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Caregiver Efficacy: The Cornerstone of Outpatient Care
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
nurse practitioner, clinical nurse specialist, and 1-2 nurses remain in the room during all HCI to monitor patients. Emergency medications are drawn up prior to initiation of HCI. Our objective is to safely reduce the number of personnel and medications wasted during HCI. Methods, Intervention, & Analysis: We studied product characteristics and risk factors that can lead to infusion related adverse events. Infusion reactions were classified based on the NCI criteria as none (grade 0), mild (grade 1), moderate (grade 2), severe (grade 3), life threatening (grade 4). Findings & Interpretation: From 2005-14, 363 HCI were performed (table 1). The mean volume of product was 72.8 (SD¼187.6) mls and median was 99.5 (0.4-1118) mls. Mean infusion time was 55.7 (SD¼52.5) minutes. The mean infusion time for CD34+ selected products was significantly shorter when compared to other products [CD34 mean¼34.2 (SD¼13.4), vs. others mean¼58.6 (SD¼55.3), (t-test p-value <0.001)]. The incidence of grade 0,1,2,3 and 4 adverse reactions was 0¼68.9%, 1¼22.6%, 2¼6.9%, 3¼0.8%, 4¼0.8%. The incidence of toxicities was: hypertension(26%) gastrointestinal(4.96%), Fever(0.8%), respiratory distress(2.5%), sepsis(0.3%), hypotension(0.6%), allergic reactions(2.5%), neurological events(1.7%). Univariate logistic regression analysis of risk factors in table 1 were not significantly associated with grade II-IV infusion reactions at significance level 0.05. Only large volume infusion (Odds ratio 1.002, 95% CI: 1.001-1.004, p¼0.002) were associated with grade II-IV infusion reactions. In a separate analysis comparing various HCI, CD34+ selected products had the lowest risk of reactions compared to other products (Chi-square test p-value¼0.027). Discussion & Implications: In summary, HCI in children are safe. This quality initiative will provided guidance regarding monitoring and potentially decrease the wastage of emergency medications.
690 Hand Offs in BMT Nursing Costandina Alexia Herbert 1, Courtney Guadiz 2, Allison Miller 3, Parisa Tsutsumi 4. 1 Outpatient BMT, Seattle Cancer Care Alliance, Seattle, WA; 2 Inpatient BMT, University of Washington Medical, Seatttle, WA; 3 Inpatient BMT nursing, University of Washington Medical, Seattle, WA; 4 Inpatient BMT, University of Washington Medical Center, Seattle, WA Topic Significance & Study Purpose/Background/ Rationale: BMT care has moved primarily to outpatient departments (OPD) yet there are still necessary hand offs between OPD and inpatient departments (IPD). In an NCCN center treating 500 BMT patients a year a quality project was undertaken to examine handoffs between IPD and OPD. The purpose was to identify teaching and preparation at hand offs, to ascertain quality of content, identify possible needs not addressed in transitions, and to build collaboration between IPD and OPD nursing. Methods, Intervention, & Analysis: A team including IPD and OPD nurses performed chart reviews of 5 allogeneic transplant patients following pre and post-transplant course care. Chart reviews of education included parameters of teaching, questions, and materials given to patients, as well as clinical trajectory. Clinical trajectory included patient specific admissions, complications and needs for consultations such as chaplaincy, social work, and psychology.
S449
Findings & Interpretation: Charting was found to be consistent for most time points and parameters. The chart review was labor intensive as documents were “nonminable” requiring word by word review. Ability to track materials given and patient satisfaction with teaching and materials was not discernable. These systems limitations therefore, rendered findings inadequate to formulate conclusions relative to quality and content of education at BMT hand offs. Discussion & Implications: Although the NCCN BMT IPD and OPD centers share an electronic medical record (EMR) standardization is needed to provide tracking of education in a results flowsheet. Education and content needs to be standardized to mesh with EMR documentation. Discussions have begun with EMR team to design standardized information and flow charts to improve tracking education handoffs for BMT patients and families simultaneous to the work of content standardization. These efforts will help ensure the best clinical outcomes for BMT patients and families.
