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Keeping an Eye on Safety in the Stem Cell Transplant Ambulatory Environment
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Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
121 BMT Data Accuracy: Fulfilling Audits and Assuring Top Quality Data Lindsay Dozeman 1, Lisa Cantwell 2, Connie Grobe 2, Shannon Hunger 3, Lisa Sturtz 3. 1 Internal Medicine, Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA; 2 Blood and Marrow Transplant, The University of Iowa Hospitals and Clinics, Iowa City, IA; 3 University of Iowa Hospitals, Iowa City, IA Background: Blood and marrow transplant (BMT) programs are federally required to report pre-transplant and posttransplant outcomes data to the CIBMTR. Programs employ data managers to review medical records and report this data to the registry. Data staff also collect and compile data for physicians, for insurance payor requests for information (RFIs), and for internal quality assurance needs. Accurate and efficient BMT data collection is essential for outcomes analyses and program administration as well as for meeting external reporting requirements. The University of Iowa Blood and Marrow Transplant Data Team utilizes three new processes to track and greatly improve data accuracy. First, the team makes use of an auditing macro within the program database which automatically tracks additions, deletions, and changes of critical data. This allows the team to monitor areas where multiple changes or potential discrepancies are being made. Next, the team partnered with the Office for Compliance to carry out FACT-required TED accuracy audits. A template was built into the program database which allows the Compliance Specialist to complete data audits on a quarterly basis through a shared front-end of the database via a protected drive on the hospital network. Through this template, the team and Compliance Specialist can communicate findings from audits performed, and results automatically generate graph and summary tables that are shared with the program during the Quarterly Quality Council Meetings. Last, the data management team utilizes the TED accuracy template to track all corrections identified from CIBMTR or through chart review. Conclusion: Performing audits and tracking data accuracy has become efficient and seamless, saving staff time and
Figure 1. The audit table tracks additions, deletions, and changes as data are entered.
Figure 2. Data staff complete the audit template when changes to data are requested/identified, and the Compliance Specialist completes the template on a quarterly basis to fulfill FACT-required TED accuracy audits.2
Figure 3. Graphs track and trend changes to fields automatically as changes are made to the data. Staff can easily view fields where the most changes were made which may indicate areas in possible need of improvement.3
Figure 4. Summary charts trend data audits completed by the Compliance Specialist which are copied into PowerPoint and presented to the BMT team on a quarterly basis.
resources by more than 50%. By utilizing existing software and automating nearly all audit processes, our team is able to view where requests for data changes are coming from, identify areas in need of improvement, and meet the multitude of demands for data while assuring that all data provided is of the highest quality.
TRANSPLANT NURSING BEST ABSTRACTS
122 Keeping an Eye on Safety in the Stem Cell Transplant Ambulatory Environment Kathleen Marie Demmel 1, Shawna Langworthy 2, Erin Lynn Sandfoss 3, Amy Hendrix 4, Anna Louise Pfankuch 5, Samantha Craig 6. 1 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, OH; 2 The Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3 Hematology/Oncology Clinic, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4 The Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnat i, OH; 5 Hem/Onc Clinic, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 6 The Cancer & Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Topic Significance & Study Purpose/Background/ Rationale: The topic of patient safety is often focused on the inpatient hospital environment. In the world of pediatric stem cell transplantation (SCT), risk laden care is often delivered in an ambulatory setting. At a large Midwestern tertiary care pediatric medical center, patients with Hematologic, Oncologic, Immunologic, and pre/post SCT conditions receive high acuity treatments in an outpatient environment. These treatments include: high alert medications, chemotherapy and biologic infusions, blood transfusions, pheresis, anesthesia for related procedures, and urgent care services. The high acuity/high volume environment can become extremely demanding. A systematic approach to monitoring patient safety is imperative. Methods, Intervention, & Analysis: A pediatric ambulatory SCT- Hem/Onc Safety dashboard was developed to monitor key safety related metrics in a specialized setting. Key inpatient safety measures served as the dashboard’s foundation
