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Too Cool for Mucositis: Oral Cryotherapy during Melphalan Infusion
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
S443
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676
Increasing Activities of Daily Living Is As Easy As 1-2-3 Deanna Best II 1, Shawn Mock II 1, Christopher E. Dandoy 1, Shivonne Kiniyalocts II 1, Erin Osterkamp II 2, Kathleen Marie Demmel 3, Kelly Mulligan 2, Angela Bell 2, Crystal Doughman 1, Miranda Flemming 2, Laura Flesch 1, Deanna Hawkins 2, Abigail Pate1, Ashely Bedel 4, Lori Ann McKenna 5, Ashley Teusink 6, Sonata Jodele 1, Rajaram Nagarajan7, John Perentesis 8, Stella M. Davies 1, Ashley West 9, Brenda Mott 10. 1 Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2 Hematology/Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, OH; 4 PharmD, Cincinnati Children’s Hospital, Cincinnati, OH; 5 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 6 Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 7 Cincinnati Children’s Hospital Medical Center, cincinnati, OH; 8 Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 9 Cincinnati Children’s Hospital, Cincinnati, OH; 10 Bone Marrow Tranpslantation and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
Too Cool for Mucositis: Oral Cryotherapy during Melphalan Infusion Lauren Bianchi 1, Malinda Law 2, D. Kathryn Tierney 3. 1 Stanford Health Care, Palo Alto, CA; 2 Infusion Treatment Area, Stanford Health Care, Palo Alto, CA; 3 Blood and Marrow Transplantation, Stanford Health Care, Stanford, CA
Topic Significance & Study Purpose/Background/ Rationale: The organisms of the human flora are the most common cause of bacteremia and sepsis in immunocompromised and bone marrow transplant (BMT) patients. Activities of daily living (ADL) may potentially lower the risk of infection by decreasing pathogenic bacteria on the skin and mouth. A literature review was inconclusive for ADLs lowering the risk of infections in BMT patients. To address ADL compliance, a multidisciplinary team of both oncology and BMT units consisting of PCAs, RNs, nursing leadership and physicians was created. Methods, Intervention, & Analysis: To improve compliance, the team adopted the ADL 1-2-3 initiative: Daily bath/ chlorhexidine (CHG) bath and linen change, at least 2 activities per day, and oral care 3 times per day. Using the Model of Improvement and through Plan Do Study Act (PDSA) testing, we created a standardized ADL process that involved all providers. Interventions included addressing 1-2-3 compliance during rounds, creating accountability in care delivery, creation of an algorithm and order set for oral care, daily text message reminders, and physician intervention with non-compliant and high-risk patients. Findings & Interpretation: Our baseline compliance with the 1-2-3 initiative was 25%. With our interventions we increased our median compliance to 66% in 90 days. The greatest impact on compliance was seen with text message reminders to staff to complete the 1-2-3 components, designated roles and responsibilities, and physician discussion with noncompliant and high-risk patients. Our current compliance, as of September 3rd, 2015, is 78.7%. Discussion & Implications: The 53% increase in ADL compliance for BMT validates the importance of a multidisciplinary team collaborating with the patient and family. Multiple factors were found to disrupt the flow of care being provided to the patient. Utilizing the oral care algorithm and order set, daily text message reminders, and physician intervention with non-compliant and high-risk patients were found to offset these disruptions. Units where compliance with ADL participation is low would be an ideal environment to incorporate the ADL 1-2-3 initiative.
