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Meeting the Inpatient Care Needs of Oncology Patients

9 minute read
Kerry Reynolds, MD, program director for Inpatient Oncology, and Denisa Gace, DO, clinical director for Inpatient Oncology at MGH, meet with a patient on Braunwald Tower 11A at BWH.

Patients with a cancer diagnosis often face complex medical challenges related to the interplay of their underlying malignancy, treatment-related side effects and other comorbid conditions that can lead to hospitalization. Within the Mass General Brigham Cancer Institute, teams work behind the scenes to find beds for patients at one of our academic medical centers or community hospitals based on the level of care the individual patient requires. Once admitted, patients are cared for by a multidisciplinary team, which includes physicians, advanced practice providers (APPs), nurses and supporting services like social work, physical and occupational therapy and pharmacy to name a few — all working seamlessly together on the unit. The model reflects our bold vision for the future of cancer care.

The Cancer Institute is expanding this proven model of inpatient care, adding new beds at both academic medical centers and throughout our network to meet the high volume of patient need. For example, the recently launched oncology unit on 11A in the Braunwald Tower at Brigham and Women’s Hospital (BWH) has been full since opening in January, with additional expansion throughout the system coming soon.

Finding the right bed at the right time

A large portion of patients with cancer who require hospitalization come through the emergency department (ED). Through detailed chart review and conversations with clinicians, the Mass General Brigham Cancer Institute Acute Care Access Team is able to identify those patients who most require an inpatient oncology bed at Massachusetts General Hospital (MGH) or BWH and patients who could be cared for safely at another Mass General Brigham hospital or with Home Hospital. The APP-led team works closely with the clinical team on the ground as well as with Admitting, ED transfer teams and the Patient Transfer and Access Center (PTAC) to match patients with available inpatient capacity and facilitate bed placement in a timely manner. The team works in close coordination behind the scenes while also connecting directly with patients and their families at times — providing clear, compassionate communication and guidance every step of the way.

“We continue to see an increasingly high number of patients requiring inpatient oncology care at our academic medical centers. We used to only be able to place those patients in beds at MGH. But since the opening of Braunwald Tower 11A at BWH, we have additional beds available,” said Nora Hathaway, CNP, who leads the Acute Care Access Team and cares for oncology patients at MGH. “Our team helps manage these access and capacity challenges through triage and navigation support. Our goal is to optimize coordination of care within the system and help on-the-ground clinicians guide patients to the most appropriate site of care.”

When patients come to the Cancer Institute from outside the MGH and BWH EDs, the Acute Care Access Team collaborates closely with PTAC, as well as outside hospital clinicians, to stay updated on the patients in the queue and the level of care they need. The team identifies patients who urgently require transfer and work with the resource nurses on the inpatient units to prioritize them for a bed. They can also identify patients who may be well served either by staying where they are or in the outpatient setting.

Eric Yenulevich, PA-C, participates in rounds on Braunwald Tower 11A, alongside Kate Martin, PA-C, and Denisa Gace, DO. The three are standing and look to be in discussion with a fourth person.
Eric Yenulevich, PA-C, clinical director for Inpatient Oncology at BWH, participates in rounds on Braunwald Tower 11A, alongside Kate Martin, PA-C, director of Advanced Practice Providers for Inpatient Oncology at BWH, and Denisa Gace, DO, clinical director for Inpatient Oncology at MGH.

A multidisciplinary approach to care

When a patient is admitted to MGH, BWH, Newton-Wellesley Hospital or Salem Hospital, they are cared for by a Cancer Institute attending physician who specializes in oncology, as well as APPs and nurses who have dedicated their careers to the field.

Kerry Reynolds, MD, is program director for Inpatient Oncology for the Cancer Institute. She and other attending physicians see patients at both MGH and BWH, working closely with each unit-based care team. She says what is unique about the model is the way in which key team members are all co-located. 