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
and associated learnings were leveraged. Initial metrics included: serious safety events/10,000 patient visits, central line associated blood stream infections/1000 catheter days, volume related peripheral IV extravasations/1000 line days, medical response team preventable codes, serious falls/ 10,000 visits, adverse drug events, and hand-washing compliance. Time to first antibiotic, chemotherapy errors/ 1000 chemotherapy doses and patient flu vaccine compliance were subsequently included in order to address the population’s unique needs. With the assistance of the medical center’s quality improvement department, real time data is generated allowing for continuous process integrity monitoring. Consequently, failures are rapidly detected promoting immediate investigation and mitigation. When process reliability declines and corrective action is deemed necessary, the medical center’s process improvement platform is utilized. Failure causes are determined by the multi-disciplinary team. These learnings assist in developing focused tests of change. Ultimately, impactful interventions are developed which restore patient care reliability and enhance safety. Findings & Interpretation: The center is now 4,000+ days Serious Safety Event Free. Despite little published on the subject, it is clear that ongoing patient safety monitoring in this environment is essential. Discussion & Implications: The SCT-Hem/Onc ambulatory setting is a complex, high acuity and high volume patient care venue. A safety dashboard provides a continuous safety surveillance and failure mitigation process. The improvement platform and accompanying methods are easily replicable and can serve as a foundation for similar centers interested in monitoring safety.
123 Perceptions of Nurses Caring for Pediatric Bone Marrow Transplant Patients Requiring Intensive Care Level Support Brienne Leary 1, Sandra Mott 2. 1 Medical-Surgical Intensive Care Unit, Boston Children’s Hospital, Boston, MA; 2 Nurse Scientist, Cardiovascular & Critical Care, Boston Children’s Hospital, Boston, MA Topic Significance & Study Purpose/Background/ Rationale: Bone marrow transplant (BMT) is used to treat children with high-risk oncologic, immunologic and genetic diseases. Despite great progress in post-transplant care, 25%45% of patients develop complications that require varying levels of intensive cardiopulmonary support throughout the conditioning and recovery process. Nurses in the pediatric intensive care unit (PICU) and BMT work in two distinct specialty domains with unique perspectives that impact practice and goals of care. This phenomenon may result in bidirectional misperceptions and tension. There is a paucity of literature on the topic. This study’s purpose is to better understand the perceptions of BMT and PICU nurses that care for BMT patients requiring intensive cardiopulmonary support and their families. The principal investigator (PI) is a fellow in the Nursing Science Fellowship and is being mentored by nurse scientists throughout the study process. Methods, Intervention, & Analysis: This qualitative descriptive, IRB approved study is ongoing at a large academic, freestanding quaternary pediatric hospital in New England. Purposive sampling invites nurses from both units that have provided direct care to critically ill pediatric BMT patients. Following informed consent, individual, open-ended, audiotaped interviews are conducted to learn the nurses’
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experiences and reflections of their perceptions caring for these children. Interviews will continue until data is saturated. Interviews are de-identified, transcribed verbatim and analyzed using conventional content analysis. The PI and nurse scientist code data independently and then compare and discuss decisions to ensure congruency. Findings & Interpretation: Preliminary findings support the unique and complex nursing role during different phases of the child’s treatment/recovery/death. Nurses’ perceptions are reflective of their experiences and clinical care priorities. Nurses shared experiences of overwhelming “sadness” and described being “morally torn” in a role dilemma of uncertainty about what to tell or not tell patients and families. Finally, participants provided innovative strategies for transfer of care and communication. Discussion & Implications: Strategies easily implemented will be actualized at study completion. Other findings will be shared with leadership and used to guide development of effective, efficient, interdisciplinary care interventions to promote patient and family-centered care for this unique population. Subsequently, this foundational study will inform future multi-site research and evaluation of these strategies on patient care outcomes.
