Issues for designing marrow transplant programs

Issues For Designing Marrow Transplant Programs Joleen Kelleher

ONE MARROW transplantation (BMT) is en-

countering another evolutionary transformaB tion. Hematopoietic growth factors, gene therapy, recombinant toxins, cloning techniques, variation in stem-cell acquisition, and pharmacological breakthroughs are changing the treatment regimens and patient outcomes. 1-3 At the same time, we are challenged by the dramatic pressure on the health care delivery system to control cost, to assure quality of care, and to curb overutilization of services. These constraints are the catalysts for hospitals to integrate cancer services. Patients and insurers are shopping not only for technical expertise but also for quality, costeffective service. The emerging theme of value measured as both quality and price is a major basis of competition between marrow transplant care provider groups. 4 Presently there are over 150 autologous and/or allogeneic transplant centers in the United States. Their sizes range from 2- to 60-bed programs. More than 6,150 transplants are performed yearly. The number of autologous transplants and new programs have outpaced allogeneic transplants in the past several years. 5 Patients undergoing marrow transplantation are usually not being treated for an acute illness episode. They have already been part of a health care system and after the transplant will return to that same care system. The BMT program may be an extension of a preexisting comprehensive cancer program where the patient received care or a separate program to which the patient was referred. A center considering designing or redesigning a marrow transplant program must focus on maximizing health and functioning, not just saving or extending life. This includes creating an environment that

From the Fred Hutchison Cancer Research Center, Seattle, WA. Joleen Kelleher, RN, MS: Bone Marrow Transplantation Consultant, and former Director of Nursing, Fred Hutchison Cancer Research Center, Seattle, WA. Address reprint requests to Joleen Kelleher, RN, MS, BMT Consultant, 990 Swanson Way, Poulsbo, WA 98370. Copyright 9 1994 by W.B. Saunders Company 0749-208119411001-000855.0010

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promotes healing and builds on the chronic care trajectory model rather than the single treatment program model. 6 This environment can be achieved by creating a unit without walls that is supported by a cancer committee, tumor board, tumor registry, multidisciplinary consultation team, cancer education resources, and skilled oncology/transplant nursing staff.7 PROGRAM DESIGN

Designing a BMT program requires considerable management skills to plan, implement, and determine the quality and suitability of the final plan. The formation of a "primary and expanded" design team may help to avoid large committees that often become dysfunctional (Table 1). s The members of the primary design team are responsible for developing the strategic plan, site visit review, developing a mechanism of continued input from the expanded design team, and implementation of the strategic plan. The expanded team members act as experts in their professional areas and develop recommendations for space and staff. These plans are submitted to the primary team for approval. This process develops commitment and investment by all groups involved. Several characteristics in the care of BMT patients require high-technology resources, skilled staff, and organizational commitment. These are the extent and duration of immunosuppression, organ-system complications, and certain unique technical issues (such as cyropreservation of stem cells and management of graft-versus-host disease). Minimum criteria for implementing a safe and successful BMT program have been approved by the American Society of Hematology and the American Society of Clinical Oncology (Table 2). 7 The purpose of the guidelines are to ensure the safe and reliable treatments of patients undergoing marrow transplantation. A recent study from the International Bone Marrow Transplantation Registry supports the American Society of Hematology/American Society of Clinical Oncology guidelines. The results of the study indicate that the number of allogeneic bone marrow transplants performed at individual insti-

Seminars in Oncology Nursing, Vol 10, No 1 (February), 1994: pp 64-71

DESIGNING BMT PROGRAMS

Table 1. Marrow Transplantation Program: Design Team Primary BMT medical director Medical hematology/oncology physician Nurse manager Oncology CNS Hospital financial administrator Chief engineer Facility planner Expanded Epidemiologist Laboratory representatives Pharmacy representative Dietary representative Social work representative Environmental service Blood bank representative Abbreviation: CNS, clinical nurse specialist.

