- Email: [email protected]
The blood cell transplant program
The Blood Cell Transplant Program Janet P. Nelson Objectives: To discuss the critical components of a blood cell transplantation (BCT) program as they relate to the standards developed by The Foundation for Accreditation of Hematopoietic Cell Therapy (FAHCT). Data sources: FAHCT Standards, book chapters, and articles pertaining to developing a BCT program. Conclusions: BCT is a burgeoning therapy for oncologic and hematologic diseases. New regulations have emerged to promote quality medical and laboratory practice in blood and marrow transplantation.
Implications for nursing practice: As BCT increases for oncologic and hematologic diseases, a growing number of oncology nurses will be caring for BCT recipients and their families. Nurses in administration, research, advance practice, and education are increasingly involved in implementing BCT as a standard therapy for a growing number of diseases. Copyright © 1997 by W.B. Saunders Company
HE SHIFT from bone marrow transplantation (BMT) to blood cell transplantation (BCT) as a treatment for hematologic and oncologic diseases has been dramatic with carefully selected transplant recipients receiving care in qualified centers throughout the country. The synergistic effects of early success in BCT, health care costs, and a changing health care climate are the driving forces of performing BCT. Currently 80% of autologous transplantations are performed with blood stem cells} This number is increasing due to new techniques such as single volume stem cell collections, less toxic but effective high-dose conditioning regimens, infusion of reduced and enriched stem cell products, and new attitudes in outpatient care. Much of the care is being offered in outpatient settings, but costs remain a concern and it is a challenge for the BCT team to deliver care in an efficient and economical manner, This article describes the critical components of developing, implementing, and maintaining a successful outpatient BCT program. The framework guiding the following discussion is based on the recently published standards for marrow and stem cell transplant programs developed by The Foundation for Accrediation of Hematopoietic Cell
Therapy (FAHCT). 2 Unique administrative and patient care issues not addressed by the FAHCT standards are also discussed. Information about generic issues of ambulatory outpatient care has been reviewed elsewhere} ,4
T
From Physician's Reliance Network, Dallas, TX. Janet E Nelson, RN, MN, OCN®: Vice President of Clinical Operations, Physician's Reliance Network, Dallas, TX. Address reprint requests to Janet P. Nelson, RN, MN, Vice President of Clinical Operations, Physician's Reliance Network, 3535 Worth St, Dallas, TX 75246. Copyright © 1997 by W.B. Saunders Company 0749-2081/97/1303-000855.00
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FAHCT STANDARDS The major objective of the FAHCT is to promote quality medical and laboratory practice in hematopoietic progenitor cell transplantation. Facilities accredited by FAHCT are required to meet minimum criteria for performing blood and marrow transplantation (Table 1). The standards apply to all sources of hematopoietic progenitor cells and all phases of collection, processing, and administration of bone marrow, peripheral blood, or placental/ umbilical cord blood. The standards were initially developed by the Regulatory Affairs Committee of the International Society for Hematotherapy and Graft Engineering (ISHAGE), and a subcommittee of the Clinical Affairs Committee of the American Society of Blood and Marrow Transplantation (ASBMT). In December 1994, the laboratory standards of ISHAGE and the ASBMT clinical standards were merged into a single document; and FAHCT was established to develop and implement the accreditation program. Institutions desiring to apply for accreditation must comply with these current standards. Accreditation is determined by evaluation of the written information provided by the applicant facility and by on-site inspection. Site inspections are performed every 3 years by experts in hematopoietic cell therapy. 2 Currently there are no accredited FAHCT programs, Established BCT
Seminars in Oncology Nursing, Vo113, No 3 (August), 1997: pp 208-215
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centers are assessing and revising their current policies and procedures for FAHCT accreditation and onsite inspection.
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should be developed in conjunction with the overall program plan.
Creating Quality Cost-Effective Care PLANNING THE BCT PROGRAM
Program Feasibility The first step in considering a BCT program is performance of a feasibility study to identify internal and external advantages and harriers to a successful program. The important questions are as follows: Is this the business we are in? Do we have the resources? If not, are they available? Can we afford it? Can we do it well? An evaluation of competing BCT programs, ability to gain market share, availability of a qualified transplantation team, and comprehensive community resources is required. Table 2 identifies the parameters to assess for the development of a BCT program. A planning committee composed of key individuals is essential to the overall success of a committed and cohesive transplant program. Table 3 lists suggested members for the BCT planning committee.
Goals and Objectives If the assessment indicates the need for a BCT program that will provide a quality product and not be a major loss for the organization, the planning process begins. A mission statement, goals and objectives for the BCT program are developed. Goals and objectives may include the following: (1) To provide a quality, cost-competitive BCT program. (2) To improve the third-party payor approval process for BCT. (3) To identify appropriate patient selection leading to excellent clinical outcomes. (4) To provide the BCT recipient with the convenience of individualized services in an ambulatory setting that promotes increased independence and quality of life. (5) To incorporate a multidisciplinary approach, including medical, nursing, dietary, physical and rehabilitation medicine, psychosocial care and patient and family education programs. The planning process will evolve over time. Strategies that may assist the planning process are listed in Table 4. Table 5 identifies administrative and clinical assignments for members of the BCT planning committee. An action plan with time lines
Although BCT costs less than BMT, 5,6 it remains an expensive therapy costing from $80,000 to $150,000. 7 Determining the costs associated with BCT is tedious, laborious and depends on the community offering this therapy. Costs vary among institutions and because of the competitive nature of the marketplace this information is private and not shared. Some of the major charges, not costs, have been recently published. Examples of charges are surgical fees for central venous catheter placement ($2,050), mobilization and apheresis ($12,000), cryopreservation of stem cells ($750), total body irradiation (TBI) ($9,000), high-dose chemotherapy ($1,950 to $17,050), and stem cell infusion ($692). 8 BCT teams are evaluating procedures and tests to determine cost effectiveness and need. Clinical practices such as mesna administration, continuous bladder irrigation and hydration versus continuous bladder irrigation and hydration alone for cyclophosphamide induced hemorrhagic cystitis are being questioned and evaluated. 9 Critical pathways have been used for BCT to guide appropriate cost effective care. Figure 1 depicts a critical pathway for outpatient BCT for treatment of breast cancer, l°
Third-Party Payors The ability to obtain market share for BCT is largely dependent on an organization's capability to become a center of excellence or preferred provider. The elements and strategies for contracting with third-party payors to cover BCT are outlined in Table 6.11 It seems likely that in the near future, third-party payors will favor FAHCT accredited BCT centers that offer competitive fees.
