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Impact of nursing schedule change on therapeutic apheresis service.

NURSES ARE THE largest group of healthcare professionals in the United States, with over four million active members (The Henry J. Kaiser Family Foundation, 2017). Despite this statistic, the American Association of Colleges of Nursing (2013) predicts a nursing shortage to arise. Nursing shortages result in both decreased quality of care provided for patients in addition to increased costs for hospitals (Snavely, 2016). In response to the nursing shortage, hospitals frequently must offer higher salaries to attract nurses to their institutions (Spetz & Given, 2003). One of the greatest challenges is to restructure nursing services in hospitals to account for this shortage, while maintaining quality of care and cost efficiency.

Many hospitals, including those without serious nurse shortages, reported sizable financial costs associated with their staffing strategies. High costs were most often attributed to the two most common short-term strategies: use of temporary nurses and increased nurse salaries (May, Bazzoli, & Gerland, 2006). With nursing salaries representing a large sector of healthcare costs, it is necessary to determine how to maximize efficiency within the nursing service, decrease additional spending, and maintain quality of care for patients (Thungjaroenkul, Cummings, & Embleton, 2007). To make apheresis services available to patients admitted outside the normal operational hours of apheresis units, the apheresis service in the study institution uses an external nursing service as a supplement. In the past, full-time (FT) nurses worked for one 8.5-hour shift 5 days per week, and the remaining hours were covered by a contracted nursing service (CNS). Though effective in managing the care of patients, this arrangement was very costly to the institution, as the contracted service is more expensive than using in-house FT nurses.

Various authors suggested using externally contracted nurses could lead to decreased quality of care for patients. They claim errors can occur because of a lack in continuity of care. Additionally, some claim supplemental staff may not be as familiar with the facility. However, Aiken, Xue, Clarke, and Sloane (2007) reported no safety and quality issues result from using non-permanent nurses. They suggested a possibility of better outcomes in situations where there was a higher percentage of supplemental nurses.

Strategies used by other institutions were reviewed to determine an effective way to reduce the use of the CNS. Some institutions use internal staffing agencies to cover for staffing needs throughout the hospital. This method has been effective in reducing costs for these agencies, as they became less reliant on external services (May et al., 2006).

A schedule change was implemented in the study institution's apheresis service in August 2013 to increase hours of operation covered by FT nurses and minimize the use of CNS. The objective was to reduce costs and maintain quality of care. The one shift per day setup was eliminated, and a daily two-shift schedule was implemented whereby each shift was 10.5 hours and the two shifts were staggered. While the apheresis unit previously turned over to the outside nurses by 4:30 p.m. daily, it would now operate from 7:30 a.m.-8:00 p.m. 5 days per week. With this change, nurses worked the same number of hours, but spread over 4 days instead of 5. The goal was to maximize the use of current staff, instead of hiring additional nurses or contracting outside services to perform therapeutic apheresis procedures. This change was predicted to greatly impact the apheresis unit by reducing costs and increasing efficiency.

It was hypothesized that:

1. Longer FT coverage would translate to fewer nursing hours contracted outside the institution.

2. More apheresis procedures could be done during the FT service hours.

3. Longer peripheral blood stem cell (PBSC) collections could be done, reducing the number of collection days for the patient, and associated difficulties such as travel costs, painful side effects from mobilizing medications, and overall discomfort.

Material and Methods

A retrospective study was conducted to compare data before and after the apheresis nurse scheduling change. Therapeutic apheresis (TA) procedures included plasmapheresis, photopheresis, cytapheresis, and PBSC collections from January 1, 20l3 to April 30, 2014. The schedule was changed from one FT shift each day to two overlapping shifts with nurses staggered throughout (see Figures 1 & 2). Hours of operation were from 7:30 a.m.-8:00 p.m., instead of 8:30 a.m.-4:30 p.m. Apheresis procedures performed between August 1 and August 31, 2013 were not included in this study, as this was a transitional period. The following parameters were assessed: number and percentage of TA procedures performed per FT per month; number and percentage of TA procedures performed by CNS per month; number and percentage of TA procedures performed by part-time nurses (PT) per month; working hours of each FT nurse per month; and number of collection days reduced for PBSC collection patients. SPSS was used for statistical analysis.

Results and Discussion

A total 1,885 therapeutic apheresis procedures, including 529 PBSC collection sessions, were analyzed. Since data were excluded from the transition period (8/1-8/31), 220 TA procedures were not included in the analysis. A breakdown of the types of procedures is illustrated in Figure 3. The majority were non-collection plasmapheresis procedures. Each of these procedures typically had a 2-4-hour duration.

Results (see Table 1) revealed the new nursing schedule (a) reduced the number and percentage of TA procedures performed by PT significantly (p<0.001); (b) reduced collection days for a subset of autologous PBSC collection patients significantly (p< 0.001); (c) saved money for both the patients and institution; (d) did not increase the number and percentage of TA procedures performed per month per FT significantly (p>0.05); (e) did not reduce the number and percentage of TA procedures performed per month by CNS significantly (p>0.05); (f) did not change the number of working hours of each FT per month significantly (p>0.05).