“It’s a model rooted in how we have always cared for patients on our dedicated oncology floors at MGH,” she said. “Bringing attendings, responding clinicians, nurses, social work — everyone — together on the same floor creates a sense of unity, purpose and connection. Patients and families can feel it. As we opened Braunwald Tower 11A at BWH, it was essential to carry that forward. And, as we grow with more beds at both MGH and BWH, we’re not just expanding capacity, we’re expanding a way of caring for people that is really collaborative and built around what’s best for the patients and their families.”

Co-locating all of the key members of the care team together in the same workspace allows for a robust rounding process that is truly the hallmark of Mass General Brigham Cancer Institute inpatient oncology care. 

“We start our multidisciplinary rounds at about 8:30 each morning,” said Eric Yenulevich, PA-C, clinical director for Inpatient Oncology at BWH. “At the beginning of their shift, the APPs receive pass off from the nocturnist and pre-round on their patients by reviewing charts and evaluating all new data, including vitals, labs, imaging and other test results. Once formal rounds begin, we collaborate with the attending physician and bedside nurse to review each patient in detail. Together, we establish a care plan for the day. Rounds typically occupy most of the morning, so we maximize the time between patient rooms to execute each patient’s plan by placing orders, discussing care with subspecialty consultants and coordinating admissions, discharges and follow-up care.”

Before rounds, bedside nurses similarly catch up on the status of their patients. 

“At the beginning of each shift, we prioritize a comprehensive unit-wide huddle where the off-going charge nurse briefs the incoming team on key events from the last 12 hours, providing context beyond individual patient reports. This includes highlighting any patient concerns, such as clinical deterioration, high fall risk, behavioral or psychosocial needs, or anticipated delays in treatment. This snapshot of the prior 12 hours helps align the entire unit, improving continuity and bridging gaps between shifts,” said Jenelle Johnson, MSN, RN, PMGT-BC, nurse director on Braunwald Tower 9AB and 11AD. “Following the huddle, nurses transition into individual report, which allows for a detailed review of each patient’s clinical status, care plan and any nuances that may impact the shift. From there, the next one to two hours are focused on establishing presence with patients, completing initial assessments, administering medications and partnering with the PCA team to support readiness for the day. This is a critical time for nurses to ‘lay eyes’ on their patients and identify any immediate needs or acute changes.”

Then, during interdisciplinary rounds, the bedside nurses will share their observations from the start of the shift or overnight and collaborate with the attending physician and APP to align on goals and priorities for the day. Once those priorities are set, the bedside nurses begin carrying out the care plan, which may include administering complex therapies such as chemotherapy or blood products, managing oxygen requirements, performing wound care, supporting goals-of-care discussions and addressing psychosocial and family needs. They are also instrumental in helping patients meet functional goals and coordinating care across disciplines.

That coordination of care across disciplines is made more efficient by the co-location of team members and the multidisciplinary nature of the rounding process. 

“Typically, everyone we need to collaborate with is present for rounds,” said Yenulevich. “For example, if we have a question or concern about a medication, we have a pharmacist right there on the unit to consult.”

Looking ahead

There are currently 95 inpatient beds at MGH and 15 beds on Braunwald Tower 11A at BWH reserved for Cancer Institute patients. When the Phillip and Susan Ragon Building at MGH is complete, the number at MGH will increase to 152. Even more are on the horizon. Additional beds will also come online at BWH, which will expand the Cancer Institute’s reach, amplify the ability to have impact and bring this model of exceptional, team-based cancer care to even more individuals.

“We do not want patients waiting in the ED or at home because they can’t get a bed at one of our academic medical centers. And when care closer to home at a community hospital is the right choice, we want to ensure it’s seamless and supported with the expertise and resources needed. By increasing the number of beds we have, we hope to ease some of our current capacity constraints,” said Reynolds. “And it’s not just about being able to take care of more inpatients. It’s also about opening the door to additional cutting-edge clinical trials. Many of these first-of-their-kind treatments require patients to be in the hospital, where they can be closely monitored and receive therapies that are not available anywhere else. With the investments being made in cancer care here at Mass General Brigham, we have the opportunity to expand in ways we never thought possible — all in service of our patients.”