The waiting around is the hardest part.

This is what staff at the Cancer Centre of Southeastern Ontario (CCSEO) kept hearing from patients who were admitted to hospital to receive a specific and aggressive kind of treatment – high dose methotrexate (HD MTX), a regimen that goes after cancer that begins in blood-forming tissue, such as the bone marrow, or in the cells of the immune system. Patients receiving HD MTX treatment have to stay in the hospital for several days, with only a few hours of every day being spent on receiving the treatment itself. Now, inspired by patient feedback and the desire to enhance care delivery for patients, a team at CCSEO has successfully trialed a new care model for the adult patient population.

“Due to the side effects and dose that we’re using, patients on HD MTX have to be monitored very closely and carefully, which is what most of their time in hospital is spent on,” says Dr. Tara Baetz, Regional Quality Lead, Systemic Treatment. “Typically a patient would spend four to seven days in hospital hooked up to an IV drip  and just walking around waiting for their blood tests and getting their fluid bags changed. We knew there had to be a better way to provide the necessary treatment in a more patient-centred manner.”

Inspired by an established model of out-patient care for HD MTX pediatric patients, Dr. Baetz challenged her colleagues at the Cancer Centre to explore ways an outpatient model could be adopted for adult patients receiving treatment in Kingston. To do this, a multidisciplinary working group was created with physician representation and staff from Pharmacy, Patient Education and Nursing to map out how to make this process possible.

After a year of planning, the team landed on a model that they thought could work. To ensure it was the right model of care though, finding the right patient to trial it with was the next crucial step.

Billy Lussier is no stranger to the healthcare system. Having faced diabetes and prostate issues, he was already well versed in administering his own medicine and navigating around the hospital when he learned that he had a specific kind of lymphoma cancer. As part of his treatment, Billy was given a regime of HD MTX – one that historically would require him to stay in the hospital for around five days. But timing can be a funny thing, and Billy’s requirement of HD MTX aligned with the newly designed outpatient model and, with his consent, Billy jumped on board to trial it.  

Through the outpatient model that the working group built, a patient would have to come to the hospital every day for supportive care and monitoring as well as blood work and a nursing assessment. However, these daily hospital visits only last a few hours and then the patient can return home.

“If you’re in the hospital you want to hope you have a friendly roommate with you, otherwise the days can be very long. If I go home, I can play games on my computer, check email and Facebook, chat with my friends and neighbours and learn some new stories to tell my nurses when I come back,” says Billy, reflecting on why the outpatient model was important to him. “If you’re in the hospital for four or five days it’s kind of dreary but knowing that you get to go home at the end of the day and be outside it’s a bit of a break from hospital life and gives you something to look forward to.”

An important element for this outpatient model to be successful is that patients feel empowered and confident to do their own monitoring when they’re at home. To help Billy feel comfortable doing this a bit of ‘mad science’ education took place before he first went home.

“It’s important that patients monitor the levels of pH in their urine to ensure their kidneys are not impacted by the treatment, so to help Billy get comfortable with that I brought in household liquids for him to practice measuring pH levels on,” says Sarah Vanderhelm, Patient Educator. “It was a valuable session of Billy learning to process and interpret readings from the pH strip and by the end he had the hang of it and felt comfortable enough to try it at home on his own.”

A challenge that the outpatient model presented was how to properly dispense the treatment. In hospital, this was done through an IV drip but this approach did not translate well to a home setting. The solution landed on was to find a medical grade backpack that could be washed and be worn throughout the day while safely delivering the treatment and supportive drugs.

Billy successfully completed the first fully outpatient model for adult HD MTX patients after two rounds of treatment at home. After each trial the working group evaluated and compiled feedback from staff, patients, and family members to improve the overall process.

“Our team is really focused on patient-centred care and care closer to home and through this model we are also able to potentially save hundreds of patient bed days,” says Dr. Baetz. “Successfully implementing this model underlines the great things we can do for patients when we work together, innovate and keep the patient need front and centre.”

As the first Cancer Centre in Ontario to successfully trial this model for the adult population, the team is now sharing their approach with colleagues across the province to help educate them on how this model was rolled out in the Southeast region.

Not every patient will be a candidate for this approach as they must be comfortable carrying a weighted backpack, confident doing their own monitoring and close enough to the hospital to return every day during treatment, but it’s an important start. 

When asked what the difference going home on this model of care has meant to him, Billy doesn’t have to think long before his response:

“At the end of the day, after the monitoring and blood work and bag top up is done I get to go home to my own bed and see my dog and cat which has made all the difference in the world.”