Nursing leadership at the study institution proposed this schedule change with the goal of decreasing costs since a significant amount of money was spent on CNS to perform apheresis procedures outside the unit's normal operational times. Though the apheresis center was open until 4:30 p.m., some patients who arrived for treatment during the operational hours of the service still received therapeutic apheresis under the care of the contracted nursing service because most procedures require 2-4 hours for completion. However, there are several complicating factors. Patients not scheduled for apheresis usually come for treatment through the emergency department. Once the need for treatment is determined, the patient must be scheduled for catheter insertion by the interventional radiologists, and in most cases transferred to another room to allow for space for the procedure. The scheduling of the catheter insertion and room transfer could take several hours alone. It is very possible that even if admitted early, a patient will not begin apheresis until later at night or even the next day. In these cases, a CNS is still required to care for these patients and administer treatment. Expanding the operation hours to 8:00 p.m. was not effective in reducing CNS. For unplanned or emergency patients, CNS was still needed.

Extending the hours of operation of the apheresis center during the week did not affect the use of CNS needed over the weekend. Since apheresis nurses work Monday-Friday, CNS was still needed to cover the emergency procedures necessary throughout the weekend.

A positive impact was observed for patients who had PBSC collections. The number of collection days was reduced for 28% of these patients because of extended procedures, made possible by the extended working hours of the nurses, and the stem cell processing laboratory. Based on prior cost-analysis literature (Shaughnessy et al., 2011), on average, the total cost of mobilization, collection, and processing of PBSCs for collection is $6,250, $2,990, and $754, respectively. These costs accumulate with the increase in the number of mobilization endeavors; therefore, methods to achieve target stem cell collections in as few collections as possible would result in significant cost reduction. This calculation did not include physicians' fees, since physicians are salaried workers at the hospital and do not charge each patient. A savings of $119,928 was estimated within 8 months for patients receiving PBSC collection procedures.

Should nursing hours be extended to 12-hour shifts? In several institutions, nursing schedules were extended from 8-hour shifts to 12-hour shifts (Scott, Hwang, & Rogers, 2006). Some nurses enjoyed this change as it allowed them to have increased continuity of care for individual patients. Additionally, nurses could enjoy more full days off, reducing difficulties associated with commuting (Richardson, Turnock, Harris, Finley, & Carson, 2007). In some cases, improved planning and care prioritization occurred because of longer shifts. Some errors were also avoided due to a decreased frequency of handoffs and poor communication (Ellis, 2008). However, there is evidence that 12-hour shifts are associated with increased errors and decreased patient safety (Gold et al., 1992; Scott, Rogers, Hwang, & Zhang, 2006). Several researchers concluded use of 12-hour shifts should be minimized (Scott et al., 2006).


To our knowledge, this is the first report to explore the technical and systematic aspects of nurse scheduling for therapeutic apheresis service. This study revealed the positive impact of schedule change for autologous patients undergoing PBSC collection, but did not demonstrate the desired impact to reduce the number of apheresis procedures done by the contracted nursing service.


Aiken, L.G., Xue, Y., Clarke, S.P., & Sloane, D.M. (2007). Supplemental nurse staffing in hospitals and quality of care. The Journal of Nursing Administration, 37(7-8), 335-342.

American Association of Colleges of Nursing. (2013). Sequestration: Estimating the impact on America's nursing workforce and healthcare discoveries. Retrieved from http://www.aacn.

Ellis, J.R. (2008). Quality of care, nurses' work schedules, and fatigue. Seattle, WA: Washington State Nurses Association.

Gold, D.R., Rogacz, S., Bock, N., Tosteson, T.D., Baum, T.M., Speizer, F.E., & Czeisler, C.A. (1992). Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. American Journal of Public Health, 82(7), 1011-1014.

May, J.H., Bazzoli, G.J., & Gerland, A.M. (2006). Hospitals' responses to nurse staffing shortages. Health Affairs, 25(4), W316-W323.

Richardson, A., Turnock, C., Harris, L., Finley, A., & Carson, S. (2007). A study examining the impact of 12-hour shifts on critical care staff. Journal of Nursing Management, 15(8), 838-846.

Scott, L.D., Hwang, W.T., & Rogers, A.E. (2006). The impact of multiple care giving roles on fatigue, stress, and work performance among hospital staff nurses. The Journal Nursing Administration, 36(2), 86-95.

Scott, L.D., Rogers, A.E., Hwang, W.T., & Zhang, Y. (2006). Effects of critical care nurses' work hours on vigilance and patient safety. American Journal of Critical Care, 15(1), 30-37.

Shaughnessy, P., Islas-Ohlmayer, M., Murphy, J., Hougham, M., MacPherson, J., Winkler, K., ... McSweeney, PA. (2011). Cost and clinical analysis of autologous hematopoietic stem cell mobilization with G-CSF and plerixafor compared to G-CSF and cyclophosphamide. Biology of Blood and Marrow Transplantation, 17(5), 729-736.

