A pre-admission chemotherapy checklist: Improving timeliness of chemotherapy initiation in a malignant hematology inpatient unit Free

Introduction

In an elective admission, patients are admitted to the hospital on a scheduled day for chemotherapy and discharged following completion of treatment with follow up in the ambulatory clinic. Ideally, all necessary components of the admission are completed prior to hospitalization to allow for timeliness of chemotherapy administration. There are currently no well-defined national benchmarks for chemotherapy initiation in elective admissions. Ultimately, unnecessary delays contribute to patient and staff dissatisfaction and overutilization of healthcare resources.

Methods

A preadmission checklist was integrated into inpatient admission workflow via electronic medical record. The checklist reminded primary oncology teams to address treatment consent, treatment orders, admission order, lab orders, central line placement planning, and post-discharge follow up for all planned admissions. An additional domain included treatment-specific task reminders such as nonformulary drug procurement and enrollment for specialized services (e.g. home health referral, infusion pump enrollment). All checklist items were completed prior to admission. Patients were included if they received preplanned inpatient chemotherapy for a hematological disorder and were admitted to one of three inpatient services (simple chemo admit). Patients were deemed complex chemo admits if they required pre-chemo preparatory regimens (e.g urine alkalization for Methotrexate), additional testing or procedures prior to chemotherapy start (e.g. central line placement), or time sensitive admission for next day chemo start (e.g. Blinatumomab). Patients who received allogeneic hematopoietic stem cell transplant (HSCT) and autologous HSCT were excluded. The primary outcome was time from admission to chemotherapy release (ACR). Secondary outcomes included time from admission to chemotherapy start (ACS) and time of day. Data was analyzed using the Kruskal-Wallis test with the Bonferroni correction method for multiple comparisons.

Results

Data from a baseline cohort, admissions which took place 3 months prior to checklist go-live, was collected for pre- and post-go-live comparison. After preadmission checklist go-live, 118 inpatient admissions for planned chemotherapy occurred from July 2024 to July 2025. Eighty-two (69%) admissions were simple chemo admits and 36 (31%) were complex chemo admits. Treated diseases included leukemia (n = 34, 29%), lymphoma (n = 67, 57%), multiple myeloma (n = 16, 14%), and other (n = 1, 1%). T cell engager therapy was administered 25 (21%) times, and the most common chemotherapy regimen was dose adjusted EPOCH (n = 26, 22%). The preadmission checklist was incomplete for 28 (24%) admissions.

The median ACR in the baseline cohort was 218 minutes (range, 41-1417) compared to 159 minutes (range, 15-1172) for the simple chemo admits with completed checklist. A 59-minute reduction in ACR after go-live was observed (p < 0.05), which was a 27% decrease from baseline. The ACR for simple chemo admits with completed checklist was also less than the ACR for simple chemo admits with incomplete checklist (n = 19, median 415 minutes, range, 36-1415, p < 0.05). Median ACS for simple chemo admits with completed checklist was 390 minutes (range, 188-1370) compared to simple chemo admits with incomplete checklist where median ACS was 803 minutes (range, 179-1402) (p < 0.05). There was no difference in median ACS for complex chemo admits with completed checklist compared to complex chemo admits with incomplete checklist (complete checklist median 639 minutes, incomplete checklist median 941 minutes, p = 0.27). Afternoon admissions had a longer ACR compared to mornings (median 620 minutes, range, 36-1415 vs. median 240 minutes, range, 26-800, p < 0.05) and evenings (median 620 minutes, median, 36-1415 vs. median 184 minutes, range, 11-1384, p < 0.05).

Conclusion

The preadmission chemotherapy checklist decreased ACR for simple chemo admits with completed checklist in comparison to the baseline cohort. ACS was less for simple chemo admits with completed checklist in comparison to simple chemo admits with incomplete checklist. Further work is needed to ensure the sustainability of this impact. Potential opportunities include optimizing bed availability in the malignant hematology unit for earlier admission times, assessing impact on length of stay, and expanding the pre-admission checklist to disease teams outside of malignant hematology.