Staffing Strategies for PDT
Customizing staff can help increase efficiency in any type of practice. Here's how.
"Four years ago, when we brought verteporfin therapy into our practice, we thought, 'How are we ever going to do this?'" Dr. Slakter remembers. Like many early adopters, he and his colleagues carefully felt their way through the transition. Now, you can benefit from their experience, particularly if you're struggling with some staffing questions.
Are you wondering if you should reassign staff from other jobs? Hire new people? Get part-time or full-time staff? Devise new ways to train staff?
The panel members' answers, drawn from experience in a variety of practice types and sizes, will help you address staffing issues in your own practice.
One doctor, two R.N.s
Two of the panelists work in practices with one physician and two R.N.s -- Patty Gumina in a solo practice and Charity Stout in a group of offices staffed by one physician per day. In these practices, R.N.s are making a major difference in both efficiency and productivity.
"We started with our existing staff, including one R.N. -- me," Ms. Gumina says. "When I was the only person infusing patients, I was spending half an hour with them from start to finish, sitting with them, running the IV and reinforcing education. It wasn't efficient."
Adding a part-time R.N. for a designated "PDT day" doubled the practice's efficiency. "It made all the difference in the world," Ms. Gumina says. "Suddenly, we could book patients every 15 minutes.
"Now, while I infuse a patient in one room, the other nurse starts the second treatment about 7 minutes later in another room," she explains. "This way, the doctor really has no down time between treatments.
"With adequate nursing staff to accommodate the patient volume, operations are going much more smoothly," Ms. Gumina says. An ophthalmic technician also helps by explaining the consent form to the patient and reviewing expectations.
In the practice where Ms. Stout is employed, several satellite offices in the Knoxville area share five physicians (one per office per day).
"Until the doctors started offering verteporfin therapy, they had no
R.N.s," she says. "They hired two of us in response to adding this treatment." Neither nurse had prior training in retina or ophthalmology, but both were experienced in starting and delivering intravenous therapy.
On days when no verteporfin treatments are scheduled, the nurses help in other areas of the practice. "We're jacks-of-all-trades," explains Ms. Stout. "We work as assistants, helping with phone calls, getting consent forms signed for the photographers, starting IVs, drawing blood for studies and assisting with other treatments."
Staffing larger practices
If one nurse wasn't enough for a single doctor, it's easy to understand why one wasn't enough for Dr. Hughes's six-physician retina practice. Adding a part-time, 1-day-per-week R.N. for verteporfin therapy has increased its efficiency, largely due to solving a simple problem of geography.
"Our photography and PDT treatment rooms are at opposite ends of our office, and our nurse was running back and forth," Dr. Hughes says. "Our new part-time R.N. focuses on PDT only, which eliminates significant stress. She sits with patients during the infusion and reinforces teaching. It's been somewhat more expensive to have another nurse, but it's a worthwhile investment."
Dr. Fineman is one of 20 retina specialists affiliated with Wills Eye Hospital in Philadelphia. They do preliminary testing at six satellite offices; verteporfin therapy is performed at the hospital. With this arrangement, the group hired a full-time R.N. specifically for verteporfin therapy at the hospital. "When I do a treatment there," he says, "I pay a fee that covers the cost of the nurse."
Do you really need an R.N.?
Mr. Holmes's practice has four physicians at five locations (two with verteporfin therapy). He investigated the need for R.N.s in the process, and the physicians have opted not to hire one.
"Each state sets the scope of practice for its licensed professionals," Mr. Holmes says. "I asked the Florida Society of Ophthalmology for its requirements for fluorescein injection. The legal counsel wrote to us that although the language alludes to a 'licensed professional,' nothing in the statutes prohibits a medical assistant with on-the-job training from doing it."
Mr. Holmes located a vocational institute that offered an IV therapy course as part of its nursing program and allowed his staff to attend. Now, all of the practice's photographers are certified in IV therapy, and they handle infusions for verteporfin therapy.
Although this novel approach is working well in Mr. Holmes's practice, Dr. Hughes noted that he has gained greater professional skill and knowledge economically by adding an R.N. one day per week.
"Fluorescein is one thing," he says.
"Verte- porfin is a little more caustic. It's considered a chemotherapeutic agent. I feel it's a small price for my peace of mind to have an IV-certified nurse do it. We have other staff members trained to help with mixing the drug and so on, but the nurse does the verteporfin infusion."
Don't forget your support
But staffing changes aren't limited to nurses. Adding staff, reorganizing or offering additional training can help streamline the process.
Caught in a crunch when they first adopted verteporfin therapy, Dr. Hughes and his colleagues also needed to assess ancillary staff and training.