692 Caregiver Efficacy: The Cornerstone of Outpatient Care Ann Breen, Teri Lewan, Amy Heissenbuttel, Michelle Hamilton, Patty Roleru, Kari Ann Kastle. Transition Services, Seattle Cancer Care Alliance, Seattle, WA Topic Significance & Study Purpose/Background/ Rationale: The cornerstone of patient safety in an ambulatory setting is caregiver education. A Caregiver Competency Checklist (CCC) and Caregiver 101 Skill’s Lab (CG101) were developed to promote caregiver efficacy. Both of these approaches provide self-directed learning with expert guidance. High risk caregiver situations are common due to insufficient financial, emotional, or time resources. During the development of the CCC and CG101 a multidisciplinary team was engaged through the Transplant Operational Committee (TCOT). Because medical care is increasingly provided in ambulatory settings care responsibilities are being shifted to the caregiver. Transition Service Program armamentarium traditionally included individual consults, classes, and online videos. New educational strategies are being deployed to customize education for caregivers and promote safety. The addition of CG101 allows active practice while CCC allows caregivers to self-evaluate their competencies in a more detailed fashion. Methods, Intervention, & Analysis: The intervention promotes active caregiver engagement. CCC provides for selfevaluation of core competencies and the CG101 provides skills practice. This approach utilizes the teach-back methodology emphasizing accountability and builds caregiver confidence. Caregivers learn about essential phone numbers, home infusion, emergency line care, home symptom management, safe lifting, and stress management. Findings & Interpretation: Preliminary class evaluation data and case examples will be presented Discussion & Implications: By using teach-back methodology, hands on skills lab, and self-evaluation caregivers and the educator will be able to individualize education. The CCC and CG101 focus education using real world examples of care needs. Evaluation of this class will be reviewed by TCOT. Constraints on professional time and financial resources necessitate finding ways to individualize care in a classroom setting. This is imperative for patient safety. Future teaching and caregiver engagement will emphasize individualized,
S450
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
“hands on” approaches. Many outpatient oncology centers face the same challenges with caregiver education and training to ensure patient safety. Other centers can adapt this model for their own setting.
recommend consideration of a course of HBOT as the preferred treatment for HC which persists despite hyperhydration and bladder irrigation, prior to use of other invasive modalities.
693
694
Hyperbaric Oxygen as an Early Treatment Modality in Cyclophosphamide Induced Hemorrhagic Cystitis Dominder Kaur 1, Shakila P. Khan 2, Vilmarie Rodriguez 2, Julia Gourde 3, Carola Arndt 4, Paul L. Claus 5. 1 Division of Pediatric and Adolescent Medicine, Pediatric Hematology/ Oncology, Mayo Clinic, Rochester, Rochester, MN; 2 Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN; 3 Pediatric Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN; 4 Division of Pediatric Hematology Oncology, Mayo Clinic, Rochester, Rochester, MN; 5 Division of Hyperbaric and Altitude Medicine, Mayo Clinic, Rochester, Rochester, MN
Examination of the Relationship Between Change in Skin Physiology of a Patient Undergoing Allogeneic Hematopoietic Stem Cell Transplantation and Acute Skin Graft Versus Host Disease Tatsuya Kishi 1, Mayumi Tsukakoshi2, Tomoko Fukuda3, Naoya Sakurada4, Yuuta Shigetomi5, Mutsumi Yokokawa6, Rui Tatehana5, Takuya Yamashita7. 1 National Cancer Center Hospital, Japan, Chuo-ku, Japan; 2 nursing, National cancer center Japan, tyuo-ku tokyo, Japan; 3 nursing, National cancer center @Japan, tyuo-ku tokyo, Japan; 4 National cancer center Japan, Chuo-ku Tokyo, Japan; 5 nursing, National cancer center Japan, chuo-ku tokyo, Japan; 6 nursing, National cancer center Japan, chuo-ku, Japan; 7 Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
