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Effects of Hypertension on Pediatric Blood and Marrow Transplant Patients and Strategies for Improving Timeliness of Interventions
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
Akiko Hashimoto15, Yoshihiro Inamoto2, Takahiro Fukuda 2. 1 Nursing Division, National Cancer Center Hospital, Tokyo, Japan; 2 Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan; 3 Division of Hematology, Keio University School of Medicine, Tokyo, Japan; 4 Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan; 5 Department of Hematology and Rheumatology, Tohoku University Hospital, Sendai, Japan; 6 Dep of Hematology, Fujita Health University, Toyoake, Aichi, Japan; 7 Department of Hematology, Yokohama City University Medical Center, Yokohama, Japan; 8 Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Konan, Japan; 9 Department of Hematology, Chiba University Hospital, Chiba, Japan; 10 Division of Hematology, Showa University, Tokyo, Japan; 11 Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 12 Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan; 13 Division of Hematology, Ehime Prefectural Central Hospital, Matsuyama, Japan; 14 Department of Cell Transplantation, Tokai University School of Medicine, Isehara, Japan; 15 NPO Blood Disorder Information& Support Service, Tokyo, Japan Topic Significance & Study Purpose/Background/ Rationale: We have collected patients’ free comments in a recently performed cross-sectional QOL survey (Kurosawa BMT 2015) among patients with acute leukemia who completed chemotherapy or allogeneic hematopoietic cell transplantation (allo-HCT). This study aimed to elucidate detailed factors that affected QOL using qualitative analysis. Methods, Intervention, & Analysis: Eligible patients were adult patients with AML or ALL who completed treatment and were not hospitalized at survey. Questionnaires were sent to patients who were interested in participation. Besides answering QOL measures, participants provided free comments regarding their experiences and thoughts as well as their disease, treatment and social backgrounds. Record units were extracted from free comments using the Berelson’s content analysis method, and were classified into 4 aspects corresponding to FACT-G. Analysis was performed separately in patients who had chemotherapy alone (CHEMO), in those who had GVHD after allo-HCT (GV) and in those who had no GVHD after allo-HCT (NOGV). Findings & Interpretation: 284 patients provided free comments between August 2011 and September 2012. 121 patients (43%) were male. Ages were 20-30’s in 88 patients, 40-50’s in 145 and 60 in 50. 20 patients were <1 year after treatment, 122 were 1-3 years, 114 were 4-10 years and 26 were 11 years after treatment. CHEMO group included 84 patients, GV 106 and NO GV 94. A total of 526 record units were extracted from all comments. The most frequent record unit was emotional aspect in CHEMO group, physical aspect in GV group and emotional and physical aspects in NOGV group. The most frequent physical record unit was chemotherapy-related side effects in CHEMO group, GVHD symptoms in GV group and various late effects in NOGV group. The most frequent emotional record unit was anxiety in CHEMO and GV groups, and need for other peoples’ understanding and supports in NOGV group. On another front, positive content such as “feeling stable and confident” was seen in all groups. The most frequent social/familial record unit was job-related issues in all groups. Discussion & Implications: Patterns of disturbance in QOL differed according to post-remission therapy and GVHD
S455
condition. Management of anxiety and job-related issues is needed for patients who completed leukemia treatment in addition to treatment for physical aspects.