Patient Selection Patient eligibility criteria is a critical component of the planning process. An expert BCT medical panel can evaluate potential risk and benefits for selected diseases. Some programs use a modified Rand Delphi technique to define appropriateness. Treatment protocols should reflect the team's judgment for the most effective transplant strategy for each disease entity treated. Patients should be treated on transplant protocols that are based on
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JANET R NELSON
Table 1. Minimal Criteria for a Blood Cell Transplant Program Components The Clinical Program
AIIogeneic BCT units
Accreditation criteria
Institutional Review Board ORB) The Blood Cell Transplant Team Program transp[ant director
Attending physicians
Consulting physicians Collection medical director Laboratory medical director Laboratory director
Nursing administrator Nursing staff
Pharmacy staff Dietary staff Other
The Clinical Unit inpatient Outpatient care Emergency care
Criteria Integrated medical team housed in geographically contiguous space with a program director, common training programs, protocols, and quality assessment systems. Access to accredited collection and process laboratory that meets the standards for FAHCT and American Blood and MarrowTransplant Registry. Access to blood bank providing 24-hour service for CMV- blood products; HLA testing laboratory accredited by the American Society of Histocompatibility and Immunogenetics; and the capability of performing deoxyribonucleic acid based HLA typing. Minimum of 10 transplants performed year before application for program accreditation. Perform minimum of 10 BCTs per year of each type (allogeneic or autologous) for which the Program is accredited. Formal review of investigational treatment protocols and patient consent forms approved by the Office for Protection from Research. Responsible for administrative and medical operations of the clinical transplantation program, including compliance with standards, Licensed to practice medicine in the United States or Canada and board certified (or non-United States/Canadian equivalent) in one or a combination of: hematology, medical oncology, immunology, and/or pediatrics. Show a minimum of 1 year experience in management of transplant patients in both inpatient and outpatient settings. U nderstand indications for BCT. Ability to perform evaluation and selection for BCT. Management of high-dose chemotherapy and irradiation, growth factors, neutropenic fever, bacterial, viral, and fungal infection, veno-occiusive disease, thrombocytopenia, hemorrhagic cystitis, nausea and vomiting, pain, posttransplant immunodeficiencies, acute and chronic graft versus host disease and terminal care. Blood cell infusion management. Allogeneic BCT considerations. Identify and select appropriate blood cell sources for BCT, including donor registries. Demonstrate knowledge of human leukocyte antigen typing, incompatible blood groups of hematopoietic progenitor cell components. Board Certified in surgery, pulmonary intensive care, gastroenterology, nephrology, infectious disease, cardiology, pathology, psychiatry, and radiation therapy. Ensures compliance with all medical aspects of the cell processing facilities, ie, donor care. Responsible for all administrative operations of the cell processing facility, including all medical aspects of the activities of the cell processing facility. Responsible for administrative operations of cell processing facility, including compliance with FAHCT standards. Possess PhD in appropriate discipline. Formally trained and experienced in the management of patients receiving BCTs. Training in hematology/oncology patient care, ability to perform pediatric and outpatient care when appropriate, administration of high-dose therapy, growth factors, blood component therapy, management of infectious complications. Nurse patient ratios satisfactory to cover the severity of patient clinical status. Ensure appropriate use and management of pharmaceuticals. Provide dietary consultations regarding patient's nutritional status, including total parenteral nutrition. Social services and physical therapy. Staff to provide efficient pretransplant patient evaluation and coordinate treatment and posttransplant follow-up care. Written policies for all procedures, including prevention and infection control, administration of high-dose therapy, immunosuppressive agents, and blood component therapy; create designated inpatient unit that minimizes airborne microbial contamination. Create patient care area reasonably free of infectious agents; provide administration of longterm infusions, and blood products. Prompt 24-hour evaluation and treatment by an attending transplant physician.
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211 Table 1. Minimal Criteria for a Blood Cell Transplant Program (Cont'd)
Components Other Departments Data management Quality management plan
Criteria Maintain accurate patient records required bythe IBMTR or ABMTR. System for review and approval of policies and procedures that document compliance with regulatory requirements and standards. Provides documentation of research protocols. Assures Institutional Review Board protocol approval. Documents implementation of new drugs or devices with any adverse outcomes. Develop system for detecting, evaluating, documenting and reporting errors, accidents, and adverse reactions.
Abbreviations: CMV, cytomegalovirus; HLA, human leukocyte antigen. Data from FAHCT.
critical analyses of data from scientific journals and meetings and/or reported to the Blood and Marrow Transplant Registry (BMTR) and the Autologous BMTR (ABMTR). Patients should participate in trials sponsored by International Cooperative Research Group, National Cancer Institute, and the other national and international research groups.12 THE BLOOD CELL TRANSPLANT TEAM
The recommended members of the BCT team and their associated criteria according to the FAHCT standards are outlined in Table 1. The following discussion highlights selected perspectives of these BCT team members.
Medical A medical and laboratory director are necessary for a certified transplant program. The program director should be board certified in hematology, medical oncology, immunology, and/or pediatric hematology/oncology. The director is responsible Table 2. Feasibility Parameters for Development of a BCT Program 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11.
Executive leadership support Physician support Physician coverage after hours, weekends, holidays Volume and type of transplant Diseases to be treated Assessment of resources to successfully provide quality, cost-effective care (eg, care beds, radiation oncology services, clinic facilities, outpatient pharmacy program, diagnostic facilities, housing, transportation) Knowledgeable and experienced staff Availability of multidisciplinary team members Costto provide service Charge to patient or payor Payor mix of patient population and reimbursement BCT in your geographic location.
for all administrative and medical operations of the clinical transplant program. The director is responsible for donor evaluation and selection, stem cell harvest procedures, and care of the patient throughout the transplant. The laboratory director is required to have a doctoral degree and be qualified by experience in stem cell processing. The medical director can also serve as the laboratory director. 2J3,14 Attending physicians are required to be licensed and either board certified or board eligible for similar specialties as the medical director. Physicians must have a minimum of I year experience in the management of transplant patients including BCT indications, patient eligibility, selection and administration of dose-intensive therapy, administration of growth factors, management of transplant related complications such as infectious disease, veno-occlusive disease, pancytopenia, hemorrhagic cystitis, and graft failure. %13
Nursing In contrast to nursing administrators who manage traditional hospital and clinical areas, the nursing administrator in an outpatient setting works in collaboration with physicians and other cliniTable 3. Suggested Members of the BCT Program Planning Committee Medical director Hospital or outpatient administrator Financial officer Nursing administrator Laboratory director Infectious disease physician Pharmacologist Blood bank representative Social worker Quality assurance manager
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JANET R NELSON
Table 4. Team Building Strategies for BCT Planning Committee 1. Assemble team and key players involved in process. 2. Articulate goals and secure commitment for providing service based on model of care selected. 3. Instill ownership of project to team members through delegation of key assignments. 4. Choose chairperson of team who can also provide leadership through planning, implementation, and evaluation process. Ideally, the chairperson should have formal authority in the system to mobilize institutional and community resources. 5. Identify time commitment for meeting schedule (eg, every week, bimonthly, monthly) and outside projects. 6. identify issues to be discussed and develop plan of action. 7. Structure multidisciplinary meeting to start on time, preplanned, with a written agenda. 8. Develop subcommittees to pursue specific tasks for committee for review and approval. Chairpersons should be technical experts (eg, clinical nurse specialist, dietician, pharmacist, insurance care coordinator, etc).