tutions for leukemia was predictive of outcome. 3 The adjusted probability of treatment-related mortality was higher among patients having transplantation at centers in which five or fewer transplants were performed per year. Instability of health care reimbursement makes it imperative that the design team develop a comprehensive business plan that begins with a strategic analysis of the external and internal financial environments (Fig 1). 9 Based on the results of this analysis, the hospital will decide whether to be a primary center for BMT or develop a jointmanaged care contract with an already existing program. The next phase of the strategic plan is financial risk analysis to define the scope and potential financial performance of the program. Data to be obtained include information on patient population and insurance coverage mix, types of transplants to be offered, treatment protocols, 5-year projection of transplant numbers, and anticipated increase in ancillary service utilization (Table 3). Nursing unit costs are variable depending on mix of patients, patient room design, ventilation system, equipment needs such as intravenous pumps, and specialized monitoring equipment. The use of disposable supplies for BMT patients tends to be higher than for general oncology patients. 9 Planning for BMT programs must include the prediction for service utilization. The greatest services needed during the initial transplant admission are from pharmacy and laboratory. Regional differences in hospital costs have resulted in a wide

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range of transplant costs. The average cost for types of transplant takes into consideration length of hospitalization and appropriate follow-up outpatient care (Table 4).1~ OPERATIONAL DESIGN

Traditionally, BMT units have been designed so that clinically complex activities are consolidated on a designated inpatient unit. Ancillary services have been organized in a manner that supports the cost-per-service reimbursement system. Patients are protected from airborne spread of infectious agents with a sophisticated, protective environment and stringent infection control practices. Care is provided by a highly skilled and dedicated team. A comprehensive description of this type of Table 2. Criteria for BMT Program issue

Criteria

Patient volume

Sufficient number of transplants (at least 10-20 per year) allowing for designated transplant program. New units should be in compliance within 2 years of operation.

Treatment outcome

Sufficient patient numbers in specific disease groups to be able to compare results with published data from other centers. Mechanism for reporting data to available registries (ie, IBMTR).

Data reporting Personnel

Trained BMT physicians. Consulting physicians with broad range of specialties. Full-time trained and committed nursing staff. Full-time BMT coordinators. Adequate support services (ie, social work, dietary).

Facilities

Designated transplant unit (two or more designated beds) Equipment, experience, and protocols for special handling of marrow after collection (ie, cyropreservation, ABO incompatibility). For allogeneic transplants, certified histocompatibility laboratory. Protocol and equipment for required isolation (high pressure, filtered air, laminar airflow). 24-hour laboratories and radiology support.

Abbreviations: IBMTR, International Bone Marrow Transplantation Registry. Data from American Society of Clinical OncologyJAmerican Society of Hematology. 7 Reprinted with permission. 9

JOLEEN KELLEHER

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E~emal

Market-driven

Organization competencies (What can we do?)

Threats/'opportunities (What might we do?)

Non--marketdriven

Values of key implementations 0Nhat do we want to

Social responsibility (What should we do?)

do?)

--Review of cancer senlice utilization & ancillary services

--Demographic forecast ol cancer population charactedstics

--Admitting patterns

--Areas ol cancer service

--Cancer diagnoses treated

--Consumer demand/preference

--Hematology/oncology physician characteristics --Finarcial performance --Facility inventory --Evaluate technology resources --Organizational assessment of patient care delivery system, communication system, educational resources --Assessment of cancer research activity

--Assessment of competitive programs' strengths, weaknesses, future plans, potential for mutual areas ol shadng --BMT program trends, regional, national --Review of BMT research results --Regulatory environmental mapping, reimbursement trends, laws, and impact of laws and regulations --Labor market

facility and of support service requirements has been previously summarized. 9"12A3 There is a subtle migration of many transplant services to the outpatient and home-care settings. This is due to the improvements in infection prophylaxis, improved management of posttransplant complications, increased utilization of peripheral stem-cell transplants, use of hematopoietic growth factors to promote earlier posttransplant engraftment, and pressure to provide cost-effective care./'~'14 Some transplant programs have already begun realignment to a "unit-without-walls" system by redesigning delivery systems to promote continuity of quality care in a cost-effective manner. Patient care units, departments, and work groups are organizing to work together in new ways.16-19 This system can appear almost seamless

