Shortened Inpatient Stays Benefit Certain Leukemia and Lymphoma Patients

Anne F. Reilly, MD, MPH Under the direction of Anne F. Reilly, MD, MPH, Medical Director of Oncology and an attending physician with the Cancer Center at Children’s Hospital of Philadelphia, a multidisciplinary team was assembled to tackle a particular goal: reducing the inpatient length of stay for children newly diagnosed with B-cell acute lymphoblastic leukemia (ALL). The team’s work successfully decreased the time these patients and families spend in the Hospital — and the initiative won an award at CHOP’s annual Quality and Patient Safety Day. Due to the project's initial success, the new approach to care has been expanded to include newly diagnosed T-cell ALL patients as well as lymphoblastic lymphoma patients, who are treated in a similar way.

Previously, patients newly diagnosed with ALL and lymphoblastic lymphoma typically remained inpatient for up to 4 weeks of initial therapy. Improvements in therapy and supportive care, however have made it clear these patients can be treated just as effectively in the outpatient setting.

“We knew that it was medically safe for most of these patients to go home earlier than we had historically kept them inpatient,” says team member Amanda DiNofia, MD, attending oncologist. “We have long encouraged patients with ALL and lymphoma to engage in their normal life activities as much as possible, knowing that patients involved in their communities do better emotionally. This initiative allowed for that process to happen much earlier.”

Shorter inpatient stays mean a lower risk of acquiring infections within the Hospital and less disruption to family life, as children can sleep in their own beds and parents don’t need to deal with childcare issues for siblings. However, team members were highly aware that a shorter inpatient stay meant less time for a family to get accustomed to the reality of a cancer diagnosis. “A big concern is to not make it seem overwhelming for the family,” said Patricia Flaherty, MPH, who was the improvement adviser for Oncology with the Office of Clinical Quality Improvement when the project was initiated.

Changes that were implemented included offering families more education early in their hospitalization, but sometimes anxious families can’t always retain all of the information offered. Therefore, materials were developed to reinforce information, such as calendar templates that can be customized for each patient with medication lists and procedure days. The implementation of structured education in the outpatient setting further helped reinforce the important information.

“The introduction of the induction calendar educational tools for families has been very well received,” says Jeneane Sullivan, MSN, RN, CPON, who is the Patient/Family Education Specialist in the Division of Oncology. “As a result, calendars for each subsequent phase of treatment for all ALL protocols have been developed. They’re given to and reviewed with the patient and family at the start of each phase of treatment. Corresponding education is provided at the same time, including an overview of chemotherapies used in that phase and what to expect, like frequency of clinic visits, how the child may be feeling, school attendance and so on.”

Staff members throughout the Division of Oncology received education on the new guidelines so that all staff provided a consistent message to families. After implementing these and other interventions, patients on average now go home 9 days after diagnosis. There has been no increase in subsequent inpatient admissions or sick visits in the oncology clinic following these earlier discharges. And there was no increase in the number of phone calls to the clinic with questions from families and no change in the types of questions asked during those calls.

At CHOP’s annual Quality and Patient Safety Day — a day dedicated to recognizing quality and safety work that happens across the institution and often isn’t known beyond individual units or teams — the ALL Length of Stay Team was awarded the Safe Keeping Achievement Award for the initiative.