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Nursing Workflow: An Integral Component to Medical Research
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Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
Presbyterian Weill Cornell, New York, NY; 5 Weill Cornell Medical College, New York, NY; 6 Apheresis/BMT, New York Presbyterian Weill Cornell, New York, NY Topic Significance & Study Purpose/Background/ Rationale: Extracorporeal apheresis (ECP) used to collect peripheral hematopoietic stem cells. At New York Presbyterian Weill/Cornell ECP typically involves the use of two peripheral venous access sites for outflow and return. Patients with poor venous access undergo temporary double lumen non-tunneled central catheter placement prior to ECP; upon completion the central line is removed at bedside. In order spare patients with end-stage renal disease (ESRD) extra invasive intravenous access with related potential problems, we conducted a pilot program utilizing arteriovenous fistula (AVF); normally used for hemodialysis (HD), in collecting peripheral hematopoietic stem cells. Methods, Intervention, & Analysis: We selected three patients with multiple myeloma (MM) requiring ECP in ESRD with mature AV fistulas. We created the ECP schedule by synchronizing with the days of the patient’s usual HD treatment schedule. The AV fistula was cannulated and decannulated by a dialysis RN. If staffing permitted, the dialysis RN managed the entire PBSC procedure. Otherwise, the apheresis RN took over the treatment right after cannulation of AVF. The first day of ECP was coordinated such that after the procedure, the patient was transferred directly to the HD unit with the AVF needles secured on the access arm. The same dialysis needles were used for dialysis on two of the three patients. The AV fistula was decannulated postdialysis by the treating dialysis RN. Findings & Interpretation: The first patient collected a total of 8.09 x 10 6/Kg hematopoietic stem cells over two days. The second patient collected a total of 3.504 x 10 6/Kg hematopoietic stem cells over two days; she was admitted shortly after for sepsis. It is unknown if the sepsis was related to the ECP. The third patient collected a total of 6.76 x 10 6/Kg hematopoietic stem cells over two days. Discussion & Implications: With dialysis and BMT unit coordination, we have successfully collected the stem cells of three separate patients with ESRD on HD utilizing their AV fistula for the ECP. This has allowed these patients to avoid additional IV access with related potential complications without negatively impacting their stem cell collection. ˇ
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678 The Advocacy Role of the Case Manager for Bone Marrow Transplant Patients throughout the Care Continuum Carmen Castillo, Mary McDonough. Case Management, Memorial Sloan Kettering Cancer Center, Manhattan, NY Topic Significance & Study Purpose/Background/Rationale: Patients undergoing a bone marrow transplant (BMT) require long term care treatments and complex discharge needs as they move throughout the care continuum. Communication lapses are frequent when transitioning from inpatient, outpatient, home care and skilled nursing facilities (SNF). Our Case Manager (CM) role was changed to meet the needs of this vulnerable population. Purpose: To streamline patient support services, one CM follows the patient throughout the care continuum. This results in improved care coordination and communication amongst acute and post-acute care settings. Identification of medication coverage issues prior to admission has limited the financial burden to patients and increased their overall quality of life (QOL). Methods, Intervention, & Analysis: The CM now meets patients when they are first identified for transplant and
educates families/patients about assistance programs for medication access and advocates with third party payers. At discharge, the same CM acts as the care coordinator between home care agencies, SNF’s, insurance companies and pharmaceutical companies. A pharmacist was added to the team to work with the CM on medication issues that included coverage and teaching. High co-pays and negotiation with insurance companies to carve out medication costs at SNF’s are handled by the CM. The CM works with post care providers to ensure continuity of care and pharmaceutical companies to create better programs to increase financial assistance. The improved CM role permits following the patient at any site of care to intervene when issues arise. Findings & Interpretation: Since this change was implemented, medication access and adherence has increased, hospital length of stay has decreased, readmissions have been prevented, patient financial burden has decreased and QOL has improved. Discussion & Implications: Discharge planning for the BMT population starts prior to admission in the outpatient setting. A multi-disciplinary approach is crucial in helping with medication assistance, access and other potential discharge issues. Changing our CM role has allowed better management of patients receiving complex treatments and during end of life care. Active involvement by the multidisciplinary team made our program successful and we hope to expand to other areas of oncology.