clans to introduce complex therapies, such as TBI, that may not be established as nonhospitalized procedures. Obtaining IRB approval for new protocols, developing informed consents, compreTable 5. Administrative and Clinical Planning Assignments for a BCT Program 1. Identify target date for implementation with sensitivity to market place 2. Compile direct and indirect cost data 3. Implement a cost analysis study 4. Determine patient volume as defined by clinic parameters 5. Determine clinic hours 6. Identify supportive services and enlist co-operation 7. Secure patient and family housing and 24-hour transportation 8. Identify legal issues relative to outpatient care 9. Establish charge structure 10. Establish outpatient medical record system 11. Order equipment, ie, intravenous pumps, monitors 12. Develop a marketing plan 13. Identify financial pricing structures for competitive bidding 14. Perform a "mock" patient billing Clinical Assignments 1. Determine types of BCT-autologous or allogeneic 2. Identify diseases to be treated and clinical protocols 3. Select patient eligibility criteria 4. Recruit medical, nursing, and administrative directors 5. Define staffing patterns 6. Create clinical documentation tools 7. Create critical pathway or caremaps 8. Develop guidelines for emergency care 9. Develop patient and family caregiver education plan 10. Perform a "mock" transplant with a "John Doe" patient
hensive patient and family caregiver education, and implementing safe staffing ratios are among the myriad of nursing administrator responsibilities. Assuring continuity of care as patients receive care in multiple departments such as surgery, apheresis laboratory, inpatient and ambulatory settings requires superb communication with numerous managers. BCT patients cared for in the outpatient setting results in high acuity levels. Nurse patient ratios to cover the severity of patient care is a constant challenge. There is little consensus or few guidelines that recommend appropriate nurse patient ratios and most nursing administrators are left to solve the problem vis a vis their own practice environment. For example, FAHCT criteria for nursing staff ratios state "sufficient nursing-patient ratios." A cadre of qualified nursing staff can be augmented with contracted blood bank apheresis services, nursing agencies, and home care services. 2 The use of licensed practical nurses, registered medical technicians, and ancillary personnel is a growing phenomena, however, it requires careful evaluation by nurse managers. Nursing administrators are crafting new roles for nurses to deliver care for BCT patients who have traditionally been cared for in a hospital setting. A BCT coordinator, exclusively dedicated to assuring efficient transition throughout the transplant trajectory, is an effective role that provides continuity of care. 15 The coordinator can establish the timing of events, verify insurance benefits, arrange for the patient's return to referring physician, and collect important follow-up information. Telephone triage nurses using computerized programs are assisting with patient symptom management. Advance nurse practitioners with prescriptive authority are managing outpatient clinics in some areas. 16 One of the newest skills transplant nurses may be required to learn is the collection of blood stem cells through apheresis. Decisions whether to train clinic nurses to do the apheresis procedure or to contract with outside services depends on the expected number of transplants performed and the costs of cross-training clinic nurses versus the expense of contractual agreements.
Pharmacy Staff BCT recipients require numerous medications, many of which are complex and self-administered. A pharmacy staff experienced in the appropriate
BCT PROGRAM
213
I
! Patient is referred to BMT Clinic, !
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Initial evaluati2n is performed,
°
Patient discharged after etoposide. !
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°
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j
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,
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1 Yes--Apheresis for a minimum of
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three consecutive days.
YesZ4:ase manager is assigned.
(Days prior to PBSC administration)
1 1
! Preauthorization for treatment is obtained by the precerfiticafion RN. BMTcase marloger contacts the insurance case manager for outpatient treatment authorization or shift Of benefits.
I 8--M1TCCycle 1 day-9.
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days. Chemotherapy is administered and stem cells are infused on an outpatient basis. Case m a n a g e r refers to primary care physician for administration of antibiotics and G-CSF. Bone scan, MUGA and CT scan may be needed after cycle 2.
No~MTIC cycles 2, 3, and 4 repeated every 21 days as an outpatient. Bone scan, MUGA, and CT scan m a y be needed after cycle
2.
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[ 12--MITC Cycle 1 day-2,
t
Fig 1. A critical pathway for outpatient blood cell transplantation. (Reprinted with permission, t°)
use and management of pharmaceuticals is essential. Pharmacists with administrative experience in purchasing, dispensing, and controlling expensive medications can assure efficient on-site pharmacy management. Hazardous waste collection and disposal, and dispensing patient care supplies and home care pumps may be managed by the pharmacy department. ~
Other Staff An array of qualified clinical personal are required to support the BCT team. Dietary staff, social workers, physical therapists, and occupational therapists are important members of the BCT team. THE CLINICAL UNIT AND FOLLOW-UP SERVICES
Care of BCT recipients requires attention to their immunocompromised status. Infectious disease physicians are important consultants to assure minimal cross-contamination of infectious diseases such as air-borne parainfluenza, respiratory syndical virus, and herpes varicella zoster. 3 Similar to other oncology clinics, the design of the waiting
rooms, nurses station, infusion suites, bathrooms and staff offices need careful planning. These issues are beyond the scope of this article and they have been reviewed elsewhere? ,4,17 A designated area and/or room should be assigned for the stem cell collection procedure. Space to accommodate several machines, disposable equipment, the patient and caregiver require approximately 40 square feet per person. Some institutions with limited space and few procedures may move the apheresis equipment between procedures to facilitate alternative use of the room. Because the procedure requires about 3 to 4 hours, an overhead television, video cassette recorder, stereo and compact disc players may alleviate patient boredom. Attractive and affordable housing for the BCT recipient and their family can be one of the major marketing tools available to attract patients to a BCT center. With increasing regularity, institutions are entering into contracts with nearby hotels to accommodate this patient population. Special arrangements with hotel staff for cleaning, meal services, transportation, access to community resources, and privacy need to be addressed.