Fig 1. Strategic plan, phase I: Internal and external analysis components.

to the patient. The use of peripheral stem cells for transplant is consistent with this change. Selected patients can safely receive a significant portion of their care in an outpatient setting. Table 5 outlines two approaches to this change in care. 15,20 The use of standardized treatment protocols and care pathways as tools for managing care can result in greater consistency in providing clinical care. 21"22These help to sequence interventions in a predictable manner and avoid problems that may compromise patient care, lengthen hospital stay, and increase cost. 23 Outcome monitoring of clinical care, satisfaction, and cost can be accomplished by using individualized collaborative care pathways. Computerizing these tools can reduce variability in the quality of service, customize care, allow for

DESIGNING BMT PROGRAMS

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Table 3. Strategic Analysis Phase I1: Program Planning and Financial Risk Analys~s

Table 4. Average Cost of Transplant Type Based on Type and Length of Stay DonorType

Inpatient LOS

Outpatient LOS

Cost of Transplant

Autologous Peripheral Bone marrow AIIogeneic Unrelated

8-10 14-21 40-44 44-50

Variable Variable 30-60 30-60

$70,000-$85,000 $80,000-$135,000 $185,000-$225,000 $200,000-$250,000

Areas of focus Type of transplant Percentage of transplant mix Anticipated length of stay Donor pool

Program goal

Types of services provided Environment Patient room design Storage

Space needs

Equipment needs

Capitol equipment Daily supplies

Ancillary services

Blood bank Pharmacy Central service Hematology Microbiology Pathology Radiology OR Services Environmental services Dietary Physical therapy Social work

Review of insurance payor mix

Coverage for BMT

Abbreviation: OR, operating room.

timely revisions of care, improve productivity, and allow for immediate collecting and aggregating of variance data. 24 Care pathways can also help to orient new nurses, physicians, families, and other members of the multidisciplinary team regarding treatment plans and expected outcomes. New clinicians can learn to identify key interventions and respond to variances. NURSING CONSIDERATIONS

Staffing Needs The "unit-without-walls" environment is best suited for nurse managers who can shift from task management to program facilitation and implementation. No one has more potential influence on the delivery of care than the nurse manager. 12 The nurse manager and staff must work effectively with multiple groups in order to facilitate care throughout the transplant process. Creating staffing schedules for the "unitwithout-walls" model can be challenging. Although the sequence of events in the transplant process is predictable, patients' individual responses to treatment and quality of life problems

Abbreviation: LOS, length of stay. Data from Hillner et al,~e and Welch et al. ~

are unpredictable. Changing therapies can have both an immediate and long-term influence on patient acuity.t2'2s The needs of BMT patients predominately fall within the domain of nursing and ancillary services. The transplant nurse is in an ideal position to serve as "case manager," who coordinates and collaborates with other services. Length of stay is controlled, and the staff experience a greater sense of control and satisfaction. 26 Inpatient acuity is variable depending on type and phase of transplant and will increase with the shift of many transplant services to the outpatient setting. The nursing care hours (NCH) per patient day required for BMT patients ranges from 9 to 15 hours. 2s As outpatient services are expanded and discharge criteria become less strict, only acutely ill patients may be cared for in the inpatient setting.14'27A unit with predominantly allogeneic transplant patients would require staffing to accommodate the higher acuity, whereas a unit with mainly autologous BMT requires less staff. Staff mix and job function demand ongoing critical review. Consulting other hospitals with marrow transplant programs can assist in determining predicted NCH. The decision to keep critical care patients on the transplant unit or to transfer them to an intensive care unit can have a dramatic influence on staffing patterns. Critical care needs are almost exclusively a phenomenon of patients undergoing related and unrelated allogeneic transplants. These critical care events include short-term mechanical ventilation for airway management because of severe mucositis, long-term mechanical ventilation for patients who develop adult respiratory distress syndrome or interstitial pneumonia, cardiopulmonary monitoring because of septic shock event or fluid imbalance with veno-occlusive disease, and complications associated with severe graft-versushost disease. 29 It is expensive to prepare an entire

