SAM Self Check-In

El Salvador´s childhood cancer program was established in 1993 and receives 200 new patients annually. The program´s patient population has grown as survival rates have increased from 5% in 1994 to 65% presently and the complexity of cancer care has changed.  Human resources and infrastructure have remained the same, causing overcrowding and an overburden of workload. With COVID-19, the standard of care measures like telemedicine for patients in follow-up care has been implemented to reduce patient attendance at the hospital. However, patients in active treatment must continue attending the hospital. In an effort to expedite patient´s hospital time duration and avoid close and unprotected contact with people who might be exposed or infected with COVID-19,  patients who attend an oncology appointment, treatment, or procedure will be able to self check-in through a kiosk at the hospital entrance in order to organize patients and accelerate the waiting time. 

El Salvador´s National Childhood Cancer program has grown in the last two decades but human resources and infrastructure remain the same, exhausting health care personnel and infrastructure´s capacity.   The cancer program currently treats 98% of pediatric cancer patients in the country aged 0-14 years.  Cancer patients are immunocompromised by treatments and it has been established that those with serious chronic medical conditions are at higher risk of getting sick from COVID-19. The program shifted in-person appointments of patients in follow-up care to telemedicine since March 2020, reducing the number of patients who attend the oncology center by 40%. Even so, the oncology center has a daily clinical staff of 20 which receives approximately 50 patients daily in an 85m2 area for oncology appointments and 40 additional patients for chemotherapy in an area of 18 cubicles measuring 1.50m each. COVID-19 testing is not available for all in El Salvador. The problem is the high flow of patients in the pediatric oncology center exposing patients, caregivers, and healthcare personnel to COVID-19 and other infectious diseases. We aim to provide the same quality of care while offering safe and rapid access to care through a check-in kiosk. 

Healthcare barcode solutions help organize and accelerate the patient admittance process, track care admission, and identify patients throughout their entire stay at the hospital. The check-in kiosk installed at the entrance of the oncology center will help patients move rapidly through the medical appointment process and screen for patients with COVID-19 symptoms.   The caregiver will scan the patient's bar code upon entering the hospital and log into the system. Patients will submit vital information in advance, like their reason for the visit: appointment (appointment with the oncologist, palliative care, brain tumor specialist, psychology, or nurse educator), treatment, pharmacy, or hospital admission as well as report any COVID-19 symptoms.  Patients can be prioritized.  For example, patients who bring their blood work results with them can be seen immediately. Every patient will be given a number based on their reason for the visit and their priority status. Thus patients will be organized allowing them to move quickly through their hospital visit and be dismissed from the hospital. This will decrease time spent in the waiting area in proximity to other patients and their caregivers, reducing exposure to COVID-19 or other infections for patients, family members, and healthcare personnel. 

El Salvador is the smallest country in Central America, bordered by the North Pacific Ocean and located between Guatemala and Honduras; it has a land area of 20,721 km2 and 320 km2 in water. The Gross Domestic Product (GDP) growth in El Salvador reached 1.862 percent in 2019, but the country has registered persistently low economic growth levels due to violence and political corruption. According to the International Monetary Fund, GDP per Capita is equal to $ 9,139.70 per year. The publication entitled "Projections and Estimates of the Population of El Salvador (1950-2050)", produced by the Ministry of Economic and General Office of Statistics and Censuses, reports the projection of El Salvador's total population for the year 2020 of   6, 765,935 inhabitants. The pediatric population (0-18 years) constitutes 35%, comprising 2,387,091 inhabitants.

El Salvador´s National Childhood Cancer Program, supported by Ayúdame a Vivir Foundation in alliance with Children National Hospital Benjamin Bloom and St. Jude Children's Research Hospital, was established in 1993.  Since its beginnings, the program seeks access to comprehensive treatment for Salvadoran children with cancer, improving patients and their family's quality of life in all stages of the disease. The program annually receives 200 new childhood cancer cases and treats 350 patients in active treatment per year in an age range of 0-<18 years. The program has full national coverage of childhood cancer; there are no other centers treating the disease in the country. Treatment is free of charge for patients, but the disease incurs a lot of out-of-pocket expenses, like travel and food allowance. Leukemia (48%) is the most frequent pediatric cancer in our community, followed by Lymphomas (13%) and Central Nervous System Tumors (12%). The treatment for patients can last a minimum of nine months to a maximum of two years and a half.  According to socioeconomic interviews, 51% of our pediatric cancer population lives in extreme poverty and 49% of our patients live within a sustainable economy.  75% of children with cancer in El Salvador have to travel between 2-12 hours to reach the hospital, and only 25 % of the patients live in the surrounding cities near the hospital. 