TRANSPLANT NURSING ADMINISTRATION
124 Fertility Preservation Prior to Myeloablative Allogeneic Peripheral Blood Stem Cell Transplant in Clinical Trials for Hematological Malignancies - Practical Challenges in Transplant Coordination Sandra Maxwell 1, Nicole Millan 2, Jacqueline Nottidge 2, Debbie Draper 1, Eleftheria Koklanaris 1, Jeanine Superata 1, Minoo Battiwalla 1, A. John Barrett 1, Erin F. Wolff 2, Sawa Ito 1. 1 Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; 2 Reproductive Endocrinology and Gynecology, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD Topic Significance & Study Purpose/Background/Rationale: The gonadotoxicity of transplant conditioning regimen is of concern for women of childbearing age, making fertility preservation (FP) an important consideration prior to therapy. We describe the challenges and successes of identifying, scheduling, enrolling, and treatment of patients with hematological malignancies for both myeloablative allogeneic stem cell transplant (allo-SCT) and FP trials at a research hospital. Methods, Intervention, & Analysis: Females in their reproductive years identified for allo-SCT were solicited for FP prior to therapy. Patients meeting eligibility in both trials were treated to controlled ovarian hyperstimulation and transvaginal oocyte retrieval while completing their evaluation for allo-SCT. Findings & Interpretation: To date, three women of childbearing age were solicited and two enrolled for FP and myeloablative haplo-identical allo-SCT trials. The allo-SCT calendar for evaluation was completed prior to their arrival at National Institutes of Health (NIH). They were consented to a screening trial for allo-SCT and evaluated for FP simultaneously. Challenges of scheduling were identified in 1) timing of screening for FP after chemotherapy 2) timing of disease assessment with bone marrow biopsy 3) radiation exposure to imaging studies 4) ovarian stimulation and the subsequent menstrual suppression 5) PPD placement 6) admission for oocyte retrieval 7) adverse event reporting.
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
121 BMT Data Accuracy: Fulfilling Audits and Assuring Top Quality Data Lindsay Dozeman 1, Lisa Cantwell 2, Connie Grobe 2, Shannon Hunger 3, Lisa Sturtz 3. 1 Internal Medicine, Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA; 2 Blood and Marrow Transplant, The University of Iowa Hospitals and Clinics, Iowa City, IA; 3 University of Iowa Hospitals, Iowa City, IA Background: Blood and marrow transplant (BMT) programs are federally required to report pre-transplant and posttransplant outcomes data to the CIBMTR. Programs employ data managers to review medical records and report this data to the registry. Data staff also collect and compile data for physicians, for insurance payor requests for information (RFIs), and for internal quality assurance needs. Accurate and efficient BMT data collection is essential for outcomes analyses and program administration as well as for meeting external reporting requirements. The University of Iowa Blood and Marrow Transplant Data Team utilizes three new processes to track and greatly improve data accuracy. First, the team makes use of an auditing macro within the program database which automatically tracks additions, deletions, and changes of critical data. This allows the team to monitor areas where multiple changes or potential discrepancies are being made. Next, the team partnered with the Office for Compliance to carry out FACT-required TED accuracy audits. A template was built into the program database which allows the Compliance Specialist to complete data audits on a quarterly basis through a shared front-end of the database via a protected drive on the hospital network. Through this template, the team and Compliance Specialist can communicate findings from audits performed, and results automatically generate graph and summary tables that are shared with the program during the Quarterly Quality Council Meetings. Last, the data management team utilizes the TED accuracy template to track all corrections identified from CIBMTR or through chart review. Conclusion: Performing audits and tracking data accuracy has become efficient and seamless, saving staff time and
Figure 1. The audit table tracks additions, deletions, and changes as data are entered.