JOLEEN KELLEHER

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Table 5. Examples of Predominately Outpatient Department Transplant Care for Breast Cancer

Site of Service Inpatient Example 1 Conditioning treatment

Outpatient

Physician Office

8-10-day stay in hospital. Anticipate D/C to OPD 24 hours after last dose of chemotherapy. Infusion of peripheral blood stem cells in OPD infusion area. Daily clinic visit. Single daily IV antibiotic treatment, Family member educated to monitor patient in home. Close living proximity to clinic. Clear guidelines on managing complications and admitting for fever. Patient stable

X

Marrow infusion Pre-engraftment

X X

Postengraftment Example II Conditioning treatment

Marrow infusion Pre-engraftment

X

Postengraftment

Description

X X X

3-4--day treatment. Depending on chemotherapy regimen, may receive overnite hydration at home and antiernetics. Family member educated to monitor side effects of chemotherapy infusion Infusion of peripheral blood stem cells in infusion area, Admit to hospital for period of neutropania, D/C when ANC> 500tram. Patient stable.

Abbreviations: ANC, absolute neutrophil count; D/C, discharge; IV, intravenous, OPD, outpatient department.

staff to manage patients requiring variable levels of critical care, especially for only a few patients. The "unit-without-walls" concept of maintaining continuity despite physical location can be successfully extended to the intensive care unit with the use of care pathways. EDUCATION

Nursing Education and training is an empowering process. investing in a mechanism to ensure skill building and information flow are critical to nursing's ability to thrive in the fast-paced transplant environment. Marrow transplant nursing combines a unique blend of skills in the areas of oncology, critical care (even if critical care patients are not kept on the unit), and outpatient services. 9 Rehabilitative care skills are quickly becoming part of the skill mix of transplant nurses. These nurses are becoming more responsible for the planning and caring of an increasing number of survivors and for teaching these survivors to live with the consequences of cure) ~ Nurse managers are in a position to develop a cadre of highly skilled, expert nurses if there is a willingness to invest in initial orientation and ongoing nursing education (Table 6).9'~2 Establishing a mentoring program within the department provides opportunities for ongoing skill building. As the number of survivors of BMT increase, more

nurses in the system and community will have direct contact with these patients and will benefit from a comprehensive training program.

Family As Designated Caregiver The increase in ambulatory treatment for various phases of transplant has increased patient self-care requirements and has placed demands on family members to manage the treatment side effects and interventions in the home setting. This "unitwithout-walls" model clearly identifies the family member as a designated primary caregiver during selected phases of treatment. Therefore, education of the caregiver is essential (Table 7). 31'3z A well-developed resource support program is mandatory. Caregivers are not only managing the physical care and treatment interventions at home but managing the household finances, experiencing alterations in patterns of living and relationships, constantly standing vigil, experiencing expectations from the healthcare system, and still trying to anticipate the future. 3~ Information should be available on housing, transportation, respite care, child care and schooling, financial support, and all available resources. Support groups can focus on pretransplant and posttransplant care. ECONOMIC CONSIDERATIONS

Reimbursement Some critics believe BMT does not represent a cost-effective use of limited health care dollars. 2s

Table 8. BMT Nursing Education

I. CoreOdentetion Concept

Focus

A. Introduction to BMT

Role of BMT in cancer treatment Evolution of types of BMT Successes over the decades Tissue typing Conditioning therapy Immunotherepy Cancer care concepts: contrasting with BMT Criteria for treatment Pretranspiant work-up Marrow harvesting/storage Conditioning regimen Marrow reinfusion Engraftment Reducing microbial contamination Universal precautions Environment issues System review Pathophysiology Incidence Assessment Treatment Nursing management TPN Blood component administration Common transplant medications Antibacterial Antifu ngal Immunomodulators Antihypertensives Antiviral Applying assessment/monitoring skills Use of care pathways