Progress in childhood cancer treatment has resulted in childhood cancer survival rates of over 80% in High-income Countries. In El Salvador, cure rates are 65%.  Abandonment of treatment rate in low and middle-income countries, one of the biggest causes of treatment failure in children with cancer, is high due to poverty, lack of access to treatment, socioeconomic factors, among others.  El Salvador has an abandonment of treatment rate of less than 1%, primarily fostered by education to the caregiver and a tracking protocol that allows healthcare personnel to detect absences in real-time. 

The team intends to focus now on emergencies like COVID-19 and complications and mortality associated with infections and cancer treatment. The pediatric oncology staff understands that strategies that will most effectively address COVID-19 and infection-related complications can be addressed within the team. The team is taking care to reduce any risk to make it as safe as possible to attend the hospital by following strict infection control measures and reducing the number of times the patient needs to go to the hospital. With the check-in kiosk, we believe we can lower the amount of time the patient spends in the hospital and reduce person-to-person contact. 

The team is reducing risks to make it as safe as possible to attend the hospital by following strict infection control measures and reducing the number of times the patient needs to go to the hospital by implementing telemedicine. With the check-in kiosk, the team believes they can lower the amount of time the patient spends in the hospital as well as screen for COVID-19 symptoms without face-to-face contact.  Patients will have a shorter stay at the hospital and thus reduce the risk of COVID-19 outbreaks within the cancer community and health care providers. 

SAM is our pediatric cancer program hospital medical support system software, developed in 2011 to provide safety and quality in chemotherapy administration, starting with the ordering of chemotherapy, continuing with order verification and preparation in the pharmacy; and concluding with nurse administration. SAM has expanded through the years, allowing the clinical team anything from safety in chemotherapy preparation, patient identification, detection of absences, modules for each discipline in the oncology team, among others. The check-in kiosk allows for improved operational efficiencies in the ambulatory setting. Implementing the check-in kiosk represents an expansion to the already existing hospital software.  The kiosk would be used by all patients who visit the pediatric cancer program day clinic. 

Although barcode technology has existed for some time, most low and middle-income country cancer programs do not rely on this technology. El Salvador´s national program has pioneered and made great innovative advances in technology by designing its own hospital software placing the program as an example in the Latinamerican region. Electronic medical records have increased efficiencies by creating virtual patient files and saving time in searching for patient data and manually entering new data. Barcode technology is usually used for tracking, validation, and inventory management. We plan to take barcode technology further by creating a system of organization for the oncology waiting room and delivering faster clinical care delivery by checking in to the hospital through a kiosk.  SAM has each patient codified by a file number and a barcode which serves to make safe and efficient chemotherapy administration. Implementing barcode technology in the ambulatory area will allow for timely feedback and improved productivity. Patients will be seen by the physician based on real-time data once they enter the hospital, decreasing time in the waiting room thus reducing the risk of COVID-19 and infections in immunocompromised patients. Productivity will be enhanced by automating manual activities, allowing for human resources to focus on other tasks and decreasing face-to-face contact between personnel and patients. This solution can be implemented in other departments of the national children´s hospital as well as other pediatric oncology programs in the Central American region. 

The pediatric cancer program sees approximately 100 daily ambulatory patients between appointments and chemotherapy at its day hospital. All these patients do a face-to-face check-in process that requires several steps, done at different moments. First, they are received by a nurse who takes their temperature, takes their weight and height, and does a short survey screening for COVID-19 symptoms. Then the patient moves on to the nurse station where they are assigned a number based on a first-come, first-serve basis. Patients wait to be called on for their oncology appointment, sometimes 5 hours later. 