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JANET P. NELSON
Table 6. The Elements of Contracting With Third-Party Payors for BCT m Dialogue initiated between insurance company and transplant center. • Insurance company sends provider information regarding number covered lives, type of insurance company HMO PPO, utilization review, reinsurance. • Letter of confidentiality agreement signed by insurance company for medical center to release information to the insurance company. • RFP sent to transplant center for completion. • Transplant center responds to RFP with clinical information. • Transplant center and insurance company develop a rapport and exchange of business information. • Insurance company chooses network transplant centers based on insurer needs and pre-established standards (selection criteria). • Site visits scheduled to provide the opportunity for representative from the insurance company to meet the health care experts, inspect the clinical area, and answer questions. • Final decision for network transplant centers. • Financial information and bidding initiated for institutional and professional components of the contract. • Methodology negotiated between insurance company and transplant center(s). • Institutional and professional components are negotiated together or separately depending on state laws. • Memorandum of understanding signed by insurance company, transplant center, and physician association. • Final negotiations begun with minor modifications in memorandum of understanding. • Contract signed for usual duration of 12 months. • Internal communication process notifies appropriate personnel and departments of contract with insurance company, medical center, and physician association. Abbreviation: RFP, request for proposal. Buchseh Bone Marrow Transplantation: Administrative and Clinical Strategies. •1995 Boston: Jones and Bartlett Publishers. Reprinted with permission. 11
Home care for the BCT patient is provided through the institutions own agencies or contracted with approved home care providers. Orientation of home care providers can assure that home care nurses have state-of-the-art transplantation knowledge and that they are familiar with transplant protocols and policies. In addition, 24-hour care or emergency care must be available. Written booklets containing outpatient guidelines and how to access emergency care are useful tools for the patient and family. Autologous BCT recipients, in contrast to allogeneic marrow recipients, may return to their primary care physician or oncologist several weeks
after reinfusion. Communication between the primary care physician, oncologist, and transplant physicians is important in providing quality follow-up care. One transplant center implemented a World Wide Web-based computerized decision support system to help primary care physicians manage the follow-up care of BMT and BCT recipients. 18 PATIENT CARE ISSUES
Psychosocial Concerns BCT is an emotional procedure for the patient and family and requires psychological support throughout the transplant trajectory. Specific stressors such as absence of social support systems, limited economic resources, loss of job security, or pre-existing psychological problems that confound the physical demands of transplantation have been reported by recipients before, during, and after transplantation. 1%2°With the increase in outpatient care and less hospitalization, more intensive psychological support for the BCT patient and family caregivers is needed to assist them in coping with issues of self-care management.
Family Caregiver The family caregiver is an integral part of the interdisciplinary team who manages the care of the transplant recipient. Researchers 2x-23 have described the needs of family caregivers in the transplant setting and the educational interventions to meet these needs. Table 7 identifies strategies to meet the educational and supportive needs of the patient and family. However, the BCT team must be prepared for the reality of patients arriving without a contiguous and committed caregiver. Some centers have created a bank of approved "lay" people capable of assisting Table 7. Strategies to Meet Educational Needs of Patient and Family 1. 2. 3. 4.
Written guidelines on selecting a BCT Program Accessibility of patient/family caregiver advocate Establish a family support network Written content on: a. Available services and resources (ie, legal services, housekeeping assistance) b. Expectations of familycaregivers c. Managing care throughout the process d. The patient's disease
Data from Compton et al, 21 McDonald et al, 22and Stetz et al. 23
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215
patients with some aspects of their outpatient management. Support systems to allow family caregiver respite periods enhances the caregivers ability to cope, deliver responsible care, and maintain a healthy family relationship. CONCLUSION
Historically, the majority of the care for BCT recipients was given in traditional hospital settings. Over the past decade, a large portion of care has shifted to new treatment settings that include extensive outpatient management or combinations
of hospital, ambulatory, and home care. The BCT program needs to develop and maintain a quality, safe, and cost-conscious environment for recipients and their families. The ability to perform BCT in a cost-effective manner is of paramount importance as health care reimbursement moves toward an exclusive managed care environment. Oncology nurses practicing in these new environments require knowledge of new regulations and guidelines in establishing and maintaining BCT units while offering quality care to the BCT recipient and their family caregivers.
REFERENCES 1. Armitage JO: New ABMTR studies evaluate growing use of autologons transplantation. ABMTR Newslett 3:1-3, 1996 2. Standards for the Hematopoietic Progenitor Cell Collection, Processing, and Transplantation Cell Collection, Processing and Transplantation, Foundation For The Accreditation of Hematopoietic Cell Therapy (ed 1). University of Nebraska Medical Center, Omaha, NE, FAHCT, 1996 3. Buchsel PC, Yarbro CH: Oncology Nursing in the Ambulatory Setting: Issues and Models of Care. Boston, MA, Jones and Bartlett, 1993 4. Buchsel PC, Whedon MB (eds): Bone Marrow Transplantation: Administrative and Clinical Strategies. Boston, MA, Jones and Bartlett, 1995 5. Juttner CA, Henon P, Gale RP: Blood cell transplants, current state, future trends, in Gale RP, Juttner CA, Henon P (eds): New York, NY, Cambridge University, 1994, pp 167-181 6. Peters W, Ross M, Vivancost P, et al: The use of intensive clinical support to permit outpatient autologous bone marrow transplantation for breast cancer. Semin Oncol 21:25-31, 1994 (suppl) 7. National Cancer Information Cancer Facts: http://pmcp; oml/ipemm.edu/pdq/600736.html 8. Westerman I, Bennett C: Costs of care for bone marrow transplantation for malignant hematopoietic disease, in Burt RK, Deeg HJ, Lothian SC, Santos GW (eds): On Call in Bone Marrow Transplantation. Austin, TX, RG Landes, 1996, pp 29-38 9. Cole P, Andria M, Lynch J: A randomized controlled trial evaluating the safety, efficacy and cost effectiveness of continuous bladder irrigation, hydration and MESNA versus continuous bladder irrigation and hydration alone in the prevention of cyclophosphamide induced hemorrhagic cystitis. Proceedings of the 3rd International Bone Marrow Transplantation Conference, Dallas, TX, Baylor Medical University, March 7-8, 1997 (abstr 4) 10. Burns JM, Tierney K, Long GD, et al: Critical pathway for administering high-dose chemotherapy followed by peripheral blood stem cell rescue in the outpatient setting. Oncol Nurs Forum 22:1219-1224, 1995