Snavely, T.M. (2016). A brief economic analysis of the looming nursing shortage in the United States. Nursing Economic$, 34(2), 98100.

Spetz, J., & Given, R. (2003). The future of the nurse shortage: Will wage increases close the gap? Health Affairs, 22(6), 199-206.

The Henry J. Kaiser Family Foundation. (2017). Total number of professionally active nurses. Retrieved from other/state-indicator/total-number-of-professionally-activenurses-by-gender/?currentTimeframe=0

Thungjaroenkul, P, Cummings, G.G., & Embleton, A. (2007). The impact of nurse staffing on hospital costs and patient length of stay: A systematic review. Nursing Economic$, 25(5), 255-265.

SEBY JACOB, MD, is Staff Physician, Advanced Wound Care Center, Milford Hospital, Milford, CT.

RACHEL FRIEDMANN is Medical Student, New York Institute of Technology College of Osteopathic Medicine, Glen Head, NY.

ADOLFO FIRPO-BETANCOURT, MD, MPA, is Medical Director of Clinical Laboratories, and Vice Chair of Pathology for Clinical Integration, Mount Sinai Hospital, New York, NY.

SHARON TINDLE, MS, is Quality Assurance Manager, Bone Marrow Transplant Program, Mount Sinai Hospital, New York, NY.

S. YOON CHOO, MD, is Associate Professor of Pathology and Medicine, Icahn School of Medicine at Mount Sinai, and Director, Clinical HLA Laboratory and Attending Physician in Transfusion Medicine, Mount Sinai Hospital, New York, NY.

DING WEN WU, MD, PhD, is Associate Professor of Pathology, and Associate Director of Transfusion Medicine, Montefiore Medical Center, New York, NY.

ACKNOWLEDGMENTS: The authors are indebted to the nursing leadership for the strategic change of the apheresis nursing schedule to improve performance. We thank the apheresis nurses for performing the therapeutic apheresis procedures in the study. We are grateful to Dr. Lorraine Miller and Flow Cytometry Laboratory staff for easy access and fast turnaround time of CD34 count tests. We acknowledge Ms. Yelena Sinitsyn and Cellular Therapy Laboratory staff members for extending operation hours to collaborate with the nursing schedule change. We also thank Ms. Godsfavour Guillet and Ms. Tamarah Kent for their meticulous efforts in data collection.

Caption: Figure 1. Nursing Schedules Prior to the Schedule Change

Caption: Figure 2. Nursing Schedule after Restructuring

Caption: Figure 3. Breakdown of Apheresis Procedure Performed from January 2013-April 2014
Table 1. Impact of Extended-Hour Operation on Therapeutic Apheresis

                                              Pre-Change (803
                                              procedures in
                                                 7 months)

# of procedures by FT                               501
Average # of procedures per month per FT       19 [+ or -] 9
Average % of procedures per month per FT       16 [+ or -] 3
Average # of procedures by CNS/month           15 [+ or -] 5
Average % of procedures by CNS/month           13 [+ or -] 5
Average # of procedures by PT/month            50 [+ or -] 5
Average % of procedures by PT/month            25 [+ or -] 4
Average working hours per FT per month        96 [+ or -] 16
# of patients with collection days reduced     0 (out of 37)
Cost saving associated with reduction                0
  of collection days (8 months)

                                              (862 procedures
                                               in 8 months)

# of procedures by FT                               652
Average # of procedures per month per FT       20 [+ or -] 3
Average % of procedures per month per FT       18 [+ or -] 2
Average # of procedures by CNS/month           14 [+ or -] 5
Average % of procedures by CNS/month           12 [+ or -] 3
Average # of procedures by PT/month            13 [+ or -] 8
Average % of procedures by PT/month            12 [+ or -] 7
Average working hours per FT per month         85 [+ or -] 6
# of patients with collection days reduced    12 (out of 43)
Cost saving associated with reduction            $119,928
  of collection days (8 months)


# of procedures by FT                         N/A
Average # of procedures per month per FT      >0.05
Average % of procedures per month per FT      >0.05
Average # of procedures by CNS/month          >0.05
Average % of procedures by CNS/month          >0.05
Average # of procedures by PT/month           <0.001 *
Average % of procedures by PT/month           <0.001 *
Average working hours per FT per month        >0.05
# of patients with collection days reduced    <0.001 *
Cost saving associated with reduction
  of collection days (8 months)

* Statistically significant CNS = contracted nursing service, FT =
full-time, N-A = not applicable, PT = part-time
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Article Details
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Title Annotation:Impacts & Innovations
Author:Jacob, Seby; Friedmann, Rachel; Firpo-Betancourt, Adolfo; Tindle, Sharon; Choo, S. Yoon; Wu, Ding We
Publication:Nursing Economics
Geographic Code:1U2NY
Date:Jul 1, 2017
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