This document summarizes efforts to lower the length of stay for outpatient plasmapheresis patients at Dignity Health St. Rose Dominican Hospitals. Meetings were held with various departments to identify issues with the current process which took patients 6 hours to 3 days to complete. The goal was set to complete the access line and plasmapheresis procedure in under 5 hours for pre-registered patients and 6.5 hours for others. Changes were implemented including redesigned workflows and order forms. For one patient, both procedures took under 5 hours on November 18th, meeting the goal.

1. LOWERING THE LENGTH OF STAY FOR PLASMAPHERESIS PATIENTS
Erin Rosenberg, MHA, MS
School of Community Health Sciences, University of Nevada, Las Vegas, NV
INTRODUCTION
• Dignity Health St. Rose Dominican Hospitals works with
United Blood Services (UBS) to perform outpatient and
inpatient therapeutic apheresis procedures.
• Table 1 - Total number of plasmapheresis cases that the St.
Rose system is seeing market wide is growing, especially
considering this data only reflects the first four months of
FY17.
• Table 2 - Majority of these cases (75%) are admitted
through the Operations Center, not the Emergency
Department.
• Summer of 2016 - Senior leadership realized that there were
flaws in the process.
OBJECTIVE
• Project Objective – Lowering the length of stay for all
patients receiving plasmapheresis on an outpatient basis.
• Length of stay - Calculated in whole days, so the data
captures the average length of stay for outpatients as zero
days.
• Purpose was to reduce the length of time, in hours,
that outpatients have to spend in the hospital.
• Anecdotal data from one patient who receives an access line
before her plasmapheresis suggests this process has taken
anywhere from six hours to three days.
• Our goal is to get the process (including access line and
plasmapheresis) completed in under five hours for patients
who pre-register and six and a half for those who do not
pre-register.
METHODS
• FIRST MEETING
• Attendees - Patient Access, Care Coordination,
Interventional Radiology (IR), Director of Operations
Center, and the Nurse Shift Managers from Same Day
Surgery (SDS) and the Surgical Observation Unit
(SOU)
• Identified initial and target states (see Figures 1 and
2).
• Created an initial checklist for the Operations
Center staff to follow when a patient’s orders come
• Identified an initial series of gaps in the process
• SECOND MEETING
• Attendees - Director of Pharmacy, Director of
Operations Center, SDS, SOU, Apheresis Nurse from
UBS, and the Director of the Lab
• Identified potential compliance and staffing efficiency
issues with UBS nurses not having EHR access
• One floor nurse has to spend almost a full hour
with this one patient helping with computer work
• Identified problems coordinating supplies and
paperwork for UBS to perform their procedures
• Potential solution identified for patient’s receiving
repeat procedures –
• THIRD MEETING
• Attendees - UBS and Compliance Specialist
• Unsure of Dignity Health’s policy to allow access to
EHR for contracted nurses
• Medical Director for UBS pointed out that some
patients being treated as inpatient status could be
treated on an outpatient basis which would free up
beds and keep patients from staying in the hospital
PATIENT INTERVIEWS
• To determine their biggest challenges with the current
process
• FINANCE DEPARTMENT
• Contacted to provide information on the following
questions:
1. How many outpatient and inpatient admits do we have
market wide for Plasmapheresis?
2. Where is their point of entry for the hospital (ER vs.
NonER)?
3. What is the average LOS for these patients?
• FINAL DEBRIEFING MEETING
• After a patient’s procedure on November 18, 2016
• TRAINING
• For Operations Center staff on new standard work
• Created checklist for them to follow
MHA COMPENTENCIES
ACKNOWLEDGEMENTS
I would like to thank the many departments at Dignity Health St. Rose Dominican
Hospital, Siena Campus and United Blood Services who worked together to improve this
process. Special thanks to Carol Rajchel who helped me everyday to navigate this
process.
FUTURE DIRECTION
• Allow apheresis nurses access to EHR system
• Consult with UBS Medical Director to determine which
inpatient cases could be performed outpatient to save days
spent in hospital
• Possible plans to create a Centers of Excellence for
Therapeutic Apheresis at St. Rose Dominican Hospital
Table 1. Total Inpatient and Outpatient Plasmapheresis Cases
Market Wide
Changes that were initiated:
1.Redesigned work process for Operations Center:
a. Orders are sent to UBS immediately
b. IR appointment time is held for patient
c. Communicate with the patient, UBS, and the
physician’s office about time and availability of bed
d. Patients are notified to bring orders with them
2.Instituted a 6pm call the night before patient’s appointment
time to ensure paperwork is complete
3.Created Therapeutic Apheresis Orders for referring
physicians (see Figure 3)
4.Revamped Hospital Admission Worksheet to highlight
necessary IR needs for Operations Center staff
5.Central Verification will work to get orders approved STAT
for admissions occurring a few days later
6.Patient Access will print out arms bands and account
numbers in advance and deliver to floor to prevent the patient
from having to check in with Patient Access
7.Patient had both procedures in less than 5 hours on
November 18, 2016
RESULTS
Figure 3. New Therapeutic Apheresis Order Forms
• MHA B.3 Problem-solving and decision-making
• MHA B.10 Analyze managerial issues related to the laws governing health care;
compliance; fiduciary responsibility
• MHA B.14 Identify policy issues and key stakeholders; design and evaluate policy
strategies.
• MHA E.1 Ability to balance multiple tasks and responsibilities; set and meet
deadlines.
• MHA C.1 and E.1 Build collaborative relationships
• MHA C.2 and C.4 Demonstrate effective oral communication and presentation skills
• MHA C.1 and D.1 and E.1 Create, participate in, and lead teams
• MHA E.1 and E.2 Hold self and others accountable for Organizational goal
attainment
• MHA C.4 Prepare effective written and business communications
• MHA B.9 Apply techniques and methods to plan, design, implement and assess
information flow and communication
• MHA E.4 Promote and manage change
CASES FY16 FY17
TOTAL
CASES
%
# In Patient 36 17 53 34%
# Out Patient 47 58 105 66%
TOTAL
CASES 83 75 158
ADMISSION FY16 FY17
TOTAL
CASES
%
ER 27 12 39 25%
NonER 56 63 119 75%
TOTAL
CASES 83 75 158
Table 2. Plasmapheresis Admissions
Figure 1. Initial State – Very linear process
Figure 2. Target State – Much more cooperative process