Improving Efficiency of BMT LTFU Clinic, Resulting in Increased Patient Satisfaction Academic research paper on "Clinical medicine"

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Abstracts / Biol Blood Marrow Transplant 20 (2014) S297-S315

pamphlet. All patients and staff from referring units asked for more visual information; video with patients going through transplant and pictures of the transplant unit. Some asked for a list with links to national and international web pages about BMT and a list with frequently asked question (FAQ). Patients suggested that staff from the transplant unit should go to referring hematology units to teach staff. Contact to the Danish Cancer Society has been established and a video production has started. Video will be ready in early 2014 and will be posted on the Danish Cancer Society's web site and a link will be present on the hospital web page. A time line with information about the deferent processes has been created and is posted on the hospital web page together with links to books about transplant, which can be downloaded. Links to relevant national and international web pages has been posted. List with FAQ has been developed and posted on the web page.

Discussion & Implications: To introduce the new part of the hospital website to doctors and nurses at referring hema-tology units. To post the website so current and future patients will get to know it. To post pictures of the BMT unit on the hospital website. Future project is to arrange visit/ meetings with referring hematology units, teaching staff.

Evidence Based Practice: Cryotherapy for Patients Receiving High Dose Melphalan

Rochelle Chiffelle, Melissa Cabrera-Behler,

Carolina Yanes del Castillo. Scottsdale Healthcare, Scottsdale,

Arizona

Topic Significance & Study Purpose/Background/Rationale:

Oral mucositis (OM) results in significant morbidity and mortality in hematopoietic stem cell transplant (HSCT) patients. HSCT nurses impact OM outcomes. Goals of this evidence based practice (EBP) project are (1) review concepts of EBP, and (2) apply EBP to the clinical problem of OM in HSCT. A PICOT question was formulated: In HSCT patients receiving high dose melphalan, does using oral cryotherapy versus not using cryotherapy decrease the amount of mucositis patients experience through day plus thirty? Three data bases were searched and ten studies were retained for critical review. The evidence supports the use of cryotherapy in HSCT. A nurse practitioner and two nurse champions led the team of nurses and other professionals to collaboratively implement the practice change.

Methods, Intervention, & Analysis: An educational session reviewing EBP, the problem and assessment of OM, the evidence, and the cryotherapy protocol, was attended by 100% of the clinical staff and support staff. Patients are given an explanation of the potential benefits of oral cryotherapy and can accept or refuse the intervention. The World Health Organization (WHO) mucositis scale is used to evaluate OM. Outcome measures include grade and duration of OM, need for hospitalization for OM, and use of TPN. Practice change is measured by how many patients are offered cryotherapy and frequency of OM grading. Data is obtained by a nurse and reviewed independently by a second nurse. Findings & Interpretation: This pilot included the first 16 patients who received melphalan. All of the patients were offered cryotherapy and 100% of patients accepted cryotherapy. The highest grade of OM was 3. Four patients had no OM. No patients were hospitalized for mucositis and no patients received TPN secondary to OM. Discussion & Implications: Findings demonstrate practice change occurs when nurses know the evidence. Additionally, when patients are presented with self care options for

symptom prevention they are willing participants. The findings are consistent with evidence in the literature: cryotherapy reduces the incidence and severity of mucositis in this setting. Further study is needed to determine how long patients need to implement cryotherapy to get maximal results and to determine best practice to prevent mucositis outside the oral cavity.

Implementation of a Standardized Cardiac Monitor Care Process to Reduce Nuisance Alarms

Kristen Coleman, Kristen Coleman, Laura Flesch, Melissa Hayward, Connie Koons, Lori Ann McKenna, Christopher Dandoy. Cincinnati Children's Hospital Medical Center, Cancer and Blood Diseases Institute, Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati, Ohio

Topic Significance & Study Purpose/Background/Rationale:

Excessive alarms create desensitization and alarm fatigue. Recently, the Joint Commission declared a sentinel event alert regarding improper alarm monitoring. Nurses play a key role in daily management of cardiac monitor care. We created and implemented a standardized cardiac monitor care process (CMCP) on a large bone marrow transplant (BMT) unit using the Improvement Methodology. The global aim of this project was to improve patient safety, satisfaction, and utilization of resources through decreasing monitor alarms by standardizing care.