B. Marrow transplant process

C. Infection control practices

D. Acute complications/toxicities

E. Medication/fluid management

F. Clinical decision making

II. Beyondthe BasicCore Education Concept

Focus

A. Outpatient management posttransplant

B. Patient/family coping

C. Psychosocial support for nursing staff

Discharge criteria Infusion therapies Symptom monitoring Patient/family/caregiver education Home care assessment Stages of coping Loss of control issues Anticipatory guidance Multidisciplinary care management Cultural aspects Survivorship Stressors in BMT Aggressive therapy Research Uncertainty/death Strategies for team building/support

D. Ethical issues specific to BMT E. Thriving in the BMT culture in. Secondary Education

Concept A. Care of the critical care patient

Abbreviation: TPN, total parenteral nutrition.

Focus Critical events Hernodynamic monitoring Mechanical ventilation

JOLEEN KELLEHER

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Table 7. Patient/Caregiver Education

Concept Orientation to system

Content

Inpatient Outpatient Home-care role as designated caregiver

Process of marrow

transplantation

Chemotherapy (outpatient administration)

Preventing infections Central-line care Marrow donor

Home environment Monitoring the patient at home Medication/IV infusions

Evaluation for BMT Conditioning Transplantation Engraftment Managing complications Self-care activities Purpose of chemotherapy Administration procedures Preventing/managingside effects Resource support Rationale

Handwashing skills Site care Flushing Troubleshooting Procedure Support services Daily activities

Preventing infections Symptom monitoring AssessmenUdecision making Resource support

Emergencies Administration techniques Self-documentation Safety

There is little research to evaluate cost-effectiveness and the cost-benefit ratio. 25'29 Welch and Larsen ~ demonstrated that transplantation for acute nonlymphocytic leukemia compares favorably in outcome with conventional therapy in morbidity and mortality. However, the study failed to consider a higher performance level of the patients undergoing BMT when determining the level of health posttherapy. HiUner et al, 1~ using reasonable assumptions, found that autologous bone marrow transplant for metastatic breast cancer provides a substantial benefit but at a cost that may be untenable. This supports the need for randomized clinical trails. Some bone marrow transplants are considered standard therapy, state-of-the-art, or investigational. In this price-sensitive environment, a BMT that is recognized as a conventional therapy is more likely to be covered than ones recognized as investigational.25 Establishing an insurance liaison position to deal with reimbursement may be a cru-

cial factor in determining the viability of a BMT program. It also gives the center an opportunity to educate third-party payors about the center's treatment standards, cost, and remission and survival data. This person can help the team remain current about reimbursement trends. Many insurers are requiring pretreatment authorization and are negotiating financial capitation as in per diem or global fee. Establishing standard guidelines regulating recipient selection and better accounting of cost of service can reduce financial risk for the institution as it negotiates contracts with insurers. 33

Length of Stay There are few treatments that have an inpatient length of stay between 35 to 44 days and a need for outpatient follow-up care up to 60 days after transplant. Flowcharting the chronology of transplant patient movement through the "seamless" system provides a method of uncovering differences between program policies and actual operations and helps to identify cost-saving changes. New therapies such as use of hematopoietic colonystimulating factors and use of peripherally harvested stem cells are examples of the therapies influencing costs and providing a potential reduction in the morbidity and length of stay associated with ABMT.1'34 Shifting of care to a lower cost unit (ie, delivering conditioning chemotherapy in the clinic or training a designated family caregiver to monitor patient and give therapy in the home) can significantly reduce length of stay and cost per transplant day while still retaining quality.

CONCLUSION

Centers that design a creative and effective BMT program can be viable in this era of limited health care dollars. Ongoing evaluation of cost and outcome is of critical importance to not only the center but also to patients, insurers, and health care policy makers. The growth and survival of this specialty will be based on this information. Nurses should take a leadership role in developing and managing the clinical and financial outcomes in this chaotic and paradoxical decade.

DESIGNING BMT PROGRAMS

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REFERENCES

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