Topic Significance & Study Purpose/Background/ Rationale: The purpose was to implement oral cryotherapy (OC) during melphalan infusion to prevent and mitigate mucositis in patients with multiple myeloma undergoing autologous HSCT. The primary endpoint of interest was the rate of unplanned hospital admissions due to mucositis. Mucositis is a debilitating side effect of certain chemotherapies and can lead to pain, decreased oral intake, infection, and hospitalization. At our institution, patients with multiple myeloma receive melphalan before HSCT, and mucositis frequently develops. While the post-transplant recovery phase is intended to occur in the outpatient setting, from 2012 through early 2014, 23% of patients were admitted due to mucositis in the absence of fever. Research indicates OC is associated with a reduction in incidence, duration, and severity of mucositis and oncology organizations support its use. As nurses administer the mucotoxic melphalan, they have the unique role of implementing OC. Methods, Intervention, & Analysis: After staff approval, OC was adopted as a standardized practice change. Beginning in early 2014, patients swirled and swallowed ice chips and water before, during, and after melphalan infusion. All unit nurses were educated on OC and were randomly assigned to care for melphalan patients, thus promoting external validity. Episodes and reasons for inpatient admissions were recorded by one researcher to facilitate reliability. The 164 patients who underwent the transplant process in the two years prior to OC implementation served as a comparison group to the 126 patients who practiced OC from February 2014 through July 2015. Findings & Interpretation The rate of admission for mucositis decreased from 23% (n¼37) before OC to 8% (n¼10) post-implementation. The proportion of patients who were never admitted increased from 20% (n¼32) before OC to 46% (n¼58) post-intervention. OC was associated with fewer unplanned admissions due to mucositis (p¼.0008) and more patients completing the transplant process in the outpatient setting (p<.0001). These findings support the published benefits of OC. Discussion & Implications: OC was an easy, low cost, and effective way to prevent mucositis and thus should be implemented in current practice. Future analyses of interest include the influence of demographic factors on development of mucositis, the financial impact of OC, and the association of mucositis and OC with neutropenic fevers.
677 Extracorporeal Apheresis Via AV Fistula in Multiple Myeloma Patients with End Stage Renal Disease Jennifer Bourke 1, Tomer M. Mark 2, Jeffrey Silberzweig 3, Uvannie Enriquez 4, Koen van Besien 5, Brigitte Herbert 4, Kenrick Michael Keppel 6, Tara Maryles 6. 1 Bone Marrow Transplant, NewYork-Presbyterian Hospital Weill Cornell Medical Center, New York, NY; 2 Department of Medicine, Weill Cornell Medical College, New York, NY; 3 Nephrology, New York Presbyterian Weill Cornell, New York, NY; 4 Dialysis, New York
S443
675
676
Increasing Activities of Daily Living Is As Easy As 1-2-3 Deanna Best II 1, Shawn Mock II 1, Christopher E. Dandoy 1, Shivonne Kiniyalocts II 1, Erin Osterkamp II 2, Kathleen Marie Demmel 3, Kelly Mulligan 2, Angela Bell 2, Crystal Doughman 1, Miranda Flemming 2, Laura Flesch 1, Deanna Hawkins 2, Abigail Pate1, Ashely Bedel 4, Lori Ann McKenna 5, Ashley Teusink 6, Sonata Jodele 1, Rajaram Nagarajan7, John Perentesis 8, Stella M. Davies 1, Ashley West 9, Brenda Mott 10. 1 Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2 Hematology/Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, OH; 4 PharmD, Cincinnati Children’s Hospital, Cincinnati, OH; 5 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 6 Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 7 Cincinnati Children’s Hospital Medical Center, cincinnati, OH; 8 Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 9 Cincinnati Children’s Hospital, Cincinnati, OH; 10 Bone Marrow Tranpslantation and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
Too Cool for Mucositis: Oral Cryotherapy during Melphalan Infusion Lauren Bianchi 1, Malinda Law 2, D. Kathryn Tierney 3. 1 Stanford Health Care, Palo Alto, CA; 2 Infusion Treatment Area, Stanford Health Care, Palo Alto, CA; 3 Blood and Marrow Transplantation, Stanford Health Care, Stanford, CA