"Five years ago, before the office staff was well-trained, we thought, 'Why is this so painful?'" he remembers. "Now it's a real joy with two technicians, a scribe, two-and-a-half front desk people, one photographer, one nurse and a part-time PDT nurse. We're seeing twice as many patients in an efficient manner without sacrificing time with the patient."
What one piece of advice about staffing, scheduling and patient flow would you offer someone just starting verteporfin therapy?
Mark Hughes, M.D.
"That's easy. Streamline your scheduling to make verteporfin therapy fit comfortably into your day."
"For my sanity, scheduling patients for PDT on a separate day works the best. In other words, I don't routinely provide verteporfin therapy on the same day I see patients. That way, PDT is on the schedule. I'm prepared for it, and I can plan my schedule around it."
"Preparation and organization are key to getting patients through in a short period. We try to do as much preparation as we can, always setting up the kits before treatment. If the kits are mixed and ready to go, it's very quick and easy to infuse."
Jamieson R. Holmes
"Use your staff efficiently. To me, this means training them to multitask. Being an administrator, I prefer not to hire somebody for just one purpose, so I hire people who can do different tasks."
Charity Stout, R.N.
"A good staff needs teamwork. We all work together. If the photographer gets backed up, we pitch in, and so forth. We're all prepared to go outside of our job definitions to work together."
Back Pain Backups?
Easing side effects doesn't have to cost you time.
Practices can streamline patient education, perfect their staff levels and training, and speed patients along. But when patients have side effects from treatment, they need extra care. Ms. Gumina sees patients at 15 minute intervals -- so where's the time to help a patient with back pain?
Dr. Fineman asked, "What do you do if a patient develops back pain and you have to stop the infusion? You might need to slowly put it in over 15 more minutes, and you'd have a backup. Has this ever been an issue for you?"
Ms. Gumina explains,"Because of our approach to handling back pain, this actually hasn't been an issue. I've found that patients who develop back pain usually do so after 50% of the verteporfin has infused. If they have back pain, we usually stand them up to increase their comfort. (We keep a nurse in each room as the IV is infusing.) At this point, we need only about 4 minutes or so to complete the infusion. I recall only one time when we needed to discontinue the drug and push it in slowly over an extended period."
The start of back pain is quite sudden, according to Dr. Hughes. "It's amazing. It starts at 7 minutes. You're watching the patient, and boom!" he says. "But I think it makes a big difference if you deal with patients to reduce the pain, standing them up and offering reassurance. You can really talk them through it. Massage the back. Help them stand up and move their legs. The next thing you know, you're down to the last 60 seconds."
Ms. Gumina agrees. "It really helps, and you can actually talk them through it," she says. "We hold their hand and say, 'You can hang in there. Another 30 seconds. You can do it!'" This approach enables staff to get patients the treatment they need while adhering to an efficient schedule.
Not sure how the staff should handle PDT duties? Here's a reference.
As the panelists in this discussion agreed, there are many varied approaches to incorporating verteporfin therapy into a practice, and they all seem to work. But if you're starting from scratch, it helps to have a starting point. Here's a general guide to dividing the responsibilities.
This person could be an existing or new employee, depending on how you think your practice would best assign these responsibilities. Duties could include:
- Ordering verteporfin and supplies for photodynamic therapy
- Keeping verteporfin appropriately and securely stored
- Teaching patients about precautions, side effects and notification
- Getting height, weight and BSA
- Calculating the verteporfin dose
- Mixing the verteporfin and preparing the IV
- Infusing the drug, maintaining the IV site and remaining with the patient during infusion
- Notifying appropriate personnel about any pump malfunction
- Completing all treatment and inventory documentation
- Following adverse event and complication protocols
- Telling the physician that infusion is complete and then assisting with laser treatment as needed
- Following OSHA standards and maintaining a clean treatment environment.
Ancillary staff plays an important role in the process, as well. Nurses and ophthalmic technicians must follow the daily schedule to do patient screenings and work-ups. Photographers have to ensure that photographs and fluorescein angiograms are in patients' charts. They also need to do measurements that the physician requests.
Of course, the front desk staff is often the linchpin of a smooth process. For practices offering verteporfin therapy, they need to handle scheduling according to protocol, mail and/or phone appointment reminders, and screen patients' phone calls. To be sure this last item goes smoothly, it helps to give them a list of frequently asked questions and answers, along with clear instructions about when to direct a call to a nurse or a physician.
As you can see, the addition of verteporfin therapy to your practice requires the commitment of many people. By planning the distribution and makeup of the work, you can use your time most efficiently and keep the patient flow running smoothly.
Ophthamology Management, Issue: August 2004