Topic Significance & Study Purpose/Background/ Rationale: Hemorrhagic cystitis is a well-recognized complication of Cyclophosphamide/Acrolein induced urothelial toxicity despite use of Mesna. It poses a management challenge if hyperhydration and bladder irrigation fail to resolve symptoms. The data regarding use of Hyperbaric Oxygen therapy (HBOT) as an early treatment modality in this clinical setting is limited. We present two cases that developed grade 3 hemorrhagic cystitis (HC) after hematopoietic stem cell transplant conditioning, and responded well to HBOT. Methods, Intervention, & Analysis: Patients who received bone marrow transplant at our institute over the past five years were screened and cases with hemorrhagic cystitis refractory to traditional first line treatment were reviewed. We identified two patients who were treated with hyperbaric oxygen. Findings & Interpretation: Case 1: 17 year old female with chronic myeloid leukemia underwent allogeneic bone marrow transplant after conditioning with Busulfan, Cyclophosphamide and Campath. She developed severe dysuria and hematuria on Day +70 from transplant, along with significant BK viruria. Initial treatments included hyperhydration, systemic estrogen, intravesical Cidofovir, Prostaglandins and Hydrocortisone over a period of two months. Treatment with HBOT was initiated due to persistent symptoms. Case 2: 26 year old male with small cell lymphocytic lymphoma underwent double umbilical cord transplant after conditioning with fludarabine, cyclophosphamide, and total body irradiation. On day +28 from transplant, he was admitted for significant hematuria with passage of clots. At this time, he was found to have Adenovirus viremia but was negative for BK virus. Hyperhydration, Tamsulosin and bladder irrigation did not lead to complete resolution of symptoms and HBOT was initiated. They were treated with 20 and 30 daily sessions, respectively; with 100% oxygen for 90 minutes at 105 kPa (2 ATA). Both patients reported improved symptoms within first two weeks of initiation of sessions along with diminishing of hematuria. Discussion & Implications: In comparison to other second line treatment modalities for HC, hyperbaric oxygen is less invasive and had higher acceptability in our patients, particularly because it is an outpatient treatment. We
Topic Significance & Study Purpose/Background/ Rationale: We prospectively investigated the water holding ability of the skin in the patients who received allogeneic hematopoietic stem cell transplantation (HSCT), and examined the relationship between the onset of acute graftversus-host disease (GVHD) and the physiological change of the skin. Methods, Intervention, & Analysis: We collected the data of skin-keratin-fluid volume and amount of sebum at precordium and lower arm from 3 HSCT recipients. In each recipient, we measured these values nine times at regular interval from the start of conditioning regimen to day 35 after stem cell infusion. We used Corneometer CM825 (Courage and Khazaka, Germany) and Sebumeter SM815 (Courage and Khazaka, Germany) for the measurement of skin-keratin-fluid volume and amount of sebum respectively. We collected clinical information from their medical records. Findings & Interpretation: The average values of the skinkeratin-fluid volume at precordium and lower arm were 68.6 and 47.2, respectively. The average value of the amount of sebum was 18.7. Acute GVHD of the skin developed in two recipients. In a recipient who had acute GVHD of the skin in stage 3 at day 7 after transplant, the average of the skinkeratin-fluid volume at precordium and lower arm were 55.5 and 28.8 respectively, and the average of the amount of sebum was 1.66. Another recipient with acute GVHD of the skin in stage 1 at day 14, the average of the skin-keratin-fluid volume at precordium and lower arm were 54.1 and 28.5 respectively, and the average of the amount of sebum was 23.6. Discussion & Implications: We found that the amount of sebum dramatically decreased just before the onset of skin GVHD during the clinical courses of some patients who received HSCT. The immune reactions derived from donor Tcells may affect the function of the sebaceous glands of these recipients. On the other hand, the onset of acute GVHD of the skin did not change the skin-keratin-fluid volumes in HSCT recipients. To investigate the impact of the onset of acute GVHD on the water holding ability of the skin will bring us the clue to develop the proper procedures of skin care for HSCT recipients.
