Among the endless number of decisions faced by those who run infusion centers, perhaps none is more hotly debated than what the “best” way is to assign patients to nurses.
Over the last six years, my team and I have worked with over 700 infusion centers, so we’ve seen the way that patient assignment is handled over 700 times. These have included everything from the largest NCI and NCCN-designated centers all the way to centers run by small private practices.
There are four prominent patient assignment strategies. Determining which one works best for your infusion center requires understanding the different definitions, unpacking the pros and cons, and assessing the impact from a service operations perspective.
The four main ways of assigning patients to nurses are:
- Pre-Assignment: At some point (usually the afternoon or evening before), all patients for an upcoming day are assigned to nurses (or pods/chairs), typically based on an acuity model or some other clinical calculus used to spread workload evenly across nurses.
- Nurse Pull in Real Time: Each nurse acts autonomously and takes an additional patient when he/she has available capacity and chair space.
- Nurse Push in Real Time: Someone (typically a charge nurse or charge nurse equivalent) assigns each patient to a nurse when the patient arrives at the infusion center and is ready for treatment.
- Primary Nursing: Each patient is assigned a nurse at the beginning of their treatment and every attempt is made to place the patient with the same nurse each visit.
Across the infusion centers that we serve, the rough percentage using each method is as follows:
- Pre-assignment: ~50%
- Real-time assignment:
- Nurse pull ~22%
- Nurse push ~27%
- Primary nursing ~1%
Pre-Assignment
It’s not surprising that many centers use pre-assignment, as that method of patient assignment gives a perception of control to the charge and floor nurses, since, in theory, the day is planned in advance. And, if infusion centers ran like trains in Europe (everyone and everything exactly where they are supposed to be at the time they are supposed to be there), it could indeed be the preferred method of assignment. Pre-assignment can give nurses the opportunity to familiarize themselves with the patients on their schedule before the day begins, including noticing that there are issues that must be remedied before treatment can begin (orders not signed, etc.).
However, infusion centers don’t run as planned. Every day there are late patients, early patients, no show patients, add-on patients, changes in the planned treatment, pharmacy/lab delays, and an endless number of other things that make the day unfold in ways that typically turn one’s beautifully scheduled day upside down. Each nurse takes a gamble each day in terms of how closely their day will match their pre-assigned schedule. Though there are days that do end up mirroring the plan, there’s a high probability that the day ends up being feast or famine in terms of patient arrivals and chair occupancy. Sometimes patients arrive at the same time or in reverse order than expected, a short treatment that becomes very long due to additional supportive agents being added or a reaction, a predicted low acuity patient that arrives and is clearly high acuity, etc. In many centers that use pre-assignment, nurses report that they struggle to take their breaks and lunches, and they report feelings of burnout and stress because of the unpredictable nature of their days, even with a carefully cultivated pre-assignment plan. In fact, pre-assignment is operationally the least efficient way to allocate patients to nurses.
Nurse Pull (Real Time)
Nurse pull is on the other end of the spectrum from pre-assignment. In a nurse pull system, nurses take patients as they are ready for them, and each nurse does so using their own calculus that likely includes chair availability, acuity/needs of the patients already being attended by the nurse, type of treatment, length of treatment, etc. Late arrivals, unsigned orders, late labs — all of the things that cause a pre-assignment system to break down — are absorbed dynamically in a nurse pull system, because nurses “match” themselves to available patients in real time. Real time approaches allow staff to dynamically flex in high variability environments like infusion centers.
Just as pre-assignment creates a sense of control for charge nurses, nurse pull often immediately conjures assumptions of chaos. However, a well- functioning nurse pull system is the opposite of chaos, since every part of the system is self-correcting and regulating in real time, not only in terms of patients, but also in terms of floor breaks and lunches (something that is an issue for every charge nurse).
There are often concerns about nurses not “pulling their own weight” or otherwise taking advantage of this sort of system. Other frequently-cited concerns include some patients or treatments being overlooked (e.g. not “chosen” by nurses) and the inability to do patient prep prior to seating the patient.
