Running head: INTEGRATIVE REVIEW 1

Integrative Review

Priscilla Ambang

Bon Secours Memorial College of Nursing

Christine Turner, PhD

NUR 4222

November17th, 2018

“I Pledge.”
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Abstract

Purpose: The purpose of this integrative review is to evaluate patient scheduling and staff

training methods amongst clinical and nonclinical staff and the impact on scheduling errors and

delays.

Background: Chemotherapy regimens in outpatient infusion require specific scheduling to

increase optimal response rates. In recent years, the demand for outpatient infusion has

increased, as providers attempt to reduce hospital admissions; however, errors in scheduling,

lapses in care, and/or missed appointments have also increased, which could be detrimental to a

patient on chemotherapy for cancer treatment.

Methods: The information obtained for this integrative review was captured from several online

databases. Five peer reviewed, scholarly articles were chosen based on their relevance to the

PICOT question. This information was used to determine the effect of procedural changes in

staffing and training, on the frequency of scheduling errors and/or delays in treatment. A

combination of quantitative and qualitative studies were chosen.

Limitations: The initial and most profound limitation was the availability of information

regarding training of non-clinical staff in the oncology outpatient setting. An alternative search

had to be used in order to obtain adequate information.

Results/Findings: The integrative review identified the need for education from a clinical and

nonclinical standpoint to ensure effective and efficient scheduling for the outpatient infusion

patient on chemotherapy. Additionally, procedural changes in scheduling had to be initiated to

support the units long term and ensure continued reduction in errors.
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Implications and Recommendations: Twofold education by an oncology nurse could help

reduce scheduling challenges in the outpatient infusion setting. As discussed in the limitations,

research on this subject is available, however the majority aligns with patient scheduling,

satisfaction, and acuity.

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Integrative Review

The purpose of this integrated review is to research information addressing staffing

concerns in the outpatient infusion setting, specifically concerns related to chemotherapy patients

and scheduling. The number of cancer patients has increased, forcing infusion centers to

evaluate efficiency and quality (Condotta, A. & Shakhlevich, 2014). In regards to the

chemotherapy patient, adherence to treatment regimens and schedules directly aligns with patient

outcomes. Lapses in treatment can prove to be detrimental (Edwards, L., Hermis, K., LeGette,

C., Lujan, L., and Scarlett, C., 2017

Recently the outpatient infusion center has been plagued with scheduling errors

prompting potential changes in training, processes, and staffing. Chemotherapy regimens and

cycles are specific and detailed (Condotta, A., & Shakhlevich, 2014). An understanding of acuity

and scheduling templates is necessary. Locating information on training of staff was quite

difficult; however locating information regarding staffing concerns was abundant. Five peer

reviewed articles, qualitative and quantitative, were studied regarding this issue (Ma, Saure,

Puterman, Taylor, & Tyldesley, 2016; Chabot &Fox, 2005; Edwards, Hermis, Legette, Lujan, &

Scarlett, 2017; Huang, et.al, 2018; Condotta, R. 2014.) Adequate training of clinical and non-

clinical staff regarding acuity and chemotherapy regimens, as well as, the initiation of updated

templates provided ideal scheduling for patients and staff. This review is being conducted to

address research relevant to the reviewers PICOT question: In the coordination of care

department of non-clinical staff, can a detailed, training seminar, presented by an experienced

oncology nurse, outlining the top ten chemo regimens administered in the Outpatient Infusion

Center, compared to the clerical directed, traditional training, decrease the number of scheduling

errors?
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Design/Search Methods

Five scholarly articles were the primary sources of this integrative review. Separate

searches were conducted using Academic Search Complete, Ebscohost, and CINAHL.