nurse practitioner, clinical nurse specialist, and 1-2 nurses remain in the room during all HCI to monitor patients. Emergency medications are drawn up prior to initiation of HCI. Our objective is to safely reduce the number of personnel and medications wasted during HCI. Methods, Intervention, & Analysis: We studied product characteristics and risk factors that can lead to infusion related adverse events. Infusion reactions were classified based on the NCI criteria as none (grade 0), mild (grade 1), moderate (grade 2), severe (grade 3), life threatening (grade 4). Findings & Interpretation: From 2005-14, 363 HCI were performed (table 1). The mean volume of product was 72.8 (SD¼187.6) mls and median was 99.5 (0.4-1118) mls. Mean infusion time was 55.7 (SD¼52.5) minutes. The mean infusion time for CD34+ selected products was significantly shorter when compared to other products [CD34 mean¼34.2 (SD¼13.4), vs. others mean¼58.6 (SD¼55.3), (t-test p-value <0.001)]. The incidence of grade 0,1,2,3 and 4 adverse reactions was 0¼68.9%, 1¼22.6%, 2¼6.9%, 3¼0.8%, 4¼0.8%. The incidence of toxicities was: hypertension(26%) gastrointestinal(4.96%), Fever(0.8%), respiratory distress(2.5%), sepsis(0.3%), hypotension(0.6%), allergic reactions(2.5%), neurological events(1.7%). Univariate logistic regression analysis of risk factors in table 1 were not significantly associated with grade II-IV infusion reactions at significance level 0.05. Only large volume infusion (Odds ratio 1.002, 95% CI: 1.001-1.004, p¼0.002) were associated with grade II-IV infusion reactions. In a separate analysis comparing various HCI, CD34+ selected products had the lowest risk of reactions compared to other products (Chi-square test p-value¼0.027). Discussion & Implications: In summary, HCI in children are safe. This quality initiative will provided guidance regarding monitoring and potentially decrease the wastage of emergency medications.
690 Hand Offs in BMT Nursing Costandina Alexia Herbert 1, Courtney Guadiz 2, Allison Miller 3, Parisa Tsutsumi 4. 1 Outpatient BMT, Seattle Cancer Care Alliance, Seattle, WA; 2 Inpatient BMT, University of Washington Medical, Seatttle, WA; 3 Inpatient BMT nursing, University of Washington Medical, Seattle, WA; 4 Inpatient BMT, University of Washington Medical Center, Seattle, WA Topic Significance & Study Purpose/Background/ Rationale: BMT care has moved primarily to outpatient departments (OPD) yet there are still necessary hand offs between OPD and inpatient departments (IPD). In an NCCN center treating 500 BMT patients a year a quality project was undertaken to examine handoffs between IPD and OPD. The purpose was to identify teaching and preparation at hand offs, to ascertain quality of content, identify possible needs not addressed in transitions, and to build collaboration between IPD and OPD nursing. Methods, Intervention, & Analysis: A team including IPD and OPD nurses performed chart reviews of 5 allogeneic transplant patients following pre and post-transplant course care. Chart reviews of education included parameters of teaching, questions, and materials given to patients, as well as clinical trajectory. Clinical trajectory included patient specific admissions, complications and needs for consultations such as chaplaincy, social work, and psychology.
S449
Findings & Interpretation: Charting was found to be consistent for most time points and parameters. The chart review was labor intensive as documents were “nonminable” requiring word by word review. Ability to track materials given and patient satisfaction with teaching and materials was not discernable. These systems limitations therefore, rendered findings inadequate to formulate conclusions relative to quality and content of education at BMT hand offs. Discussion & Implications: Although the NCCN BMT IPD and OPD centers share an electronic medical record (EMR) standardization is needed to provide tracking of education in a results flowsheet. Education and content needs to be standardized to mesh with EMR documentation. Discussions have begun with EMR team to design standardized information and flow charts to improve tracking education handoffs for BMT patients and families simultaneous to the work of content standardization. These efforts will help ensure the best clinical outcomes for BMT patients and families.