11. Nelson J: Centers of excellence for marrow transplantation, in Buchsel PC, Whedon M (eds): Bone Marrow Transplantation: Administrative and Clinical Strategies. Boston, MA, Jones and Bartlett, 1995, pp 443-454 12. Buchsel PC, Kapustay PM: Peripheral stem cell transplantation: Oncology Nursing: Patient Treatment and Support 2:1-13, 1995 13. Appelbanm F, Fay J, Herzig G, et al: American society for blood and marrow transplantation guidelines for training. Biol Blood Marrow Transplant 1:56-58, 1995 14. Phillips G, Armitage J, Bearman S, et al: American society for blood and marrow transplantation. Guidelines for clinical centers. Biol Blood Marrow Transplant 1:56-57, 1995 15. Voell V, Maguire K: Developing case management for bone marrow transplantation. Oncol Nurs Forum 24:321, 1997 (abstr) 16. DeMeyer E, Buchsel PC: Multidisciplinary team contributions in the management of chronic graft versus host disease J Onc Nurs (in press) 17. Lamldn L: The new ambulatory oncology clinic, in Buchsel PC, Yarbro CH (eds): Oncology Nursing in the Ambulatory Setting: Issues and Models of Care. Boston, MA, Jones and Bartlett, 1993, pp 105-124 18. American Association of Health Providers. 200:29, 1997 19. Haberman MR: Psychosocial aspects of bone marrow transplantation. Semin Oncol Nurs 4:55-59, 1988 20. Syrjala K: Meeting the psychological needs of recipients and families, in Buchsel PC, Whedon MB (eds): Bone Marrow Transplantation: Administrative and Clinical Strategies. Boston, MA, Jones and Bartlett, 1995, pp 283-302 21. Compton K, McDonald JC, Stetz KM: The caring relationship during marrow transplantation. Oncol Nuts Forum 23:1428-1431, 1996 22. McDonald JC, Stetz KM, Compton K: Educational interventions for family caregivers during marrow transplantation. Oncol Nurs Forum 23:1432-1439, 1996 23. Stetz KM, McDonald JC, Compton K: Needs and experience of family caregivers during marrow transplantation. Oncol Nurs Forum 23:1422-1427, 1996
Implications for nursing practice: As BCT increases for oncologic and hematologic diseases, a growing number of oncology nurses will be caring for BCT recipients and their families. Nurses in administration, research, advance practice, and education are increasingly involved in implementing BCT as a standard therapy for a growing number of diseases. Copyright © 1997 by W.B. Saunders Company
HE SHIFT from bone marrow transplantation (BMT) to blood cell transplantation (BCT) as a treatment for hematologic and oncologic diseases has been dramatic with carefully selected transplant recipients receiving care in qualified centers throughout the country. The synergistic effects of early success in BCT, health care costs, and a changing health care climate are the driving forces of performing BCT. Currently 80% of autologous transplantations are performed with blood stem cells} This number is increasing due to new techniques such as single volume stem cell collections, less toxic but effective high-dose conditioning regimens, infusion of reduced and enriched stem cell products, and new attitudes in outpatient care. Much of the care is being offered in outpatient settings, but costs remain a concern and it is a challenge for the BCT team to deliver care in an efficient and economical manner, This article describes the critical components of developing, implementing, and maintaining a successful outpatient BCT program. The framework guiding the following discussion is based on the recently published standards for marrow and stem cell transplant programs developed by The Foundation for Accrediation of Hematopoietic Cell
Therapy (FAHCT). 2 Unique administrative and patient care issues not addressed by the FAHCT standards are also discussed. Information about generic issues of ambulatory outpatient care has been reviewed elsewhere} ,4
T
From Physician's Reliance Network, Dallas, TX. Janet E Nelson, RN, MN, OCN®: Vice President of Clinical Operations, Physician's Reliance Network, Dallas, TX. Address reprint requests to Janet P. Nelson, RN, MN, Vice President of Clinical Operations, Physician's Reliance Network, 3535 Worth St, Dallas, TX 75246. Copyright © 1997 by W.B. Saunders Company 0749-2081/97/1303-000855.00
208
FAHCT STANDARDS The major objective of the FAHCT is to promote quality medical and laboratory practice in hematopoietic progenitor cell transplantation. Facilities accredited by FAHCT are required to meet minimum criteria for performing blood and marrow transplantation (Table 1). The standards apply to all sources of hematopoietic progenitor cells and all phases of collection, processing, and administration of bone marrow, peripheral blood, or placental/ umbilical cord blood. The standards were initially developed by the Regulatory Affairs Committee of the International Society for Hematotherapy and Graft Engineering (ISHAGE), and a subcommittee of the Clinical Affairs Committee of the American Society of Blood and Marrow Transplantation (ASBMT). In December 1994, the laboratory standards of ISHAGE and the ASBMT clinical standards were merged into a single document; and FAHCT was established to develop and implement the accreditation program. Institutions desiring to apply for accreditation must comply with these current standards. Accreditation is determined by evaluation of the written information provided by the applicant facility and by on-site inspection. Site inspections are performed every 3 years by experts in hematopoietic cell therapy. 2 Currently there are no accredited FAHCT programs, Established BCT
Seminars in Oncology Nursing, Vo113, No 3 (August), 1997: pp 208-215
BCT PROGRAM
centers are assessing and revising their current policies and procedures for FAHCT accreditation and onsite inspection.
209
should be developed in conjunction with the overall program plan.
Creating Quality Cost-Effective Care PLANNING THE BCT PROGRAM
Program Feasibility The first step in considering a BCT program is performance of a feasibility study to identify internal and external advantages and harriers to a successful program. The important questions are as follows: Is this the business we are in? Do we have the resources? If not, are they available? Can we afford it? Can we do it well? An evaluation of competing BCT programs, ability to gain market share, availability of a qualified transplantation team, and comprehensive community resources is required. Table 2 identifies the parameters to assess for the development of a BCT program. A planning committee composed of key individuals is essential to the overall success of a committed and cohesive transplant program. Table 3 lists suggested members for the BCT planning committee.
Goals and Objectives If the assessment indicates the need for a BCT program that will provide a quality product and not be a major loss for the organization, the planning process begins. A mission statement, goals and objectives for the BCT program are developed. Goals and objectives may include the following: (1) To provide a quality, cost-competitive BCT program. (2) To improve the third-party payor approval process for BCT. (3) To identify appropriate patient selection leading to excellent clinical outcomes. (4) To provide the BCT recipient with the convenience of individualized services in an ambulatory setting that promotes increased independence and quality of life. (5) To incorporate a multidisciplinary approach, including medical, nursing, dietary, physical and rehabilitation medicine, psychosocial care and patient and family education programs. The planning process will evolve over time. Strategies that may assist the planning process are listed in Table 4. Table 5 identifies administrative and clinical assignments for members of the BCT planning committee. An action plan with time lines
Although BCT costs less than BMT, 5,6 it remains an expensive therapy costing from $80,000 to $150,000. 7 Determining the costs associated with BCT is tedious, laborious and depends on the community offering this therapy. Costs vary among institutions and because of the competitive nature of the marketplace this information is private and not shared. Some of the major charges, not costs, have been recently published. Examples of charges are surgical fees for central venous catheter placement ($2,050), mobilization and apheresis ($12,000), cryopreservation of stem cells ($750), total body irradiation (TBI) ($9,000), high-dose chemotherapy ($1,950 to $17,050), and stem cell infusion ($692). 8 BCT teams are evaluating procedures and tests to determine cost effectiveness and need. Clinical practices such as mesna administration, continuous bladder irrigation and hydration versus continuous bladder irrigation and hydration alone for cyclophosphamide induced hemorrhagic cystitis are being questioned and evaluated. 9 Critical pathways have been used for BCT to guide appropriate cost effective care. Figure 1 depicts a critical pathway for outpatient BCT for treatment of breast cancer, l°
Third-Party Payors The ability to obtain market share for BCT is largely dependent on an organization's capability to become a center of excellence or preferred provider. The elements and strategies for contracting with third-party payors to cover BCT are outlined in Table 6.11 It seems likely that in the near future, third-party payors will favor FAHCT accredited BCT centers that offer competitive fees.