Timeframe for this review was research completed in the last ten years. There was some

difficulty locating current research, occurring within the last ten years, regarding training and

scheduling. Searches were conducted, using a variety of terms including “scheduling errors in

outpatient infusion,” scheduling in outpatient infusion,”, “training non-clinical staff,” training

staff,” as well as, “chemotherapy scheduling,” and “chemotherapy in outpatient infusion.” While

conducting these searches specific criteria were set such as peer reviewed and full text. A

different approach to obtaining the literature had to be identified. Upon changing to research

regarding staffing and scheduling efficiency, a good amount of information was obtained,

including 74 articles total from the three previously referenced online databases. Out of these 74,

19, were relevant to the reviewer’s PICOT question, “In the coordination of care department of

non-clinical staff, can a detailed, training seminar, presented by an experienced oncology nurse,

outlining the top ten chemo regimens administered in the Outpatient Infusion Center, compared

to the clerical directed, traditional training, decrease the number of scheduling errors?”

Ultimately, five articles proved to be useful in the review, due to their information identifying

challenges in scheduling, importance of decreasing lapses in care, and detailed information in all

elements of research.

Findings/Results

Each study reviewed provided similar information regarding the challenges faced when

scheduling in the outpatient and ambulatory care setting, especially amongst chemotherapy

patients. Each article also clearly identified the importance of maintaining treatment schedules
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for optimal outcomes (Chabot,G., & Fox, M., 2005; Condotta, A., 2014; Edwards, et.al., 2017;

Huang, Y., 2018; Ma, X. Saure, A., Puterman, M., Tyldesley, S., 2016 ). A summary of the

research articles is located in Appendix, Table 1 – Article evaluation. The researchers used

different methods to address this challenge, two of which were deeply associated with acuity and

algorithms infusion. These articles all support the idea that with adequate understanding,

training, and methods, scheduling errors amongst non-clinical and clinical staff were decreased,

and all demonstrated improved efficiency.

The first study, “Acuity Based Scheduling,” (Edwards, Hermis, LeGette, LuJan, and

Scarlett, 2017) sought to address lengthy wait times in outpatient infusion, especially amongst

individuals scheduled for short infusions, or injections. The researchers identified these lengthy

wait times aligned with increased patient volume. The study planned to use a lean approach to

increase “efficiency and efficacy.” An interdisciplinary team developed a quality improvement

plan to address patient acuity and scheduling. Treatment types were given a level one through

six, based on anticipated length of infusion. Individual nurse assignments were based on an

acuity not exceeding twenty per day. Results were measured using six criteria, capacity, infusion

hours, patient visits, chair turns, and average infusion length. Improvement was noted across all

metrics.

The next study also had twofold results, minimizing patient wait times and addressing

nurse workloads (Condotta, 2014). The researcher identified scheduling concerns as associated

with cancer patients, “cyclic” regimens and “rigid protocols.” (Condotta, 2014) Unlike the other

studies presented in this review, the researcher/author presented much information about

chemotherapy regimens and schedules, resulting in a better understanding of these treatment

modalities. Additionally, it provided a detailed description of the current state in the clinic used
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in the study. The researcher goes on to discuss scheduling and delves in more of a mathematical

formula, somewhat difficult to decipher. The information provided was quite lengthy and

cumbersome; however it aligned with the subject at hand in this integrative review. Numerous,

quite detailed, statistical formulas were used. While these prove to be significant, based on the

conclusion, the information was tedious and hard to relay. The researcher concluded “the

concept of template schedule can be used to as a powerful algorithmic tool to tackle complex

scheduling problems,” (Condotta, 2014).

Research conducted at a regional British Columbia Cancer Center, was the subject of the

next study (Ma, Sure, Puterman, Taylor, Tyldesley, 2015). The abstract discusses patients

receiving timely access to care. The introduction explains the increase patient demand as it aligns

with higher acuity that one might see with a cancer patient. The researcher also puts much

emphasis on efficiency and efficacy. Unique to this study in this integrative review, was the use

of a quantitative, Discrete Event Simulation, in order to study patient scheduling. This

scheduling was associated with new patient consults; however the information provided was

useful in this integrative review, as it outlined a patient requiring a lengthy appointment. Again,

as has been noted in much of this research, an algorithmic method was the result. When using

this algorithm to develop scheduling schematic, it proved to be beneficial. The researchers used

scheduling rules to address concerns, and found a positive impact, though the intervention and

result is system specific.