Figure 2. Data staff complete the audit template when changes to data are requested/identified, and the Compliance Specialist completes the template on a quarterly basis to fulfill FACT-required TED accuracy audits.2
Figure 3. Graphs track and trend changes to fields automatically as changes are made to the data. Staff can easily view fields where the most changes were made which may indicate areas in possible need of improvement.3
Figure 4. Summary charts trend data audits completed by the Compliance Specialist which are copied into PowerPoint and presented to the BMT team on a quarterly basis.
resources by more than 50%. By utilizing existing software and automating nearly all audit processes, our team is able to view where requests for data changes are coming from, identify areas in need of improvement, and meet the multitude of demands for data while assuring that all data provided is of the highest quality.
TRANSPLANT NURSING BEST ABSTRACTS
122 Keeping an Eye on Safety in the Stem Cell Transplant Ambulatory Environment Kathleen Marie Demmel 1, Shawna Langworthy 2, Erin Lynn Sandfoss 3, Amy Hendrix 4, Anna Louise Pfankuch 5, Samantha Craig 6. 1 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, OH; 2 The Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3 Hematology/Oncology Clinic, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4 The Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnat i, OH; 5 Hem/Onc Clinic, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 6 The Cancer & Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Topic Significance & Study Purpose/Background/ Rationale: The topic of patient safety is often focused on the inpatient hospital environment. In the world of pediatric stem cell transplantation (SCT), risk laden care is often delivered in an ambulatory setting. At a large Midwestern tertiary care pediatric medical center, patients with Hematologic, Oncologic, Immunologic, and pre/post SCT conditions receive high acuity treatments in an outpatient environment. These treatments include: high alert medications, chemotherapy and biologic infusions, blood transfusions, pheresis, anesthesia for related procedures, and urgent care services. The high acuity/high volume environment can become extremely demanding. A systematic approach to monitoring patient safety is imperative. Methods, Intervention, & Analysis: A pediatric ambulatory SCT- Hem/Onc Safety dashboard was developed to monitor key safety related metrics in a specialized setting. Key inpatient safety measures served as the dashboard’s foundation
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
and associated learnings were leveraged. Initial metrics included: serious safety events/10,000 patient visits, central line associated blood stream infections/1000 catheter days, volume related peripheral IV extravasations/1000 line days, medical response team preventable codes, serious falls/ 10,000 visits, adverse drug events, and hand-washing compliance. Time to first antibiotic, chemotherapy errors/ 1000 chemotherapy doses and patient flu vaccine compliance were subsequently included in order to address the population’s unique needs. With the assistance of the medical center’s quality improvement department, real time data is generated allowing for continuous process integrity monitoring. Consequently, failures are rapidly detected promoting immediate investigation and mitigation. When process reliability declines and corrective action is deemed necessary, the medical center’s process improvement platform is utilized. Failure causes are determined by the multi-disciplinary team. These learnings assist in developing focused tests of change. Ultimately, impactful interventions are developed which restore patient care reliability and enhance safety. Findings & Interpretation: The center is now 4,000+ days Serious Safety Event Free. Despite little published on the subject, it is clear that ongoing patient safety monitoring in this environment is essential. Discussion & Implications: The SCT-Hem/Onc ambulatory setting is a complex, high acuity and high volume patient care venue. A safety dashboard provides a continuous safety surveillance and failure mitigation process. The improvement platform and accompanying methods are easily replicable and can serve as a foundation for similar centers interested in monitoring safety.