Patient Selection Patient eligibility criteria is a critical component of the planning process. An expert BCT medical panel can evaluate potential risk and benefits for selected diseases. Some programs use a modified Rand Delphi technique to define appropriateness. Treatment protocols should reflect the team's judgment for the most effective transplant strategy for each disease entity treated. Patients should be treated on transplant protocols that are based on
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JANET R NELSON
Table 1. Minimal Criteria for a Blood Cell Transplant Program Components The Clinical Program
AIIogeneic BCT units
Accreditation criteria
Institutional Review Board ORB) The Blood Cell Transplant Team Program transp[ant director
Attending physicians
Consulting physicians Collection medical director Laboratory medical director Laboratory director
Nursing administrator Nursing staff
Pharmacy staff Dietary staff Other
The Clinical Unit inpatient Outpatient care Emergency care
Criteria Integrated medical team housed in geographically contiguous space with a program director, common training programs, protocols, and quality assessment systems. Access to accredited collection and process laboratory that meets the standards for FAHCT and American Blood and MarrowTransplant Registry. Access to blood bank providing 24-hour service for CMV- blood products; HLA testing laboratory accredited by the American Society of Histocompatibility and Immunogenetics; and the capability of performing deoxyribonucleic acid based HLA typing. Minimum of 10 transplants performed year before application for program accreditation. Perform minimum of 10 BCTs per year of each type (allogeneic or autologous) for which the Program is accredited. Formal review of investigational treatment protocols and patient consent forms approved by the Office for Protection from Research. Responsible for administrative and medical operations of the clinical transplantation program, including compliance with standards, Licensed to practice medicine in the United States or Canada and board certified (or non-United States/Canadian equivalent) in one or a combination of: hematology, medical oncology, immunology, and/or pediatrics. Show a minimum of 1 year experience in management of transplant patients in both inpatient and outpatient settings. U nderstand indications for BCT. Ability to perform evaluation and selection for BCT. Management of high-dose chemotherapy and irradiation, growth factors, neutropenic fever, bacterial, viral, and fungal infection, veno-occiusive disease, thrombocytopenia, hemorrhagic cystitis, nausea and vomiting, pain, posttransplant immunodeficiencies, acute and chronic graft versus host disease and terminal care. Blood cell infusion management. Allogeneic BCT considerations. Identify and select appropriate blood cell sources for BCT, including donor registries. Demonstrate knowledge of human leukocyte antigen typing, incompatible blood groups of hematopoietic progenitor cell components. Board Certified in surgery, pulmonary intensive care, gastroenterology, nephrology, infectious disease, cardiology, pathology, psychiatry, and radiation therapy. Ensures compliance with all medical aspects of the cell processing facilities, ie, donor care. Responsible for all administrative operations of the cell processing facility, including all medical aspects of the activities of the cell processing facility. Responsible for administrative operations of cell processing facility, including compliance with FAHCT standards. Possess PhD in appropriate discipline. Formally trained and experienced in the management of patients receiving BCTs. Training in hematology/oncology patient care, ability to perform pediatric and outpatient care when appropriate, administration of high-dose therapy, growth factors, blood component therapy, management of infectious complications. Nurse patient ratios satisfactory to cover the severity of patient clinical status. Ensure appropriate use and management of pharmaceuticals. Provide dietary consultations regarding patient's nutritional status, including total parenteral nutrition. Social services and physical therapy. Staff to provide efficient pretransplant patient evaluation and coordinate treatment and posttransplant follow-up care. Written policies for all procedures, including prevention and infection control, administration of high-dose therapy, immunosuppressive agents, and blood component therapy; create designated inpatient unit that minimizes airborne microbial contamination. Create patient care area reasonably free of infectious agents; provide administration of longterm infusions, and blood products. Prompt 24-hour evaluation and treatment by an attending transplant physician.
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211 Table 1. Minimal Criteria for a Blood Cell Transplant Program (Cont'd)
Components Other Departments Data management Quality management plan
Criteria Maintain accurate patient records required bythe IBMTR or ABMTR. System for review and approval of policies and procedures that document compliance with regulatory requirements and standards. Provides documentation of research protocols. Assures Institutional Review Board protocol approval. Documents implementation of new drugs or devices with any adverse outcomes. Develop system for detecting, evaluating, documenting and reporting errors, accidents, and adverse reactions.
Abbreviations: CMV, cytomegalovirus; HLA, human leukocyte antigen. Data from FAHCT.
critical analyses of data from scientific journals and meetings and/or reported to the Blood and Marrow Transplant Registry (BMTR) and the Autologous BMTR (ABMTR). Patients should participate in trials sponsored by International Cooperative Research Group, National Cancer Institute, and the other national and international research groups.12 THE BLOOD CELL TRANSPLANT TEAM
The recommended members of the BCT team and their associated criteria according to the FAHCT standards are outlined in Table 1. The following discussion highlights selected perspectives of these BCT team members.
Medical A medical and laboratory director are necessary for a certified transplant program. The program director should be board certified in hematology, medical oncology, immunology, and/or pediatric hematology/oncology. The director is responsible Table 2. Feasibility Parameters for Development of a BCT Program 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11.
Executive leadership support Physician support Physician coverage after hours, weekends, holidays Volume and type of transplant Diseases to be treated Assessment of resources to successfully provide quality, cost-effective care (eg, care beds, radiation oncology services, clinic facilities, outpatient pharmacy program, diagnostic facilities, housing, transportation) Knowledgeable and experienced staff Availability of multidisciplinary team members Costto provide service Charge to patient or payor Payor mix of patient population and reimbursement BCT in your geographic location.
for all administrative and medical operations of the clinical transplant program. The director is responsible for donor evaluation and selection, stem cell harvest procedures, and care of the patient throughout the transplant. The laboratory director is required to have a doctoral degree and be qualified by experience in stem cell processing. The medical director can also serve as the laboratory director. 2J3,14 Attending physicians are required to be licensed and either board certified or board eligible for similar specialties as the medical director. Physicians must have a minimum of I year experience in the management of transplant patients including BCT indications, patient eligibility, selection and administration of dose-intensive therapy, administration of growth factors, management of transplant related complications such as infectious disease, veno-occlusive disease, pancytopenia, hemorrhagic cystitis, and graft failure. %13
Nursing In contrast to nursing administrators who manage traditional hospital and clinical areas, the nursing administrator in an outpatient setting works in collaboration with physicians and other cliniTable 3. Suggested Members of the BCT Program Planning Committee Medical director Hospital or outpatient administrator Financial officer Nursing administrator Laboratory director Infectious disease physician Pharmacologist Blood bank representative Social worker Quality assurance manager
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JANET R NELSON
Table 4. Team Building Strategies for BCT Planning Committee 1. Assemble team and key players involved in process. 2. Articulate goals and secure commitment for providing service based on model of care selected. 3. Instill ownership of project to team members through delegation of key assignments. 4. Choose chairperson of team who can also provide leadership through planning, implementation, and evaluation process. Ideally, the chairperson should have formal authority in the system to mobilize institutional and community resources. 5. Identify time commitment for meeting schedule (eg, every week, bimonthly, monthly) and outside projects. 6. identify issues to be discussed and develop plan of action. 7. Structure multidisciplinary meeting to start on time, preplanned, with a written agenda. 8. Develop subcommittees to pursue specific tasks for committee for review and approval. Chairpersons should be technical experts (eg, clinical nurse specialist, dietician, pharmacist, insurance care coordinator, etc).