692 Caregiver Efficacy: The Cornerstone of Outpatient Care Ann Breen, Teri Lewan, Amy Heissenbuttel, Michelle Hamilton, Patty Roleru, Kari Ann Kastle. Transition Services, Seattle Cancer Care Alliance, Seattle, WA Topic Significance & Study Purpose/Background/ Rationale: The cornerstone of patient safety in an ambulatory setting is caregiver education. A Caregiver Competency Checklist (CCC) and Caregiver 101 Skill’s Lab (CG101) were developed to promote caregiver efficacy. Both of these approaches provide self-directed learning with expert guidance. High risk caregiver situations are common due to insufficient financial, emotional, or time resources. During the development of the CCC and CG101 a multidisciplinary team was engaged through the Transplant Operational Committee (TCOT). Because medical care is increasingly provided in ambulatory settings care responsibilities are being shifted to the caregiver. Transition Service Program armamentarium traditionally included individual consults, classes, and online videos. New educational strategies are being deployed to customize education for caregivers and promote safety. The addition of CG101 allows active practice while CCC allows caregivers to self-evaluate their competencies in a more detailed fashion. Methods, Intervention, & Analysis: The intervention promotes active caregiver engagement. CCC provides for selfevaluation of core competencies and the CG101 provides skills practice. This approach utilizes the teach-back methodology emphasizing accountability and builds caregiver confidence. Caregivers learn about essential phone numbers, home infusion, emergency line care, home symptom management, safe lifting, and stress management. Findings & Interpretation: Preliminary class evaluation data and case examples will be presented Discussion & Implications: By using teach-back methodology, hands on skills lab, and self-evaluation caregivers and the educator will be able to individualize education. The CCC and CG101 focus education using real world examples of care needs. Evaluation of this class will be reviewed by TCOT. Constraints on professional time and financial resources necessitate finding ways to individualize care in a classroom setting. This is imperative for patient safety. Future teaching and caregiver engagement will emphasize individualized,
S450
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
“hands on” approaches. Many outpatient oncology centers face the same challenges with caregiver education and training to ensure patient safety. Other centers can adapt this model for their own setting.
recommend consideration of a course of HBOT as the preferred treatment for HC which persists despite hyperhydration and bladder irrigation, prior to use of other invasive modalities.
693
694
Hyperbaric Oxygen as an Early Treatment Modality in Cyclophosphamide Induced Hemorrhagic Cystitis Dominder Kaur 1, Shakila P. Khan 2, Vilmarie Rodriguez 2, Julia Gourde 3, Carola Arndt 4, Paul L. Claus 5. 1 Division of Pediatric and Adolescent Medicine, Pediatric Hematology/ Oncology, Mayo Clinic, Rochester, Rochester, MN; 2 Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN; 3 Pediatric Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN; 4 Division of Pediatric Hematology Oncology, Mayo Clinic, Rochester, Rochester, MN; 5 Division of Hyperbaric and Altitude Medicine, Mayo Clinic, Rochester, Rochester, MN
Examination of the Relationship Between Change in Skin Physiology of a Patient Undergoing Allogeneic Hematopoietic Stem Cell Transplantation and Acute Skin Graft Versus Host Disease Tatsuya Kishi 1, Mayumi Tsukakoshi2, Tomoko Fukuda3, Naoya Sakurada4, Yuuta Shigetomi5, Mutsumi Yokokawa6, Rui Tatehana5, Takuya Yamashita7. 1 National Cancer Center Hospital, Japan, Chuo-ku, Japan; 2 nursing, National cancer center Japan, tyuo-ku tokyo, Japan; 3 nursing, National cancer center @Japan, tyuo-ku tokyo, Japan; 4 National cancer center Japan, Chuo-ku Tokyo, Japan; 5 nursing, National cancer center Japan, chuo-ku tokyo, Japan; 6 nursing, National cancer center Japan, chuo-ku, Japan; 7 Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