679 Nursing Workflow: An Integral Component to Medical Research Kathleen Choo 1, Marianne Holly Wallace 2, Pamela GrantNavarro 3, Jennifer Feustel 2. 1 Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan-Kettering Cancer Center, New York, NY; 2 Adult Bone Marrow Transplant, Memorial Sloan Kettering Cancer Center, New York, NY; 3 Nursing, Memorial Sloan Kettering, Lindenhurst, NY Topic Significance & Study Purpose/Background/ Rationale: The nursing staff of the adult bone marrow transplant unit of this NCI designated comprehensive cancer center collaborated with the institutional investigators to develop a workflow for the serial collection of stool samples of transplant recipients for correlative research studies. The samples were obtained in order to study the relationship between the gastrointestinal microbiota and the complications often seen in allogeneic transplant including graft versus host disease (GVHD), bloodstream infections and Clostridium difficile infection. Methods, Intervention, & Analysis: A critical component to ensure the success of this medical research protocol was to develop a durable and practical nursing workflow to document the collection of specimens ordered upon hospital admission and weekly thereafter. Recognizing the unique challenges of research stool collection, including variable frequency of bowel movements and inability to produce a specimen on the day the test was ordered, a nursing workflow needed to be developed to address this challenge. Findings & Interpretation: The nursing workflow identified when stools were required and when they were obtained since the research specimens were not scanned into our electronic system. An alert was also included in nursing handoff for pending specimen collection. Education was provided to the nursing staff highlighting the study goals, the purpose, duration and workflow creating enthusiasm for the protocol and ensuring staff contribution and program success.
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
Discussion & Implications: As a result of the diligent attention of the nursing staff, this institution houses the largest fecal bio-specimen bank in current existence. It currently contains over 4,000 specimens collected at various time points from over 900 transplant recipients. This vast collection has contributed to many important research findings linking gut flora with GVHD, post-transplant mortality and Clostridium difficile infection. The collaboration between the nursing staff and the institutional investigators remains crucial to the success of ongoing research. This multidisciplinary alliance highlights the contribution of the nursing staff and the importance of developing structured workflows to achieve positive outcomes in the research process.
680 Challenges of Extracorporeal Photopheresis (ECP) in the Patient Population in the Adult Bone Marrow Transplant (ABMT) Outpatient Clinic Mary Elizabeth Christen, Megan Weese, Marcene McGuire. Adult Bone Marrow Transplant Clinic, Duke Medical Center, Durham, NC Topic Significance & Study Purpose/Background/ Rationale: To identify common challenges in the patient population receiving ECP in the outpatient setting and to develop strategies to improve procedure efficiency and minimize risks to patient safety. ECP is a procedure for patients with refractory cutaneous T-cell lymphoma (CTCL) and also used to treat graft-versus-host disease (GvHD) and solid organ transplant rejection. The procedure is performed through blood apheresis and exposure of separated T-cells to a psoralen derivative. This is then exposed to UV radiation, which results in alteration of DNA, causing cell death. These altered T-cells are then returned to the patient, resulting in a cytoxic effect (Klassen, 2010). One of the challenges facing ECP treatment is being able to collect effectively. Lipemic plasma, Lipidemia, Neutropenia, Anemia, and Hypertension can affect adequate cell collection. Methods, Intervention, & Analysis: Collections over 6 month were reviewed. Rates and access were compared for overall efficiency. After review, we noted an increase in system pressure alarm at the start of the collection procedure. These alarms cause a disruption in the procedure and possibly decreased efficacy. Two protocols were developed with assistance of Therako INC. One is to decrease the collect rate to 20 mL/min and return rate to 5 mL/min in the air purge phase. The second is to increase the collect rate to 40 mL/min and the return to 45 mL/min in the collect phase. Findings & Interpretation: Initiation of the updated standard of practice (SOP) has increased our collection efficacy as evidenced by collections disruptions, a decrease in total treatment times, and anecdotal increase in patient satisfaction. Discussion & Implications: Optimization of our ECP procedure may increase the effectiveness of treatment for CTCL, GvHD, and solid organ rejection. This may lead to more rapid decrease in immunosuppressive therapy.