The fourth study, “Alternative Outpatient Chemotherapy Scheduling Method to Improve

Patient Service Quality and Nurse Satisfaction” (Huang, et.al., 2018) provided the most useful

information in this integrative review. The researchers identified challenge was obvious, and

aligned with this reviewer concerns. The problems reported were issues concerning optimal
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scheduling and unsafe patient volumes at specific times throughout the day. A new approach was

developed and implemented, after a one day review was conducted for baseline information.

Constraints were identified and used to measure success or failure, including a 3:1 patient-nurse

ratio, a 1:1 patient-nurse ratio for the first 30 minutes and last 15 minutes of treatment. The

researchers adequately described the change and how it was communicated to staff, as well as

pre and post change staff responses. An improvement in chair utilization and constraint

violations were as noted, and decreased by 3.2% and 27% respectively.

The last article in this integrative review “The Creation of a Patient-Classification System

in an Outpatient Infusion Center Setting,” (Chabot, G., & Fox, M., 2005) and the only qualitative

sample, surrounds research completed at an oncology medical group with a goal of establishing

scheduling guidelines. The challenge surrounded the multitude of changes in chemotherapy

administration, mutli-drug regimens, and introduction of targeted therapies that could result in

pronounced infusion reactions (Chabot & Fox, 2005). This information falls out of the suggested

timeframe, however the information is quite relevant and useful to this integrative review. The

researcher reports prior to implementation there was no specific data collection, just “subjective

information highlighted the pressing need (Chabot & Fox, 2005)” The researcher identified and

implemented several key changes such as minimum 30 minute visits, specific nurse assignments,

and times allotted for lunch. Also, schedulers were educated on guidelines per treatment,

anticipated length of time, and acuity level. Implementation yielded positive results in patient

satisfaction, decreased late arrivals, and increased job satisfaction amongst nurses.

Discussion/ Implications
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The original concern posed by this author’s PICOT question, centered on chemotherapy

education delivered to non-clinical staff by an experienced clinical nurse, with the goal of

reducing scheduling errors. Research regarding this unique scenario was limited to nonexistent.

Further review by this author established another opportunity for research, an improvement

surrounding the experienced clinical staff understanding the factors that affect scheduling

coordinators. The research in this integrative review displayed two common themes, appropriate

allocation of time for specific regimens and scheduling reflecting chemotherapy regimens, as

well as patient acuity and nurse assignments.

Time Allocation

Each article in this integrative review issue (Ma, Saure, Puterman, Taylor, & Tyldesley,

2016; Chabot &Fox, 2005; Edwards, Hermis, Legette, Lujan, & Scarlett, 2017; Huang, et.al,

2018; Condotta, R. 2014.) touched on the multitude of changes in chemotherapy regimens and

treatment modalities, as the strain this has placed on outpatient infusion centers. Previous

scheduling templates were not developed to handle a large variety of treatment protocols and

leaned heavily on one simple model. The research in this review supports that this can no longer

be the case, each article made some reference to efficiency as it relates to schedule and nurse

availability. The appropriate allocation of time is necessary when the appointment is initially

scheduled to increase efficiency and efficacy (Edwards, Hermis, LeGette, Lujon, Scarlett, 2017).

Patient Acuity

Research abounds regarding patient acuity and nurse patient ratios. Clinical and non-

clinical staff need to understand treatment regimens, scheduling templates, and the importance of

patient safety. This integrative review supports a proactive approach to schedule to continually
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address these challenges (Chabot, G. & Fox, M., 2005; Edwards, L., et.al., 2017; Condotta, A. &

Shakhlevich, N.V., 2014). Processes and procedures need to align with the evolution of the

higher acuity patient in outpatient infusion, especially those in the cancer realm.

Limitations

The most profound limitation was attempting to find research aligning to a very unique

PICOT question and scenario. A search of numerous databases yielded no useful information,

resulting in a change in researched information. The information presented in this integrative

review still provides useful information, however also demonstrates the need for more research

regarding training of non-clinical staff. The criteria regarding timeframes, research completed

just in the last ten years was somewhat of a limitation also. The sample of five articles was

useful, and in fact, the information overwhelming in some, especially those heavy laden with

algorithms. Also, one might consider the sheer variety of settings, and results, a limitation. Each

article, while displaying similar challenges and positive conclusions, the research avenues, data

collection and analysis, and implementation were all very unique and site specific. Researchers

would need to determine a best course of action for future implementation.