In fact, the opposite happens. Nurses highly value autonomy and treat it with respect, with one even commenting, “I feel like I’m being treated like a professional for the first time in my career.” There is also no such thing as a “favorite” type of treatment. For every nurse that prefers short treatments, there is a nurse that prefers longer or more complex treatments. There are nurses who love C1D1 and others who don’t. Some nurses love clinical trial nursing; others strongly prefer standard of care treatments. In a nurse pull environment, the day of each nurse may look very different than that of his/her peers, but every nurse leaves feeling like they got a good slate of patients, as he/she chose them. Nurse pull is also very good for the charge nurse, as he/she goes from being a frazzled scheduling administrator tied to a desk to having the freedom to engage with floor nurses, patients, trainees, etc.
There are a couple of guardrails that help ensure that a nurse pull system runs smoothly and fairly. These include set “protected times” that prompt a charge nurse to check-in with a treating nurse if he/she hasn’t taken another patient (which may be completely justified by the patient situation, but after a certain period of time it’s appropriate for the charge nurse to check in), monitoring the patient queue to ensure that a particular patient is not passed over multiple times (this is almost always due to the patient being known to staff as ‘challenging’ and is almost never a result of the treatment type), and ensuring that a given nurse takes each treatment type periodically in order to stay competent with all treatments.
Nurse Push (Real Time)
Nurse push is a middle ground between pre-assignment and nurse pull. In a nurse push system, patients aren’t assigned before they arrive. When a patient arrives, a charge nurse (or other designated person) determines in the moment which nurse will take the patient. Typically, this is determined by criteria similar to those mentioned above, but the charge nurse will be the one applying the organization’s desired standards to the situation to determine which nurse to select. Individual nurses don’t make choices regarding when they get patients or which patients they take.
Nurse push is, in some ways, the best of both worlds. Since a single person (or designated group) is still doing assignments, there’s a sense of fairness across nurses, and a scoring system (often including acuity) may also drive decisions. Because the assignment is done in the moment, the system is able to accommodate shocks (like late arrivals, same-day add-ons, etc.) much more easily than in a pre-assignment system. Nurse push is also a good solution in a situation where all nurses aren’t able to care for all patients (e.g. due to license/training/pregnancy, etc.).
However, nurse push still relies heavily on non-floor nurses to manage the overall system, meaning that charge nurses are primarily administrative personnel and have little or no time to assist floor nurses, offer training to newer nurses, problem solve, etc. It also doesn’t provide the autonomy to floor nurses that a nurse pull system offers, something that is especially important in today’s world where nursing satisfaction is critical to keeping units fully staffed and capable.
Primary Nursing
Primary nursing is extremely rare in the infusion world, but there are institutions that try hard to do it. In a primary nursing design, every attempt is made to pair a patient with the same nurse each time he/she comes for treatment. There are also hybrids of this, such as primary team nursing (e.g. patients see one of the same three nurses each visit). This system is the least resistant to system shocks and requires significantly more energy on the administrative side, both in terms of scheduling and daily unit management. Additionally, it can also result in the need for additional FTE to manage the workload. Primary nursing isn’t a choice that institutions make because of operational efficiency; it’s chosen because an institution has a particular philosophy regarding patient care that is aligned with the notion of primary nursing.
Conclusion
So what is the best way to manage nursing assignments in an infusion center? From an operations and efficiency perspective, nurse pull is the clear winner, with nurse push a close second and pre-assignment coming in at third place. In general, we recommend that centers aspire to move to a real time methodology. Some choose to move to nurse push first, and then move onto nurse pull.
AI-powered technology can help with this transition. iQueue for Infusion Centers leverages AI, machine learning and predictive analytics to help centers stay operationally agile by optimizing their scheduling templates, level-loading the daily schedule across the nursing staff, flagging future problem days for preventive action, and identifying which appointments should be rescheduled to improve the experience for patients and staff alike.
Our Patient Assignment tools can be an important part of any center’s real time nurse pull or nurse push strategy, providing information, objective recommendations based on your standards, and in-the-moment visualization into the unit. For those that aren’t ready to consider trying pull or nurse push at this time, our Nurse Assignment feature can make the process and administration of a pre-assignment system as efficient as possible and give time back to the charge nurse by automating the pre-assignment process.
Learn more about iQueue for Infusion Centers and how we can help impact your assignment strategy.