681 Effective Use of a Chemotherapy/Stem Cell Champion on a Complex Bone Marrow Transplantation Unit Piper Leigh Coleman 1, Caryl Shelton 2, Brenda Mott 3, Kimberly Horgan 3, Kathleen Marie Demmel 4, Laura Flesch 5. 1 Bone Marrow Transplantation, Cincinnati Children’s Hospital
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Medical Center, Cincinnati, OH; 2 Bone Marrow Transplant, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3 Bone Marrow Tranpslantation and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, OH; 5 Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Topic Significance & Study Purpose/Background/ Rationale: Bone Marrow Transplant (BMT) conditioning regimens and cell infusions are complex and administration errors potentially cause significant patient harm. Implementing reliability strategies such as standardization, checklists, training, feedback, and reminders can have a direct impact in patient safety and improved patient outcomes. Methods, Intervention, & Analysis: An intervention to increase chemotherapy administration and stem cell (nucleated, mononucleated) infusion reliability, which align with healthcare’s movement towards executing high reliability principles, was implemented in a large tertiary care pediatric medical center’s 36 bed BMT unit. The unit averages 95-105 transplants annually and has 135 nurses. To understand potential mechanisms for medication errors, we critically reviewed safety reports and assessed nurses’ educational needs. Based off these findings, the BMT unit initiated a standardized checklist verification process for conditioning regimen orders and developed the Chemotherapy/Stem Cell Champion [Champion] role. The Champion is a senior nurse with at least 2 years experience on the unit and has completed an intense chemotherapy/cell infusion training program. The Champion is identified each shift. To minimize interruptions, a quiet zone was designated for the Champion and patient’s bedside nurse to complete the two person chemotherapy check process. A repeat double check is also completed at the bedside prior to chemotherapy administration. On days of cell infusions, the Champion assists the bedside nurse with medication delivery, equipment setup, patient and product verification, and patient monitoring. Findings & Interpretation: The Champion role has improved conditioning regimen verification and administration. Additionally, communication between the nurses and physicians has strengthened. The chemotherapy quiet zone has decreased order review interruptions. The two nurse check has helped identify near misses since being initiated. Assisting the bedside nurse on days of cell infusions has positively affected the timeliness and safety of cell administration. Discussion & Implications: The Champion is viewed as an essential BMT unit resource. The Champion maintains process standardization and clear communication between nurses as well as with attending physicians. The Champion role continues to evolve, including increasing the number of Champions to ensure representation on off shifts and expanding training to biannually. The additional training addresses changes, concerns, and provides education of new research, techniques, and medications which may affect the standardized process.
682 Effect of Pre Transplant Residual Leukemia on Post Allogeneic Transplant Survival Outcomes for AML Patients with Primary Induction Failure Jose C. Cruz 1, Paul J. Shaughnessy 2, Seema Naik 1, Behyar Zoghi 2, Carlos Bachier 2. 1 Blood and Marrow Transplantation, Texas Transplant Institute, San Antonio, TX;
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
Presbyterian Weill Cornell, New York, NY; 5 Weill Cornell Medical College, New York, NY; 6 Apheresis/BMT, New York Presbyterian Weill Cornell, New York, NY Topic Significance & Study Purpose/Background/ Rationale: Extracorporeal apheresis (ECP) used to collect peripheral hematopoietic stem cells. At New York Presbyterian Weill/Cornell ECP typically involves the use of two peripheral venous access sites for outflow and return. Patients with poor venous access undergo temporary double lumen non-tunneled central catheter placement prior to ECP; upon completion the central line is removed at bedside. In order spare patients with end-stage renal disease (ESRD) extra invasive intravenous access with related potential problems, we conducted a pilot program utilizing arteriovenous fistula (AVF); normally used for hemodialysis (HD), in collecting peripheral hematopoietic stem cells. Methods, Intervention, & Analysis: We selected three patients with multiple myeloma (MM) requiring ECP in ESRD with mature AV fistulas. We created the ECP schedule by synchronizing with the days of the patient’s usual HD treatment schedule. The AV fistula was cannulated and decannulated by a dialysis RN. If staffing permitted, the dialysis RN managed the entire PBSC procedure. Otherwise, the apheresis RN took over the treatment right after cannulation of AVF. The first day of ECP was coordinated such that after the procedure, the patient was transferred directly to the HD unit with the AVF needles secured on the access arm. The same dialysis needles were used for dialysis on two of the three patients. The AV fistula was decannulated postdialysis by the treating dialysis RN. Findings & Interpretation: The first patient collected a total of 8.09 x 10 6/Kg hematopoietic stem cells over two days. The second patient collected a total of 3.504 x 10 6/Kg hematopoietic stem cells over two days; she was admitted shortly after for sepsis. It is unknown if the sepsis was related to the ECP. The third patient collected a total of 6.76 x 10 6/Kg hematopoietic stem cells over two days. Discussion & Implications: With dialysis and BMT unit coordination, we have successfully collected the stem cells of three separate patients with ESRD on HD utilizing their AV fistula for the ECP. This has allowed these patients to avoid additional IV access with related potential complications without negatively impacting their stem cell collection. ˇ