clans to introduce complex therapies, such as TBI, that may not be established as nonhospitalized procedures. Obtaining IRB approval for new protocols, developing informed consents, compreTable 5. Administrative and Clinical Planning Assignments for a BCT Program 1. Identify target date for implementation with sensitivity to market place 2. Compile direct and indirect cost data 3. Implement a cost analysis study 4. Determine patient volume as defined by clinic parameters 5. Determine clinic hours 6. Identify supportive services and enlist co-operation 7. Secure patient and family housing and 24-hour transportation 8. Identify legal issues relative to outpatient care 9. Establish charge structure 10. Establish outpatient medical record system 11. Order equipment, ie, intravenous pumps, monitors 12. Develop a marketing plan 13. Identify financial pricing structures for competitive bidding 14. Perform a "mock" patient billing Clinical Assignments 1. Determine types of BCT-autologous or allogeneic 2. Identify diseases to be treated and clinical protocols 3. Select patient eligibility criteria 4. Recruit medical, nursing, and administrative directors 5. Define staffing patterns 6. Create clinical documentation tools 7. Create critical pathway or caremaps 8. Develop guidelines for emergency care 9. Develop patient and family caregiver education plan 10. Perform a "mock" transplant with a "John Doe" patient
hensive patient and family caregiver education, and implementing safe staffing ratios are among the myriad of nursing administrator responsibilities. Assuring continuity of care as patients receive care in multiple departments such as surgery, apheresis laboratory, inpatient and ambulatory settings requires superb communication with numerous managers. BCT patients cared for in the outpatient setting results in high acuity levels. Nurse patient ratios to cover the severity of patient care is a constant challenge. There is little consensus or few guidelines that recommend appropriate nurse patient ratios and most nursing administrators are left to solve the problem vis a vis their own practice environment. For example, FAHCT criteria for nursing staff ratios state "sufficient nursing-patient ratios." A cadre of qualified nursing staff can be augmented with contracted blood bank apheresis services, nursing agencies, and home care services. 2 The use of licensed practical nurses, registered medical technicians, and ancillary personnel is a growing phenomena, however, it requires careful evaluation by nurse managers. Nursing administrators are crafting new roles for nurses to deliver care for BCT patients who have traditionally been cared for in a hospital setting. A BCT coordinator, exclusively dedicated to assuring efficient transition throughout the transplant trajectory, is an effective role that provides continuity of care. 15 The coordinator can establish the timing of events, verify insurance benefits, arrange for the patient's return to referring physician, and collect important follow-up information. Telephone triage nurses using computerized programs are assisting with patient symptom management. Advance nurse practitioners with prescriptive authority are managing outpatient clinics in some areas. 16 One of the newest skills transplant nurses may be required to learn is the collection of blood stem cells through apheresis. Decisions whether to train clinic nurses to do the apheresis procedure or to contract with outside services depends on the expected number of transplants performed and the costs of cross-training clinic nurses versus the expense of contractual agreements.
Pharmacy Staff BCT recipients require numerous medications, many of which are complex and self-administered. A pharmacy staff experienced in the appropriate
BCT PROGRAM
213
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°
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,
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! Preauthorization for treatment is obtained by the precerfiticafion RN. BMTcase marloger contacts the insurance case manager for outpatient treatment authorization or shift Of benefits.
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days. Chemotherapy is administered and stem cells are infused on an outpatient basis. Case m a n a g e r refers to primary care physician for administration of antibiotics and G-CSF. Bone scan, MUGA and CT scan may be needed after cycle 2.
No~MTIC cycles 2, 3, and 4 repeated every 21 days as an outpatient. Bone scan, MUGA, and CT scan m a y be needed after cycle
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Fig 1. A critical pathway for outpatient blood cell transplantation. (Reprinted with permission, t°)
use and management of pharmaceuticals is essential. Pharmacists with administrative experience in purchasing, dispensing, and controlling expensive medications can assure efficient on-site pharmacy management. Hazardous waste collection and disposal, and dispensing patient care supplies and home care pumps may be managed by the pharmacy department. ~
Other Staff An array of qualified clinical personal are required to support the BCT team. Dietary staff, social workers, physical therapists, and occupational therapists are important members of the BCT team. THE CLINICAL UNIT AND FOLLOW-UP SERVICES
Care of BCT recipients requires attention to their immunocompromised status. Infectious disease physicians are important consultants to assure minimal cross-contamination of infectious diseases such as air-borne parainfluenza, respiratory syndical virus, and herpes varicella zoster. 3 Similar to other oncology clinics, the design of the waiting
rooms, nurses station, infusion suites, bathrooms and staff offices need careful planning. These issues are beyond the scope of this article and they have been reviewed elsewhere? ,4,17 A designated area and/or room should be assigned for the stem cell collection procedure. Space to accommodate several machines, disposable equipment, the patient and caregiver require approximately 40 square feet per person. Some institutions with limited space and few procedures may move the apheresis equipment between procedures to facilitate alternative use of the room. Because the procedure requires about 3 to 4 hours, an overhead television, video cassette recorder, stereo and compact disc players may alleviate patient boredom. Attractive and affordable housing for the BCT recipient and their family can be one of the major marketing tools available to attract patients to a BCT center. With increasing regularity, institutions are entering into contracts with nearby hotels to accommodate this patient population. Special arrangements with hotel staff for cleaning, meal services, transportation, access to community resources, and privacy need to be addressed.
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JANET P. NELSON
Table 6. The Elements of Contracting With Third-Party Payors for BCT m Dialogue initiated between insurance company and transplant center. • Insurance company sends provider information regarding number covered lives, type of insurance company HMO PPO, utilization review, reinsurance. • Letter of confidentiality agreement signed by insurance company for medical center to release information to the insurance company. • RFP sent to transplant center for completion. • Transplant center responds to RFP with clinical information. • Transplant center and insurance company develop a rapport and exchange of business information. • Insurance company chooses network transplant centers based on insurer needs and pre-established standards (selection criteria). • Site visits scheduled to provide the opportunity for representative from the insurance company to meet the health care experts, inspect the clinical area, and answer questions. • Final decision for network transplant centers. • Financial information and bidding initiated for institutional and professional components of the contract. • Methodology negotiated between insurance company and transplant center(s). • Institutional and professional components are negotiated together or separately depending on state laws. • Memorandum of understanding signed by insurance company, transplant center, and physician association. • Final negotiations begun with minor modifications in memorandum of understanding. • Contract signed for usual duration of 12 months. • Internal communication process notifies appropriate personnel and departments of contract with insurance company, medical center, and physician association. Abbreviation: RFP, request for proposal. Buchseh Bone Marrow Transplantation: Administrative and Clinical Strategies. •1995 Boston: Jones and Bartlett Publishers. Reprinted with permission. 11
Home care for the BCT patient is provided through the institutions own agencies or contracted with approved home care providers. Orientation of home care providers can assure that home care nurses have state-of-the-art transplantation knowledge and that they are familiar with transplant protocols and policies. In addition, 24-hour care or emergency care must be available. Written booklets containing outpatient guidelines and how to access emergency care are useful tools for the patient and family. Autologous BCT recipients, in contrast to allogeneic marrow recipients, may return to their primary care physician or oncologist several weeks
after reinfusion. Communication between the primary care physician, oncologist, and transplant physicians is important in providing quality follow-up care. One transplant center implemented a World Wide Web-based computerized decision support system to help primary care physicians manage the follow-up care of BMT and BCT recipients. 18 PATIENT CARE ISSUES
Psychosocial Concerns BCT is an emotional procedure for the patient and family and requires psychological support throughout the transplant trajectory. Specific stressors such as absence of social support systems, limited economic resources, loss of job security, or pre-existing psychological problems that confound the physical demands of transplantation have been reported by recipients before, during, and after transplantation. 1%2°With the increase in outpatient care and less hospitalization, more intensive psychological support for the BCT patient and family caregivers is needed to assist them in coping with issues of self-care management.