Methods, Intervention, & Analysis: Through small tests of change, we developed and implemented a standardized CMCP in a 24-bed BMT unit. The CMCP included: 1) process of initial ordering and setting of monitor based on age appropriate standards; 2) pain free daily replacement of electrodes; 3) daily individualized assessment of cardiac monitor settings; 4) reliable process for appropriate discontinuation of monitor. The model for improvement was used to design, test, and implement changes. The key drivers and interventions can be seen in Figure 1. Changes that were implemented after testing and adaptation: family/patient engagement in CMCP, creation of a monitor care log to address settings, lead changes, and discontinuation; development of a pain free process for electrode removal; increase in high respiratory rate settings. Compliance with the CMCP was measured as percent compliance with the overall process. Alarms were measured in cardiac monitor alarms per monitored patient day.

Findings & Interpretation: From January-September 2013, percent compliance with the CMCP increased from 30% to >90% compliance (median=93%) Figure 2. Number of alarms per patient day decreased from 180 to 25 (median=32) alarms/day during this time period Figure 3. Discussion & Implications: Implementation of the standardized CMCP results in a significant decrease in cardiac monitor alarms per patient day.

Improving Efficiency of BMT LTFU Clinic, Resulting in Increased Patient Satisfaction

Dalena Craven, Kendra Bumgarner. Nationwide Children's Hospital, Columbus, Ohio

Topic Significance & Study Purpose/Background/Rationale:

Clinic staff of the multidisciplinary bone marrow transplant (BMT) long term follow up (LTFU) clinic evaluated current process and flow and identified several areas of improvement.

Abstracts / Biol Blood Marrow Transplant 20 (2014) S297-S315

Wait times for patients were long with extended periods of time between providers. In addition, scheduling tests, procedures and consults was difficult due to lack of organization. After comprehensive evaluation the clinic staff devised a plan to improve patient satisfaction, flow and decrease wait times. Methods, Intervention, & Analysis: Several modifications to the current system were implemented in an effort to improve efficiency, Figure 1. An identification system was implemented outside each room to decrease interruptions of provider visits. The patient's schedule was displayed in the room for visibility by staff and family. A schedule of patients and scheduled appointments was made available in the clinic office. A strict schedule of provider times was employed and presented in Figure 2. Ongoing monthly meetings were held with the multidisciplinary team to determine optimal clinic scheduling, revise evaluation guidelines and review each patient case. Clinic staff was responsible for clinic flow, patient information and patient follow up after visits. A letter was sent to families scheduled for annual visit one month prior to the appointment. This letter outlined expectations (i.e. labs pre-drawn, no walk-ins) to improve adherence to the new structure.

Findings & Interpretation: At 2 months the clinic staff evaluated effectiveness of changes to clinic. A significant improvement was noted in patient wait times, see Figure 3. However, within six months adherence by some providers declined. The majority of labs are completed prior to the clinic day. Walk-ins dramatically decreased. Monthly meetings help to bring closure to the past month and prepare for the next, thus guaranteeing everyone's expectations are consistent.

Discussion & Implications: The implemented changes significantly improved the multidisciplinary BMT LTFU clinic. Future directions are aimed at evaluating patient satisfaction and increasing adherence to provider schedule.