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ˇ
678 The Advocacy Role of the Case Manager for Bone Marrow Transplant Patients throughout the Care Continuum Carmen Castillo, Mary McDonough. Case Management, Memorial Sloan Kettering Cancer Center, Manhattan, NY Topic Significance & Study Purpose/Background/Rationale: Patients undergoing a bone marrow transplant (BMT) require long term care treatments and complex discharge needs as they move throughout the care continuum. Communication lapses are frequent when transitioning from inpatient, outpatient, home care and skilled nursing facilities (SNF). Our Case Manager (CM) role was changed to meet the needs of this vulnerable population. Purpose: To streamline patient support services, one CM follows the patient throughout the care continuum. This results in improved care coordination and communication amongst acute and post-acute care settings. Identification of medication coverage issues prior to admission has limited the financial burden to patients and increased their overall quality of life (QOL). Methods, Intervention, & Analysis: The CM now meets patients when they are first identified for transplant and
educates families/patients about assistance programs for medication access and advocates with third party payers. At discharge, the same CM acts as the care coordinator between home care agencies, SNF’s, insurance companies and pharmaceutical companies. A pharmacist was added to the team to work with the CM on medication issues that included coverage and teaching. High co-pays and negotiation with insurance companies to carve out medication costs at SNF’s are handled by the CM. The CM works with post care providers to ensure continuity of care and pharmaceutical companies to create better programs to increase financial assistance. The improved CM role permits following the patient at any site of care to intervene when issues arise. Findings & Interpretation: Since this change was implemented, medication access and adherence has increased, hospital length of stay has decreased, readmissions have been prevented, patient financial burden has decreased and QOL has improved. Discussion & Implications: Discharge planning for the BMT population starts prior to admission in the outpatient setting. A multi-disciplinary approach is crucial in helping with medication assistance, access and other potential discharge issues. Changing our CM role has allowed better management of patients receiving complex treatments and during end of life care. Active involvement by the multidisciplinary team made our program successful and we hope to expand to other areas of oncology.
679 Nursing Workflow: An Integral Component to Medical Research Kathleen Choo 1, Marianne Holly Wallace 2, Pamela GrantNavarro 3, Jennifer Feustel 2. 1 Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan-Kettering Cancer Center, New York, NY; 2 Adult Bone Marrow Transplant, Memorial Sloan Kettering Cancer Center, New York, NY; 3 Nursing, Memorial Sloan Kettering, Lindenhurst, NY Topic Significance & Study Purpose/Background/ Rationale: The nursing staff of the adult bone marrow transplant unit of this NCI designated comprehensive cancer center collaborated with the institutional investigators to develop a workflow for the serial collection of stool samples of transplant recipients for correlative research studies. The samples were obtained in order to study the relationship between the gastrointestinal microbiota and the complications often seen in allogeneic transplant including graft versus host disease (GVHD), bloodstream infections and Clostridium difficile infection. Methods, Intervention, & Analysis: A critical component to ensure the success of this medical research protocol was to develop a durable and practical nursing workflow to document the collection of specimens ordered upon hospital admission and weekly thereafter. Recognizing the unique challenges of research stool collection, including variable frequency of bowel movements and inability to produce a specimen on the day the test was ordered, a nursing workflow needed to be developed to address this challenge. Findings & Interpretation: The nursing workflow identified when stools were required and when they were obtained since the research specimens were not scanned into our electronic system. An alert was also included in nursing handoff for pending specimen collection. Education was provided to the nursing staff highlighting the study goals, the purpose, duration and workflow creating enthusiasm for the protocol and ensuring staff contribution and program success.
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
Discussion & Implications: As a result of the diligent attention of the nursing staff, this institution houses the largest fecal bio-specimen bank in current existence. It currently contains over 4,000 specimens collected at various time points from over 900 transplant recipients. This vast collection has contributed to many important research findings linking gut flora with GVHD, post-transplant mortality and Clostridium difficile infection. The collaboration between the nursing staff and the institutional investigators remains crucial to the success of ongoing research. This multidisciplinary alliance highlights the contribution of the nursing staff and the importance of developing structured workflows to achieve positive outcomes in the research process.