Topic Significance & Study Purpose/Background/ Rationale: Hemorrhagic cystitis is a well-recognized complication of Cyclophosphamide/Acrolein induced urothelial toxicity despite use of Mesna. It poses a management challenge if hyperhydration and bladder irrigation fail to resolve symptoms. The data regarding use of Hyperbaric Oxygen therapy (HBOT) as an early treatment modality in this clinical setting is limited. We present two cases that developed grade 3 hemorrhagic cystitis (HC) after hematopoietic stem cell transplant conditioning, and responded well to HBOT. Methods, Intervention, & Analysis: Patients who received bone marrow transplant at our institute over the past five years were screened and cases with hemorrhagic cystitis refractory to traditional first line treatment were reviewed. We identified two patients who were treated with hyperbaric oxygen. Findings & Interpretation: Case 1: 17 year old female with chronic myeloid leukemia underwent allogeneic bone marrow transplant after conditioning with Busulfan, Cyclophosphamide and Campath. She developed severe dysuria and hematuria on Day +70 from transplant, along with significant BK viruria. Initial treatments included hyperhydration, systemic estrogen, intravesical Cidofovir, Prostaglandins and Hydrocortisone over a period of two months. Treatment with HBOT was initiated due to persistent symptoms. Case 2: 26 year old male with small cell lymphocytic lymphoma underwent double umbilical cord transplant after conditioning with fludarabine, cyclophosphamide, and total body irradiation. On day +28 from transplant, he was admitted for significant hematuria with passage of clots. At this time, he was found to have Adenovirus viremia but was negative for BK virus. Hyperhydration, Tamsulosin and bladder irrigation did not lead to complete resolution of symptoms and HBOT was initiated. They were treated with 20 and 30 daily sessions, respectively; with 100% oxygen for 90 minutes at 105 kPa (2 ATA). Both patients reported improved symptoms within first two weeks of initiation of sessions along with diminishing of hematuria. Discussion & Implications: In comparison to other second line treatment modalities for HC, hyperbaric oxygen is less invasive and had higher acceptability in our patients, particularly because it is an outpatient treatment. We
Topic Significance & Study Purpose/Background/ Rationale: We prospectively investigated the water holding ability of the skin in the patients who received allogeneic hematopoietic stem cell transplantation (HSCT), and examined the relationship between the onset of acute graftversus-host disease (GVHD) and the physiological change of the skin. Methods, Intervention, & Analysis: We collected the data of skin-keratin-fluid volume and amount of sebum at precordium and lower arm from 3 HSCT recipients. In each recipient, we measured these values nine times at regular interval from the start of conditioning regimen to day 35 after stem cell infusion. We used Corneometer CM825 (Courage and Khazaka, Germany) and Sebumeter SM815 (Courage and Khazaka, Germany) for the measurement of skin-keratin-fluid volume and amount of sebum respectively. We collected clinical information from their medical records. Findings & Interpretation: The average values of the skinkeratin-fluid volume at precordium and lower arm were 68.6 and 47.2, respectively. The average value of the amount of sebum was 18.7. Acute GVHD of the skin developed in two recipients. In a recipient who had acute GVHD of the skin in stage 3 at day 7 after transplant, the average of the skinkeratin-fluid volume at precordium and lower arm were 55.5 and 28.8 respectively, and the average of the amount of sebum was 1.66. Another recipient with acute GVHD of the skin in stage 1 at day 14, the average of the skin-keratin-fluid volume at precordium and lower arm were 54.1 and 28.5 respectively, and the average of the amount of sebum was 23.6. Discussion & Implications: We found that the amount of sebum dramatically decreased just before the onset of skin GVHD during the clinical courses of some patients who received HSCT. The immune reactions derived from donor Tcells may affect the function of the sebaceous glands of these recipients. On the other hand, the onset of acute GVHD of the skin did not change the skin-keratin-fluid volumes in HSCT recipients. To investigate the impact of the onset of acute GVHD on the water holding ability of the skin will bring us the clue to develop the proper procedures of skin care for HSCT recipients.