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National Comprehensive Cancer Network

About NCCN

National Comprehensive Cancer Network® (NCCN®) Best Practices Committee Infusion Efficiency Workgroup Toolkit: Providing Oncology Treatments in the Outpatient Setting

What is the NCCN Best Practices Committee Infusion Efficiency Workgroup?

Formed by NCCN in 2015, the Infusion Efficiency Workgroup studies capacity and efficiency challenges faced by many cancer centers and recommends best practices for operating efficient and effective infusion centers while maintaining high patient safety standards. The Workgroup operates under the auspices of the NCCN Best Practices Committee, which focuses on enhancing cancer center operations.

What is the focus of this toolkit?

In 2018, the Infusion Efficiency Workgroup focused on looking ahead to consider what the ideal future might look like for infusion centers —  which treat patients with acute as well as chronic diseases who require intravenous medications. Recent trends indicated a shift of treatments to the outpatient and home settings. The Workgroup conducted a survey to determine in which setting (inpatient, outpatient, or home) cancer centers are currently providing the majority of specific cancer treatments, such as Dose Adjusted EPOCH, ICE +/ Rituximab, and High Dose or Intermediate-Dose Cytarabine Consolidation. This analysis revealed much variation among cancer centers and led to the creation of this toolkit, which identifies the best practices for providing certain treatments in the outpatient setting.

Which Regimens are covered in this toolkit?

  • Blinatumomab
  • Dose Adjusted EPOCH
  • Gemtuzumab
  • Inotuzumab
  • HyperCVAD Arm A
  • Cytarabine/Daunorubicin Liposome Induction
  • ICE +/ Rituximab
  • High Dose or Intermediate-Dose Cytarabine Consolidation
  • High Dose Methotrexate

Where can I access the toolkit?

The toolkit is available as a PDF on the NCCN website. Click here to view the toolkit.

In the development of this toolkit, the NCCN Infusion Efficiency Workgroup encountered frequently asked questions. Moffitt Cancer Center shared their experiences transitioning regimens to outpatient settings through the following responses:

Why did you decide to transition these regimens to the outpatient setting?

Lack of hospital beds and delays in scheduling chemotherapy led to patient dissatisfaction. Beyond bed availability, there was an understanding that patients didn’t want to be in the hospital and being there over and over again for something routine felt like it made their overall experience worse. There are many other potential reasons but these have been the primary drivers.

How did you get started?

We built a cross-functional leadership team that included all stakeholders (Nursing, Pharmacy, Physicians, PAs and ARNPs, Social Work, IT, etc.) and asked this group to work through the issues associated with adoption in their areas. It was important to be gradual and do one chemotherapy regimen at a time and even one patient at a time so that everyone could see that this worked and was safe. Doing something new is always hard but once there were early successes, everyone was bought in for the long term.

How long did “getting started” take?

It took about 9-12 months from idea stage to the first patient receiving Arm A of HyperCVAD in the outpatient setting. Each regimen since then has taken less time (generally 3-6 months from idea to implementation).

What were the smartest decisions that were made regarding this change?

Creation of a cross-functional, empowered leadership team was probably the most important decision. We needed everyone to come together and to make decisions together. Probably the second smartest decision was hiring a full time Physician Assistant to run this service and see these patients daily. It prevents a lot of uncertainty for the patient and subsequently heads off potential readmissions due to this uncertainty, which might not be grounded in objective reasons for admission.

How will our institution troubleshoot infusion pump issues?

This is critical because in the middle of the night someone may need to address issues. The vast majority of the pump issues are rare but are handled overnight by providing the patient with instructions to call InfuSystem (or your respective pump provider) for issues with their pump. If they are not immediately available, the patient is instructed the call the charge nurse on the primary chemotherapy floor where these regimens are delivered. While pump issues are rare, this is an important process to have in place.

What changes would we need to make to our scheduling system to accommodate these new regimens?

Likely, none. These are small numbers of patients in the overall population (3-7 per day), and in an infusion center that sees 300 patients per day, a 1% increase is not noticeable. The area where this is noticeable is on the inpatient side where suddenly a 3% increase in bed availability provides a lot of flexibility.

Is this possible at any site?

Yes, if you build a strong team, follow the toolkit, and carry out the plan. Most concerns come from the fear of change and once people see happy patients, a lot of that resistance to change fades.

To see additional frequently asked questions and access the toolkit, click here or email sugalski@nccn.org.