705 Effects of Hypertension on Pediatric Blood and Marrow Transplant Patients and Strategies for Improving Timeliness of Interventions Michelle Lewyckyj 1, Adam S. Nelson 2, Kathleen Novak 3, Ashley Teusink 4, Sonata Jodele 2, Christopher E. Dandoy 2, Laura Flesch 2. 1 BMT, Cincinnat Children’s Hospital Medical Center, Cincinnati, OH; 2 Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3 Cancer and Blood Diseases Institute Blood and Marrow Transplant, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4 Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Topic Significance & Study Purpose/Background/Rationale: Transplant associated hypertension (HTN) is a known complication during pediatric hematopoietic stem cell transplant (HSCT). Risks for developing HTN depends on a variety of factors including use of calcineurin inhibitors, graft versus host disease (GVHD) requiring steroids, total body irradiation (TBI), renal injury, transplant associated thrombotic microangiopathy (TMA), and the use of chemotherapy. Uncontrolled HTN in pediatric HSCT may lead to significant life threatening complications and even death. Managing pediatric HSCT associated HTN is a challenge due to ranges of patients’ ages, heights, and weights of normal blood pressure (BP). The project goal was to improve practices around early detection, evaluation, and management of HTN for pediatric HSCT patients. Methods, Intervention, & Analysis: We analyzed existing practice related to over 50% of patients with uncontrolled HTN. We identified the following variables as barriers to adequate HTN management: poor communication between nursing and providers, delayed communication from nursing to providers for ordering of rescue antihypertensive medications, inconsistent verification of HTN with appropriate manual BP cuff amongst RNs, poor understanding of normal BP ranges amongst RNs and providers. We implemented the following interventions: appropriate BP parameter settings upon admission, documentation of HTN plan in daily nursing plan of care, verification of BP > 95th percentile with manual BP within 10 minutes. Upon verification of elevated BP> 95th percentile, RN administered first line antihypertensive treatment dose and notified provider within 30 minutes of intervention. Finally, formal education to RNs explaining effects of untreated HTN, inadequacy with treating HTN prior to the process change and normal BP’s for patients based on age and height. Findings & Interpretation: Our observations showed anxiety within RNs performing an intervention before communicating directly to provider and providers not following the process or changing BP parameters outside 95th percentile. Other findings included implementing a standardized process for measuring and ordering appropriate BP ranges on each patient, and empowering RNs to accurately assess and treat patients with HTN. This has initially resulted in a decrease of patients with BP >95thpercentile to 25%. Discussion & Implications: We anticipate this process will improve our efficiency with managing HTN and ultimately improve outcomes and care of pediatric HSCT patients.
Akiko Hashimoto15, Yoshihiro Inamoto2, Takahiro Fukuda 2. 1 Nursing Division, National Cancer Center Hospital, Tokyo, Japan; 2 Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan; 3 Division of Hematology, Keio University School of Medicine, Tokyo, Japan; 4 Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan; 5 Department of Hematology and Rheumatology, Tohoku University Hospital, Sendai, Japan; 6 Dep of Hematology, Fujita Health University, Toyoake, Aichi, Japan; 7 Department of Hematology, Yokohama City University Medical Center, Yokohama, Japan; 8 Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Konan, Japan; 9 Department of Hematology, Chiba University Hospital, Chiba, Japan; 10 Division of Hematology, Showa University, Tokyo, Japan; 11 Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 12 Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan; 13 Division of Hematology, Ehime Prefectural Central Hospital, Matsuyama, Japan; 14 Department of Cell Transplantation, Tokai University School of Medicine, Isehara, Japan; 15 NPO Blood Disorder Information& Support Service, Tokyo, Japan Topic Significance & Study Purpose/Background/ Rationale: We have collected patients’ free comments in a recently performed cross-sectional QOL survey (Kurosawa BMT 2015) among patients with acute leukemia who completed chemotherapy or allogeneic hematopoietic cell transplantation (allo-HCT). This study aimed to elucidate detailed factors that affected QOL using qualitative analysis. Methods, Intervention, & Analysis: Eligible patients were adult patients with AML or ALL who completed treatment and were not hospitalized at survey. Questionnaires were sent to patients who were interested in participation. Besides answering QOL measures, participants provided free comments regarding their experiences and thoughts as well as their disease, treatment and social backgrounds. Record units were extracted from free comments using the Berelson’s content analysis method, and were classified into 4 aspects corresponding to FACT-G. Analysis was performed separately in patients who had chemotherapy alone (CHEMO), in those who had GVHD after allo-HCT (GV) and in those who had no GVHD after allo-HCT (NOGV). Findings & Interpretation: 284 patients provided free comments between August 2011 and September 2012. 