680 Challenges of Extracorporeal Photopheresis (ECP) in the Patient Population in the Adult Bone Marrow Transplant (ABMT) Outpatient Clinic Mary Elizabeth Christen, Megan Weese, Marcene McGuire. Adult Bone Marrow Transplant Clinic, Duke Medical Center, Durham, NC Topic Significance & Study Purpose/Background/ Rationale: To identify common challenges in the patient population receiving ECP in the outpatient setting and to develop strategies to improve procedure efficiency and minimize risks to patient safety. ECP is a procedure for patients with refractory cutaneous T-cell lymphoma (CTCL) and also used to treat graft-versus-host disease (GvHD) and solid organ transplant rejection. The procedure is performed through blood apheresis and exposure of separated T-cells to a psoralen derivative. This is then exposed to UV radiation, which results in alteration of DNA, causing cell death. These altered T-cells are then returned to the patient, resulting in a cytoxic effect (Klassen, 2010). One of the challenges facing ECP treatment is being able to collect effectively. Lipemic plasma, Lipidemia, Neutropenia, Anemia, and Hypertension can affect adequate cell collection. Methods, Intervention, & Analysis: Collections over 6 month were reviewed. Rates and access were compared for overall efficiency. After review, we noted an increase in system pressure alarm at the start of the collection procedure. These alarms cause a disruption in the procedure and possibly decreased efficacy. Two protocols were developed with assistance of Therako INC. One is to decrease the collect rate to 20 mL/min and return rate to 5 mL/min in the air purge phase. The second is to increase the collect rate to 40 mL/min and the return to 45 mL/min in the collect phase. Findings & Interpretation: Initiation of the updated standard of practice (SOP) has increased our collection efficacy as evidenced by collections disruptions, a decrease in total treatment times, and anecdotal increase in patient satisfaction. Discussion & Implications: Optimization of our ECP procedure may increase the effectiveness of treatment for CTCL, GvHD, and solid organ rejection. This may lead to more rapid decrease in immunosuppressive therapy.
681 Effective Use of a Chemotherapy/Stem Cell Champion on a Complex Bone Marrow Transplantation Unit Piper Leigh Coleman 1, Caryl Shelton 2, Brenda Mott 3, Kimberly Horgan 3, Kathleen Marie Demmel 4, Laura Flesch 5. 1 Bone Marrow Transplantation, Cincinnati Children’s Hospital
S445
Medical Center, Cincinnati, OH; 2 Bone Marrow Transplant, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3 Bone Marrow Tranpslantation and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, OH; 5 Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Topic Significance & Study Purpose/Background/ Rationale: Bone Marrow Transplant (BMT) conditioning regimens and cell infusions are complex and administration errors potentially cause significant patient harm. Implementing reliability strategies such as standardization, checklists, training, feedback, and reminders can have a direct impact in patient safety and improved patient outcomes. Methods, Intervention, & Analysis: An intervention to increase chemotherapy administration and stem cell (nucleated, mononucleated) infusion reliability, which align with healthcare’s movement towards executing high reliability principles, was implemented in a large tertiary care pediatric medical center’s 36 bed BMT unit. The unit averages 95-105 transplants annually and has 135 nurses. To understand potential mechanisms for medication errors, we critically reviewed safety reports and assessed nurses’ educational needs. Based off these findings, the BMT unit initiated a standardized checklist verification process for conditioning regimen orders and developed the Chemotherapy/Stem Cell Champion [Champion] role. The Champion is a senior nurse with at least 2 years experience on the unit and has completed an intense chemotherapy/cell infusion training program. The Champion is identified each shift. To minimize interruptions, a quiet zone was designated for the Champion and patient’s bedside nurse to complete the two person chemotherapy check process. A repeat double check is also completed at the bedside prior to chemotherapy administration. On days of cell infusions, the Champion assists the bedside nurse with medication delivery, equipment setup, patient and product verification, and patient monitoring. Findings & Interpretation: The Champion role has improved conditioning regimen verification and administration. Additionally, communication between the nurses and physicians has strengthened. The chemotherapy quiet zone has decreased order review interruptions. The two nurse check has helped identify near misses since being initiated. Assisting the bedside nurse on days of cell infusions has positively affected the timeliness and safety of cell administration. Discussion & Implications: The Champion is viewed as an essential BMT unit resource. The Champion maintains process standardization and clear communication between nurses as well as with attending physicians. The Champion role continues to evolve, including increasing the number of Champions to ensure representation on off shifts and expanding training to biannually. The additional training addresses changes, concerns, and provides education of new research, techniques, and medications which may affect the standardized process.
682 Effect of Pre Transplant Residual Leukemia on Post Allogeneic Transplant Survival Outcomes for AML Patients with Primary Induction Failure Jose C. Cruz 1, Paul J. Shaughnessy 2, Seema Naik 1, Behyar Zoghi 2, Carlos Bachier 2. 1 Blood and Marrow Transplantation, Texas Transplant Institute, San Antonio, TX;