsies performed before and after initiation of the bone marrow biopsy clinic were tracked for time from order placement to: procedure being done; diagnosis rendered; and for those whose biopsy result needed therapy, initiation of treatment. From 8/4/2020 to 8/12/2021 there were 140 bone marrow biopsies performed, all through IR. The average time from order to the procedure was 23.1 days; from order to diagnosis was 27.8 days and from order to treatment was 54.8 days. After implementation of the bone marrow biopsy clinic, from 9/8/2021 to 5/25/2022 there have been 61 bone marrow biopsies performed (those ordered through IR were excluded). The average time from order to the procedure was 6.8 days; from order to diagnosis was 11.4 days and from order to treatment was 27.3 days. The differences in the average wait times for all 3 measures (time to procedure, diagnosis and treatment) were highly statistically significant (P < .001 for each), in favor of shorter wait times for those performed in the bone marrow clinic as compared to those done through IR. Implementation of a dedicated weekly bone marrow biopsy clinic significantly reduced wait times for the procedure, diagnosis and treatment initiation. This should be considered at other VA centers to improve the care of our veterans.
Clinical Situation
Bone marrow biopsies often need to be performed expeditiously in order to alleviate patient concerns and quickly determine a diagnosis and treatment plan. However, with increasing subspecialization there are fewer hematology/oncology providers available to perform this procedure.
Literature
Our VA previously addressed this issue by having all bone marrow biopsies performed through Interventional Radiology (IR). The average time from order to procedure, though, was 18.6 days (Arfons LM, AVAHO 2016).
Intervention
A weekly bone marrow biopsy clinic was formed, utilizing a small group (heme/onc physician, nurse practitioner and key nursing staff). In collaboration with pathology, interior design, pharmacy, facilities and environmental services, a standard operating procedure was developed, which included a staffing model, procedural checklist, documentation template, scheduling and ordering system.
Outcomes/Implications
Bone marrow biopsies performed before and after initiation of the bone marrow biopsy clinic were tracked for time from order placement to: procedure being done; diagnosis rendered; and for those whose biopsy result needed therapy, initiation of treatment. From 8/4/2020 to 8/12/2021 there were 140 bone marrow biopsies performed, all through IR. The average time from order to the procedure was 23.1 days; from order to diagnosis was 27.8 days and from order to treatment was 54.8 days. After implementation of the bone marrow biopsy clinic, from 9/8/2021 to 5/25/2022 there have been 61 bone marrow biopsies performed (those ordered through IR were excluded). The average time from order to the procedure was 6.8 days; from order to diagnosis was 11.4 days and from order to treatment was 27.3 days. The differences in the average wait times for all 3 measures (time to procedure, diagnosis and treatment) were highly statistically significant (P < .001 for each), in favor of shorter wait times for those performed in the bone marrow clinic as compared to those done through IR. Implementation of a dedicated weekly bone marrow biopsy clinic significantly reduced wait times for the procedure, diagnosis and treatment initiation. This should be considered at other VA centers to improve the care of our veterans.
Clinical Situation
Bone marrow biopsies often need to be performed expeditiously in order to alleviate patient concerns and quickly determine a diagnosis and treatment plan. However, with increasing subspecialization there are fewer hematology/oncology providers available to perform this procedure.
Literature
Our VA previously addressed this issue by having all bone marrow biopsies performed through Interventional Radiology (IR). The average time from order to procedure, though, was 18.6 days (Arfons LM, AVAHO 2016).
Intervention
A weekly bone marrow biopsy clinic was formed, utilizing a small group (heme/onc physician, nurse practitioner and key nursing staff). In collaboration with pathology, interior design, pharmacy, facilities and environmental services, a standard operating procedure was developed, which included a staffing model, procedural checklist, documentation template, scheduling and ordering system.
Outcomes/Implications
Bone marrow biopsies performed before and after initiation of the bone marrow biopsy clinic were tracked for time from order placement to: procedure being done; diagnosis rendered; and for those whose biopsy result needed therapy, initiation of treatment. From 8/4/2020 to 8/12/2021 there were 140 bone marrow biopsies performed, all through IR. The average time from order to the procedure was 23.1 days; from order to diagnosis was 27.8 days and from order to treatment was 54.8 days. After implementation of the bone marrow biopsy clinic, from 9/8/2021 to 5/25/2022 there have been 61 bone marrow biopsies performed (those ordered through IR were excluded). The average time from order to the procedure was 6.8 days; from order to diagnosis was 11.4 days and from order to treatment was 27.3 days. The differences in the average wait times for all 3 measures (time to procedure, diagnosis and treatment) were highly statistically significant (P < .001 for each), in favor of shorter wait times for those performed in the bone marrow clinic as compared to those done through IR. Implementation of a dedicated weekly bone marrow biopsy clinic significantly reduced wait times for the procedure, diagnosis and treatment initiation. This should be considered at other VA centers to improve the care of our veterans.
Discontinuation of Allopurinol for Tumor Lysis Syndrome Report
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.