Another limitation is this researcher’s limited experience and expertise in the research

realm. Another, more experienced researcher may have been able to find and present clearer,

concise information.

Conclusion

The information in this integrative review displayed the scheduling challenges unique to

outpatient infusion, specifically patients on chemotherapy. The articles discussed patient

treatment, regimens, potential detrimental effects related to lapse in care, as well as, evidence
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supporting change, after specific implementation. While an alteration was necessary in how this

researchers PICOT question was researched, the information yielded supported the underlining

question. Education of clinical and non-clinical schedulers, in conjunction with the initiation of

acuity based scheduling, related to chemotherapy regimens, decreases the incidence of errors,

scheduling delays, and lapses in care. In doing so, this support treatment goals and positive

treatment outcomes.
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References
Chabot, G., Fox, M. (2005). The creation of a patient-classification system in an outpatient

Infusion Center Setting. Oncology Nursing Forum (32)3

Condotta, A. (2014). Scheduling patient appointments via multilevel template: a case study in

chemotherapy. Operations Research for Health Care(3), P 129-144

Edwards, L., Hermis, K., LeGette, C., Lujan, L., Scarlett, C. (2017) Acuity based scheduling.

Clinical Journal of Oncology Nursing (21) 2

Huang, Y., Bryce, A., Culbertson, T., Connor, S., Looker, S., Altman, K., Collins, J., Stellner,

W., McWilliams, R., Moreno-Aspitio, A., Ailawadhi, S., Mesa, R. (2018). Alternative

outpatient chemotherapy scheduling method to improve patient service quality and nurse

satisfaction. American Society of Clinical Oncology (14)2

Ma, X., Saure, A., Puterman, M., Taylor, M., Tyldesley, S. (2016). Capacity planning and

appointment scheduling for new patient oncology consults. Health Care Management

Science (19) p.347-361

Running head: INTEGRATIVE REVIEW 13

Appendix (Charts)

APA Citation Author Ma, X., British Columbia Cancer Agency (no further information regarding qualifica
Qualifications

Background/Problem Timely access to medical care especially high acuity such as cancer, effecting life expectancy and patient health
Statement

Conceptual/theoretical Conceptual framework; simulation, optimization

Framework

Design/ Quantitative research method using Discrete-Event Simulation (DES)

Method/Philosophical
Underpinnings

Sample/ British Columbia Cancer Agency regional center

Setting/Ethical Three performance metrics weekly number of add-on consults, percentage to patients booked without their corresponding wait
Considerations time tolerances, and the total NPC slot utilization. Simulation and optimization model; established scheduling rules

Major Variables Three performance metrics weekly number of add-on consults, percentage to patients booked without their corresponding wait
Studied (and their time tolerances, and the total NPC slot utilization. Simulation and optimization model;
definition), if
appropriate

Measurement British Columbia Cancer Agency regional center

Tool/Data Collection Three performance metrics weekly number of add-on consults, percentage to patients booked without their corresponding wait
Method time tolerances, and the total NPC slot utilization. Simulation and optimization model; established scheduling rules

Data Analysis Analyzed “the impact of multiple system configurations and scheduling rules on resource utilization, service levels, and
unplanned extra workload.

Findings/Discussion
Twofold findings: Scheduling rules and specialization mix
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Appraisal/Worth to Useful to this practice and setting, however geared towards medical perspective, not nursing, or non-clinical. Conclusion
practice reports best patient appointment scheduling rule is system specific with many types of influences

APA Citation Author Author Qualifications: Chabot, G. RN, MA, OCN, Tower Hematology/Oncology Medical
Qualifications Group, Southern California

Background/Problem In recent years, there has a been a change with a transition of chemotherapy from inpatient to
Statement Outpatient, as well as, new treatment modalities, including multi-drug regimens, and
New targeted therapies with the potential for complicated reactions. This prompted a need for
Scheduling guidelines.