Implementation of a Robust Intervention to Address Central Line Associated Blood Stream Infection Rates in an Acute Oncology and Stem Cell Patient Population in an Academic Setting

Regina DeGennaro. University of Virginia Health System, Charlottesville, Virginia

Topic Significance & Study Purpose/Background/Rationale:

Oncology patients require vigilance to prevent life-threatening infections. The oncology nursing role to reduce central line-associated blood stream infections (CLABSI) is documented widely (Whited, A. & Lowe, J. ,2013). An opportunity to improve quality and safety was identified in an acute hematology/oncology population in an academic setting. Implementing evidence to reduce CLABSI's as infection rates rose, became priority to reduce morbidity and mortality. A systems gap assessment was recommended, performed and analyzed. An educational intervention was proposed, implemented and evaluated. Reduction in CLABSI rates was demonstrated by implementing CL insertion and maintenance "bundle" approach (Centers for Disease Control and Prevention, 2011). Initial research occurred in critical care settings but specific attention to oncology and immuno-compromised patient population is required (Fraser, T. & Gordon, 2001).

Methods, Intervention, & Analysis: Nurses in the Adult Hematology/Oncology (AHO), a 29 bed unit, and Adult Stem Cell Transplantation (ASCT), an eight bed unit, implemented an intervention to reduce CLABSI rates. Four steps included: 1) education; 2) standardized approach to central venous

catheter (CVC) maintenance; 3) practice audits three times per week on all patients and 4) immediate peer feedback. Prior to implementation, CLABSI rates were 4.85 (AHO) and 3.21 (ASCT) times the National Healthcare Safety Network (NHSN) Mean. Post intervention, rates decreased to 1.15 times NHSN Mean within one quarter. Both units reached over 185 preventable CLABSI free days. Nurses completed CVC education and collaborated with the medical team to address appropriateness of CVCs. CLABSI nursing champions were identified to support education and interdisciplinary collaboration.

Findings & Interpretation: Knowledge deficit regarding existing policy was identified. Educational sessions addressed this gap. The CLABSI rate for AHO in October-December 2012 measured 6.79 (NHSN Mean 1.40) and measured 7.71 for ASCT (NHSN Mean 2.40). In April - June the AHO rate measured 1.62 and measured 0 for ASCT. Findings post-intervention included: 1) reduced practice confusion; 2) increased compliance of 98% with best practices; 3) no breaks in sterility; and 4) increased policy knowledge. Discussion & Implications: Findings are consistent with recommendations for reducing CLABSI in non-ICU setting. Pre and post data indicate education and process standardization reduced CLABSI incidence and addressed a quality and safety gap for health systems.

Building Capacity for the Future of Hematopoetic Cell Transplant Nursing

Kathleen Shannon-Dorcy, Rosemary Ford, Debra Stauffer. Seattle Cancer Care Alliance, Seattle, Washington

Topic Significance & Study Purpose/Background/Rationale:

Significance/Background March 1969 Dr. Don Thomas and his team carried out the first Hematopoetic Cell Transplant (HCT). Dr Thomas attributed the success of HCT to the expert team of nurses and physicians. Now 45 years later a need exists to increase the capacity of centers to meet the growing demand for HCTs. The National Marrow Donor Program® sponsored the System Capacity Initiative to analyze and suggest interventions on how to care for a 2-3 fold increase in HCT patients by 2020. In light of health care delivery shifting to the outpatient department (OPD), a HCT nursing leadership team proposed a pilot transition from academia to practice model with a local university.

Methods, Intervention, & Analysis: Interventions In January 2012 the pilot began and a total of 24 students have rotated through the OPD with a precepted model of learning. HCT experts have taught conferences on death and dying, biology of cancer, immunology, line management and history of HCT.

Objectives 1. Establish a clinical oncology rotation for BSN students. 2. Create a residency program with nurses completing the HCT clinical oncology rotation. 3. Increase the applicant pool for future HCT staffing. Findings & Interpretation: Findings From the initial 18 months of the pilot both the University and the HCT center have met objectives for the program. Students rank the HCT clinical experience as valuable for knowledge and skill acquisition. The HCT center has hired 5 nurses for residency, 2 have accepted full time HCT positions. Discussion & Implications: Implications Today's HCT's centers are challenged to find innovative ways to expand recruitment and increase applicant pools for HCT nursing. The tradition of nurses working inpatient first as mandatory no longer is appropriate as most care of patients has moved