The number of pediatric cancer patients in El Salvador remains the same in the last decades. We have national coverage of cancer patients aged 0-12. The check-in kiosk would impact these ambulatory patients. We estimate during the first year that about 70% of patients will use digital sign-in. Moreover, we estimate that during the first year, the digital self sign-in will allow us to potentiate appointments with other disciplines, such as psychology or nurse educators, who currently are not available by appointment, just walk-ins. In five years, we believe all patients will be using the check-in kiosk. 

Long waiting times at the hospital expose children with cancer, their caregivers, and health care personnel to COVID-19 and other infections. The pediatric cancer center serves about 100 patients daily with a clinical staff of approximately 20, including physicians, nurses, pharmacy, and psychosocial team. To expedite the consultation process, a self sign-in kiosk is suggested to organize the process and potentiate efficiencies. Some of the specific indicators to measure progress are the following:

1. Consultation should end earlier than it is ending without the check-in kiosk. Currently, children with cancer wait between 2-6 hours to be seen by the oncologist.  With the kiosk, waiting time should be reduced to a maximum of waiting time of 3 hours and patients should be discharged earlier from the hospital. 

2. Out-patient chemotherapy following the oncology appointment should begin earlier as they are discharged from the oncology and patients should leave earlier. Many patients travel up to 5 hours to get to the hospital. Initiating chemotherapy earlier would prevent the bottleneck at the ambulatory cubicles. 

3. There should be fewer patients in the waiting area with the app that would allow them to wait for their appointment outside the hospital. 

4.Increased patient satisfaction.

We have 6 people on the team. Two are full-time oncologists at the pediatric cancer center, a full-time psychologist, a full-time nurse educator, a full-time software engineer,  and a member of the Board of Directors. In the implementation phase, all members of the clinical area are involved. 

The team has been very involved in searching for solutions during the pandemic to deliver the best quality care to pediatric cancer patients. Telemedicine was successfully launched by the team in early March 2020 and it has now replaced 40% of face-to-face interactions. The team is composed of a multidisciplinary group that respects each other professionally and is open to each person´s contributions. The particulars behind each idea are constructed by the oncologists, psychologist, member of the board of directors, and nurse educator. Each person brings in a different view of the problem with the necessities each may face from their own line of work. The member of the board of directors is also an active volunteer who contributes to the palliative care program and has experience and contact with patient{s needs. The execution of the software creation is the responsibility of the software engineer with the aid of the nurse educator, who has been extensively involved in the creation, modification, and execution of the software program.  Many successful additions of the software have been done this way, with each person contributing with ideas and counsel. 

The project´s team has worked together for many years and on many projects, sharing common goals, expectations, and a passion for the pediatric oncology program. We have respect and appreciation for the contributions each team member delivers and with this respect for each other comes a fair distribution of power, recognition, and risks. We share the same values and goals: union and passion, respect and compassion, and honesty. We belong to the same team and we work together to achieve our mission to help all children with cancer in El Salvador live. Each one of us is a key piece to achieve our goal and we are united by our passion for the cause. We believe we are equal. That is why we treat all of our patients, staff, volunteers, visitors, donors, and stakeholders with respect, kindness, and compassion. We are committed to the responsible and ethical management of our resources. 

The pediatric cancer program has established a successful software program that allows the safe indication, preparation, and administration of chemotherapy, reducing errors with patients.  The team has digitized patient´s files, treatment protocols, and the patient´s route in the hospital.  The software has evolved slowly over the years, simplifying hospital operations and saving time in processes for doctors, nurses, and the rest of the interdisciplinary team. Granted that great advances have been made for a low and middle-income cancer program, we are aware much mentorship and counseling is needed to continue growing and 

With the COVID pandemic, FAV has experienced a financial crisis. All its profits are oriented towards chemotherapy and salaries. There is little capital to invest in projects such as the installation of a bar code reader. These are projects that improve the efficiency of patient attention and care but are not necessities.  We could benefit from orientation in the development of a business plan and in pursuing potential investors for future technological endeavors.   Also, we believe this project could have an enormous impact on the daily care of patients, potentiating efficiencies and providing better overall attention to patients.  These types of projects are noteworthy in a context where financial demands are big and we could benefit from orientation in branding and expanding these services elsewhere. 

The team has a devoted and professional IT team that can develop the app to fit our population's needs. 

We would be interested in partnering with anyone with experience in providing direction to develop this proposal efficiently and effectively. We do not know of any particular organization or Solve Members who could aid in this process.