Conceptual/theoretical Qualitative research; Theoretical framework

Framework

Design/ Qualitative research. Researcher reported no data collection prior to implementation. The challenges
Method/Philosophical And concerns were determined through subjective data obtained from staff.
Underpinnings

Sample/ Setting/Ethical A nine physician private practice, seeing 150 patients, 50-60 patients requiring treatment.
Considerations Researcher reviewed regimens scheduled over one week of time.

Major Variables Studied Nurse Job satisfaction

(and their definition), if Patient satisfaction
appropriate

Measurement Tool/Data -Number of patients treated by the same staff

Collection Method -scheduling of treatment visits
-Positive feedback from nurses
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Data Analysis Limited data, subjective from staff, and a review of procedures.

Findings/Discussion Treatments spread out according to acuity level; late appointments decreased; positive feedback from nurses

Appraisal/Worth to Organizes the daily patient scheduling log by matching nurses scheduled hours with patient care needs
practice

APA Citation Author Author Qualifications: Edwards, L. MSN, RN, NE-BC

Qualifications

Background/Problem Long wait times for chemotherapy, especially short treatments in the ambulatory care setting. Significant increases in
Statement patient volumes, increased concerns about wait times

Conceptual/theoretical Theoretical framework attempting to make current practices more efficient. Increase chair use
Framework and maximize scheduled hours

Design/ Quality improvement project involving an Interdisciplinary team of nurses, administrators, and pharmacists.
Method/Philosophical
Underpinnings

Sample/ Setting/Ethical Regional Care Centers of the University of Texas MD Anderson Cancer Center; rapid cycle test of change; 17 chairs,
Considerations 136 infusion hours
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Major Variables Studied (and six procedure levels, capacity, infusion hours, utilization rate, patient visits, chair turns, and average infusion length
their definition), if
appropriate

Measurement Tool/Data Target goal was 110 hours per day with an 80% use rate.
Collection Method

Data Analysis Information of variables pre and post change

Findings/Discussion Metrics related tosix procedure levels, capacity, infusion hours, utilization rate, patient visits, chair turns, and average
infusion length improved across all outcome measures. Per Press Ganey survey, patient satisfaction also improved.

Appraisal/Worth to practice “Delineating infusion chairs and rooms by acuity level can provide an efficient approach to patient care. “

APA Citation Author Huang, Y., PhD. Mayo Clinic

Qualifications

Background/Problem Midday peak volume leads to inadequate staffing at peak hours and a lack of appointment availability
Statement

Conceptual/theoretical Quantitative research. Conceptual framework, new model to optimize safety and effeciency in terms of staffing
Framework resource violations

Design/ Used an optimization approach to determine when to schedule different patient types on the basis of treatment
Method/Philosophical
Underpinnings
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Sample/ Setting/Ethical 19 chair community chemotherapy infusion center; One clinic day was selected for baseline analysis
Considerations

Major Variables Studied (and Existing management models,

their definition), if
appropriate

Measurement Tool/Data Staffing violations, nurse-patient ratios; tracked before and after implementation
Collection Method

Data Analysis Management model analyzed in detail including tracking of patients through actual encounters and measurement of
constraint violations

Findings/Discussion Identified staffing violations reduces nearly 50%; 18% reduction in maximum chair utilization and 27% reduction in
staffing violations

Appraisal/Worth to practice Proposed optimization approach aligning with nursing resource and workload balance throughout a day effectively
improves service quality and staff satisfaction.

APA Citation Author Condotta, A., School of Computing, University of Leeds, LS2 9JT, United Kingdom
Qualifications

Background/Problem Increasing number of cancer patients negatively effecting efficiency and quality
Statement

Conceptual/theoretical none
Framework
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Design/ Algorithms to identify scheduling challenges and solutions

Method/Philosophical
Underpinnings

Sample/ Setting/Ethical Large volume chemotherapy Outpatient infusion clinic(s)

Considerations

Major Variables Studied (and Timely treatments in shorter timeframes, reducing cost of treatment
their definition), if
appropriate

Measurement Tool/Data Patient waiting times, improving nurses schedules, increasing clinic capacity
Collection Method

Data Analysis Algorithmic and difficult to decipher

Appraisal/Worth to practice Providing good schedules for nurses and patients with multi-day treatments