121 patients (43%) were male. Ages were 20-30’s in 88 patients, 40-50’s in 145 and 60 in 50. 20 patients were <1 year after treatment, 122 were 1-3 years, 114 were 4-10 years and 26 were 11 years after treatment. CHEMO group included 84 patients, GV 106 and NO GV 94. A total of 526 record units were extracted from all comments. The most frequent record unit was emotional aspect in CHEMO group, physical aspect in GV group and emotional and physical aspects in NOGV group. The most frequent physical record unit was chemotherapy-related side effects in CHEMO group, GVHD symptoms in GV group and various late effects in NOGV group. The most frequent emotional record unit was anxiety in CHEMO and GV groups, and need for other peoples’ understanding and supports in NOGV group. On another front, positive content such as “feeling stable and confident” was seen in all groups. The most frequent social/familial record unit was job-related issues in all groups. Discussion & Implications: Patterns of disturbance in QOL differed according to post-remission therapy and GVHD
S455
condition. Management of anxiety and job-related issues is needed for patients who completed leukemia treatment in addition to treatment for physical aspects.
705 Effects of Hypertension on Pediatric Blood and Marrow Transplant Patients and Strategies for Improving Timeliness of Interventions Michelle Lewyckyj 1, Adam S. Nelson 2, Kathleen Novak 3, Ashley Teusink 4, Sonata Jodele 2, Christopher E. Dandoy 2, Laura Flesch 2. 1 BMT, Cincinnat Children’s Hospital Medical Center, Cincinnati, OH; 2 Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3 Cancer and Blood Diseases Institute Blood and Marrow Transplant, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4 Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Topic Significance & Study Purpose/Background/Rationale: Transplant associated hypertension (HTN) is a known complication during pediatric hematopoietic stem cell transplant (HSCT). Risks for developing HTN depends on a variety of factors including use of calcineurin inhibitors, graft versus host disease (GVHD) requiring steroids, total body irradiation (TBI), renal injury, transplant associated thrombotic microangiopathy (TMA), and the use of chemotherapy. Uncontrolled HTN in pediatric HSCT may lead to significant life threatening complications and even death. Managing pediatric HSCT associated HTN is a challenge due to ranges of patients’ ages, heights, and weights of normal blood pressure (BP). The project goal was to improve practices around early detection, evaluation, and management of HTN for pediatric HSCT patients. Methods, Intervention, & Analysis: We analyzed existing practice related to over 50% of patients with uncontrolled HTN. We identified the following variables as barriers to adequate HTN management: poor communication between nursing and providers, delayed communication from nursing to providers for ordering of rescue antihypertensive medications, inconsistent verification of HTN with appropriate manual BP cuff amongst RNs, poor understanding of normal BP ranges amongst RNs and providers. We implemented the following interventions: appropriate BP parameter settings upon admission, documentation of HTN plan in daily nursing plan of care, verification of BP > 95th percentile with manual BP within 10 minutes. Upon verification of elevated BP> 95th percentile, RN administered first line antihypertensive treatment dose and notified provider within 30 minutes of intervention. Finally, formal education to RNs explaining effects of untreated HTN, inadequacy with treating HTN prior to the process change and normal BP’s for patients based on age and height. Findings & Interpretation: Our observations showed anxiety within RNs performing an intervention before communicating directly to provider and providers not following the process or changing BP parameters outside 95th percentile. Other findings included implementing a standardized process for measuring and ordering appropriate BP ranges on each patient, and empowering RNs to accurately assess and treat patients with HTN. This has initially resulted in a decrease of patients with BP >95thpercentile to 25%. Discussion & Implications: We anticipate this process will improve our efficiency with managing HTN and ultimately improve outcomes and care of pediatric HSCT patients.