Family Caregiver The family caregiver is an integral part of the interdisciplinary team who manages the care of the transplant recipient. Researchers 2x-23 have described the needs of family caregivers in the transplant setting and the educational interventions to meet these needs. Table 7 identifies strategies to meet the educational and supportive needs of the patient and family. However, the BCT team must be prepared for the reality of patients arriving without a contiguous and committed caregiver. Some centers have created a bank of approved "lay" people capable of assisting Table 7. Strategies to Meet Educational Needs of Patient and Family 1. 2. 3. 4.
Written guidelines on selecting a BCT Program Accessibility of patient/family caregiver advocate Establish a family support network Written content on: a. Available services and resources (ie, legal services, housekeeping assistance) b. Expectations of familycaregivers c. Managing care throughout the process d. The patient's disease
Data from Compton et al, 21 McDonald et al, 22and Stetz et al. 23
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215
patients with some aspects of their outpatient management. Support systems to allow family caregiver respite periods enhances the caregivers ability to cope, deliver responsible care, and maintain a healthy family relationship. CONCLUSION
Historically, the majority of the care for BCT recipients was given in traditional hospital settings. Over the past decade, a large portion of care has shifted to new treatment settings that include extensive outpatient management or combinations
of hospital, ambulatory, and home care. The BCT program needs to develop and maintain a quality, safe, and cost-conscious environment for recipients and their families. The ability to perform BCT in a cost-effective manner is of paramount importance as health care reimbursement moves toward an exclusive managed care environment. Oncology nurses practicing in these new environments require knowledge of new regulations and guidelines in establishing and maintaining BCT units while offering quality care to the BCT recipient and their family caregivers.
REFERENCES 1. Armitage JO: New ABMTR studies evaluate growing use of autologons transplantation. ABMTR Newslett 3:1-3, 1996 2. Standards for the Hematopoietic Progenitor Cell Collection, Processing, and Transplantation Cell Collection, Processing and Transplantation, Foundation For The Accreditation of Hematopoietic Cell Therapy (ed 1). University of Nebraska Medical Center, Omaha, NE, FAHCT, 1996 3. Buchsel PC, Yarbro CH: Oncology Nursing in the Ambulatory Setting: Issues and Models of Care. Boston, MA, Jones and Bartlett, 1993 4. Buchsel PC, Whedon MB (eds): Bone Marrow Transplantation: Administrative and Clinical Strategies. Boston, MA, Jones and Bartlett, 1995 5. Juttner CA, Henon P, Gale RP: Blood cell transplants, current state, future trends, in Gale RP, Juttner CA, Henon P (eds): New York, NY, Cambridge University, 1994, pp 167-181 6. Peters W, Ross M, Vivancost P, et al: The use of intensive clinical support to permit outpatient autologous bone marrow transplantation for breast cancer. Semin Oncol 21:25-31, 1994 (suppl) 7. National Cancer Information Cancer Facts: http://pmcp; oml/ipemm.edu/pdq/600736.html 8. Westerman I, Bennett C: Costs of care for bone marrow transplantation for malignant hematopoietic disease, in Burt RK, Deeg HJ, Lothian SC, Santos GW (eds): On Call in Bone Marrow Transplantation. Austin, TX, RG Landes, 1996, pp 29-38 9. Cole P, Andria M, Lynch J: A randomized controlled trial evaluating the safety, efficacy and cost effectiveness of continuous bladder irrigation, hydration and MESNA versus continuous bladder irrigation and hydration alone in the prevention of cyclophosphamide induced hemorrhagic cystitis. Proceedings of the 3rd International Bone Marrow Transplantation Conference, Dallas, TX, Baylor Medical University, March 7-8, 1997 (abstr 4) 10. Burns JM, Tierney K, Long GD, et al: Critical pathway for administering high-dose chemotherapy followed by peripheral blood stem cell rescue in the outpatient setting. Oncol Nurs Forum 22:1219-1224, 1995
11. Nelson J: Centers of excellence for marrow transplantation, in Buchsel PC, Whedon M (eds): Bone Marrow Transplantation: Administrative and Clinical Strategies. Boston, MA, Jones and Bartlett, 1995, pp 443-454 12. Buchsel PC, Kapustay PM: Peripheral stem cell transplantation: Oncology Nursing: Patient Treatment and Support 2:1-13, 1995 13. Appelbanm F, Fay J, Herzig G, et al: American society for blood and marrow transplantation guidelines for training. Biol Blood Marrow Transplant 1:56-58, 1995 14. Phillips G, Armitage J, Bearman S, et al: American society for blood and marrow transplantation. Guidelines for clinical centers. Biol Blood Marrow Transplant 1:56-57, 1995 15. Voell V, Maguire K: Developing case management for bone marrow transplantation. Oncol Nurs Forum 24:321, 1997 (abstr) 16. DeMeyer E, Buchsel PC: Multidisciplinary team contributions in the management of chronic graft versus host disease J Onc Nurs (in press) 17. Lamldn L: The new ambulatory oncology clinic, in Buchsel PC, Yarbro CH (eds): Oncology Nursing in the Ambulatory Setting: Issues and Models of Care. Boston, MA, Jones and Bartlett, 1993, pp 105-124 18. American Association of Health Providers. 200:29, 1997 19. Haberman MR: Psychosocial aspects of bone marrow transplantation. Semin Oncol Nurs 4:55-59, 1988 20. Syrjala K: Meeting the psychological needs of recipients and families, in Buchsel PC, Whedon MB (eds): Bone Marrow Transplantation: Administrative and Clinical Strategies. Boston, MA, Jones and Bartlett, 1995, pp 283-302 21. Compton K, McDonald JC, Stetz KM: The caring relationship during marrow transplantation. Oncol Nuts Forum 23:1428-1431, 1996 22. McDonald JC, Stetz KM, Compton K: Educational interventions for family caregivers during marrow transplantation. Oncol Nurs Forum 23:1432-1439, 1996 23. Stetz KM, McDonald JC, Compton K: Needs and experience of family caregivers during marrow transplantation. Oncol Nurs Forum 23:1422-1427, 1996