123 Perceptions of Nurses Caring for Pediatric Bone Marrow Transplant Patients Requiring Intensive Care Level Support Brienne Leary 1, Sandra Mott 2. 1 Medical-Surgical Intensive Care Unit, Boston Children’s Hospital, Boston, MA; 2 Nurse Scientist, Cardiovascular & Critical Care, Boston Children’s Hospital, Boston, MA Topic Significance & Study Purpose/Background/ Rationale: Bone marrow transplant (BMT) is used to treat children with high-risk oncologic, immunologic and genetic diseases. Despite great progress in post-transplant care, 25%45% of patients develop complications that require varying levels of intensive cardiopulmonary support throughout the conditioning and recovery process. Nurses in the pediatric intensive care unit (PICU) and BMT work in two distinct specialty domains with unique perspectives that impact practice and goals of care. This phenomenon may result in bidirectional misperceptions and tension. There is a paucity of literature on the topic. This study’s purpose is to better understand the perceptions of BMT and PICU nurses that care for BMT patients requiring intensive cardiopulmonary support and their families. The principal investigator (PI) is a fellow in the Nursing Science Fellowship and is being mentored by nurse scientists throughout the study process. Methods, Intervention, & Analysis: This qualitative descriptive, IRB approved study is ongoing at a large academic, freestanding quaternary pediatric hospital in New England. Purposive sampling invites nurses from both units that have provided direct care to critically ill pediatric BMT patients. Following informed consent, individual, open-ended, audiotaped interviews are conducted to learn the nurses’
S113
experiences and reflections of their perceptions caring for these children. Interviews will continue until data is saturated. Interviews are de-identified, transcribed verbatim and analyzed using conventional content analysis. The PI and nurse scientist code data independently and then compare and discuss decisions to ensure congruency. Findings & Interpretation: Preliminary findings support the unique and complex nursing role during different phases of the child’s treatment/recovery/death. Nurses’ perceptions are reflective of their experiences and clinical care priorities. Nurses shared experiences of overwhelming “sadness” and described being “morally torn” in a role dilemma of uncertainty about what to tell or not tell patients and families. Finally, participants provided innovative strategies for transfer of care and communication. Discussion & Implications: Strategies easily implemented will be actualized at study completion. Other findings will be shared with leadership and used to guide development of effective, efficient, interdisciplinary care interventions to promote patient and family-centered care for this unique population. Subsequently, this foundational study will inform future multi-site research and evaluation of these strategies on patient care outcomes.
TRANSPLANT NURSING ADMINISTRATION
124 Fertility Preservation Prior to Myeloablative Allogeneic Peripheral Blood Stem Cell Transplant in Clinical Trials for Hematological Malignancies - Practical Challenges in Transplant Coordination Sandra Maxwell 1, Nicole Millan 2, Jacqueline Nottidge 2, Debbie Draper 1, Eleftheria Koklanaris 1, Jeanine Superata 1, Minoo Battiwalla 1, A. John Barrett 1, Erin F. Wolff 2, Sawa Ito 1. 1 Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; 2 Reproductive Endocrinology and Gynecology, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD Topic Significance & Study Purpose/Background/Rationale: The gonadotoxicity of transplant conditioning regimen is of concern for women of childbearing age, making fertility preservation (FP) an important consideration prior to therapy. We describe the challenges and successes of identifying, scheduling, enrolling, and treatment of patients with hematological malignancies for both myeloablative allogeneic stem cell transplant (allo-SCT) and FP trials at a research hospital. Methods, Intervention, & Analysis: Females in their reproductive years identified for allo-SCT were solicited for FP prior to therapy. Patients meeting eligibility in both trials were treated to controlled ovarian hyperstimulation and transvaginal oocyte retrieval while completing their evaluation for allo-SCT. Findings & Interpretation: To date, three women of childbearing age were solicited and two enrolled for FP and myeloablative haplo-identical allo-SCT trials. The allo-SCT calendar for evaluation was completed prior to their arrival at National Institutes of Health (NIH). They were consented to a screening trial for allo-SCT and evaluated for FP simultaneously. Challenges of scheduling were identified in 1) timing of screening for FP after chemotherapy 2) timing of disease assessment with bone marrow biopsy 3) radiation exposure to imaging studies 4) ovarian stimulation and the subsequent menstrual suppression 5) PPD placement 6) admission for oocyte retrieval 7) adverse event reporting.