Topic Significance & Study Purpose/Background/ Rationale: The organisms of the human flora are the most common cause of bacteremia and sepsis in immunocompromised and bone marrow transplant (BMT) patients. Activities of daily living (ADL) may potentially lower the risk of infection by decreasing pathogenic bacteria on the skin and mouth. A literature review was inconclusive for ADLs lowering the risk of infections in BMT patients. To address ADL compliance, a multidisciplinary team of both oncology and BMT units consisting of PCAs, RNs, nursing leadership and physicians was created. Methods, Intervention, & Analysis: To improve compliance, the team adopted the ADL 1-2-3 initiative: Daily bath/ chlorhexidine (CHG) bath and linen change, at least 2 activities per day, and oral care 3 times per day. Using the Model of Improvement and through Plan Do Study Act (PDSA) testing, we created a standardized ADL process that involved all providers. Interventions included addressing 1-2-3 compliance during rounds, creating accountability in care delivery, creation of an algorithm and order set for oral care, daily text message reminders, and physician intervention with non-compliant and high-risk patients. Findings & Interpretation: Our baseline compliance with the 1-2-3 initiative was 25%. With our interventions we increased our median compliance to 66% in 90 days. The greatest impact on compliance was seen with text message reminders to staff to complete the 1-2-3 components, designated roles and responsibilities, and physician discussion with noncompliant and high-risk patients. Our current compliance, as of September 3rd, 2015, is 78.7%. Discussion & Implications: The 53% increase in ADL compliance for BMT validates the importance of a multidisciplinary team collaborating with the patient and family. Multiple factors were found to disrupt the flow of care being provided to the patient. Utilizing the oral care algorithm and order set, daily text message reminders, and physician intervention with non-compliant and high-risk patients were found to offset these disruptions. Units where compliance with ADL participation is low would be an ideal environment to incorporate the ADL 1-2-3 initiative.
Topic Significance & Study Purpose/Background/ Rationale: The purpose was to implement oral cryotherapy (OC) during melphalan infusion to prevent and mitigate mucositis in patients with multiple myeloma undergoing autologous HSCT. The primary endpoint of interest was the rate of unplanned hospital admissions due to mucositis. Mucositis is a debilitating side effect of certain chemotherapies and can lead to pain, decreased oral intake, infection, and hospitalization. At our institution, patients with multiple myeloma receive melphalan before HSCT, and mucositis frequently develops. While the post-transplant recovery phase is intended to occur in the outpatient setting, from 2012 through early 2014, 23% of patients were admitted due to mucositis in the absence of fever. Research indicates OC is associated with a reduction in incidence, duration, and severity of mucositis and oncology organizations support its use. As nurses administer the mucotoxic melphalan, they have the unique role of implementing OC. Methods, Intervention, & Analysis: After staff approval, OC was adopted as a standardized practice change. Beginning in early 2014, patients swirled and swallowed ice chips and water before, during, and after melphalan infusion. All unit nurses were educated on OC and were randomly assigned to care for melphalan patients, thus promoting external validity. Episodes and reasons for inpatient admissions were recorded by one researcher to facilitate reliability. The 164 patients who underwent the transplant process in the two years prior to OC implementation served as a comparison group to the 126 patients who practiced OC from February 2014 through July 2015. Findings & Interpretation The rate of admission for mucositis decreased from 23% (n¼37) before OC to 8% (n¼10) post-implementation. The proportion of patients who were never admitted increased from 20% (n¼32) before OC to 46% (n¼58) post-intervention. OC was associated with fewer unplanned admissions due to mucositis (p¼.0008) and more patients completing the transplant process in the outpatient setting (p<.0001). These findings support the published benefits of OC. Discussion & Implications: OC was an easy, low cost, and effective way to prevent mucositis and thus should be implemented in current practice. Future analyses of interest include the influence of demographic factors on development of mucositis, the financial impact of OC, and the association of mucositis and OC with neutropenic fevers.
677 Extracorporeal Apheresis Via AV Fistula in Multiple Myeloma Patients with End Stage Renal Disease Jennifer Bourke 1, Tomer M. Mark 2, Jeffrey Silberzweig 3, Uvannie Enriquez 4, Koen van Besien 5, Brigitte Herbert 4, Kenrick Michael Keppel 6, Tara Maryles 6. 1 Bone Marrow Transplant, NewYork-Presbyterian Hospital Weill Cornell Medical Center, New York, NY; 2 Department of Medicine, Weill Cornell Medical College, New York, NY; 3 Nephrology, New York Presbyterian Weill Cornell, New York, NY; 4 Dialysis, New York