Blood & Marrow Transplantation

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Kim Schmit-Pokorny, who will be talking with us about any and all questions you have regarding Blood and Marrow Transplantation. Welcome Kim!

 kschmit 

Hi Elaine! I recognize your logon!

 stenstrup 

Hi, everyone. Happy to be a part of the conversation!

 kschmit 

Hope some more people join - anything you want to talk about?

 stenstrup 

Yes. re: coordinators -- How do you use this role where you are? Do they have a patient list? Do they see patients in the clinics w/ the providers?

 kschmit 

Good question - and I love to talk about this

 kschmit 

We break out our transplant patients by diagnosis - doctors/case managers

 kschmit 

We call our 'coordinators' case managers - they coordinate care and services for the entire transplant process

 kschmit 

Coordinate from referral thru long term follow-up

 kschmit 

They work with a specific disease - NHL/HD, Leukemia, and myeloma

 kschmit 

They get the referrals, see them in clinic with the MD, do a lot of the teaching

 kschmit 

We then follow all the pre transplant workup - let the MD know if something is going on

 kschmit 

Then we coordinate the collection. The MD may only see the patient at consultation, and once prior to admission.

 kschmit 

Once the pt is admitted - we back off a little - but still follow inpt. We do the transplant infusion.

 kschmit 

And, then do all the discharge planning - and follow them in clinic - and long term.

 kschmit 

The case managers love the 'entire' process - and really get to know the patient and family. And the patient sees us as the main contact.

 kschmit 

Long answer - do you use coordinators?

 stenstrup 

Our NCs are divided into outpt - most are here - and 1-2 inpt NCs (nurse coordinators). The inpt NCs make sure the follow up tests are completed if still inpt (like Day +28 BMBX), etc. They do the d/c teaching. But the inpt RNs do the infusions and much of the d/c teaching. It is good to hear another perspective. We are always looking at ways we can do things differently. How many patients do the case managers have (what is their typical load)?

 kschmit 

Typical load - kind of a long answer

 kschmit 

Each case mgr does about 25-35 transplants per year (more if auto, less if allo)

 kschmit 

And, they also continue to follow the patients transplanted previously - which may be 100s.

 stenstrup 

In your experience, is this the typical way NCs or case managers are utilized within a program?

 kschmit 

And, then there are the patients who come for referrals that don't actually get a transplant. We do a lot of work upfront - but at times the patient doesn't make it to txplant.

 kschmit 

I have heard of both models - what we do, what you do.

 kschmit 

So much depends on what works for your center.

 oncnurse 

Do you require a certain level of education for nurse coordinators- bachelors? Masters?

 kschmit 

We are all in the same building - and the doctors are all part of the same system - so everything happens under 1 roof.

 kschmit 

We require a bachelors, prefer masters.

 kschmit 

We ideally want onc/hem background. But, I have found that I can teach someone onc.

 kschmit 

What I can't teach someone is to critically think - and be organized to be able to case manage.

 kschmit 

I have hired several people over the years with no onc background - and they have done very well!

 kschmit 

Do you have a minimum education?

 stenstrup 

Some of our more "seasoned" staff do not have their BSN, but I think many do. No one w/ MSN.

 kschmit 

It is getting hard to find nurses with a MSN - who don't want to be NPs.

 kschmit 

Do you have separate people do the National Marrow Donor Program (NMDP) stuff - or do your case mgr/coordinators?

 stenstrup 

Our NCs and a few other admin staff take care of that.

 nursenow 

As do ours at UC Davis

 kschmit 

Same here - we have some admin staff do a lot of the NMDP stuff.

 stenstrup 

Do research nurses help out with drawing labs on inpts? Right now, all our labs (and with close to 150 protocols, that's a lot of labs!) are drawn by the inpt RNs.

 kschmit 

We do have some of our research nurses draw labs.

 kschmit 

It depends on the protocol - and the amount of detail involved.

 kschmit 

I agree - our inpt RNs get overwhelmed by the amount of research labs

 stenstrup 

Sorry, jumped to another topic. Should have asked if that was OK.

 kschmit 

Fine!

 Laurl at ONS 

No asking!;-) All questions good!

 oncnurse 

Can you give some guidance re: the orientation you think is appropriate/necessary for nurse coordinators?

 kschmit 

We have the case mgrs follow another case mgr for about 6-8 weeks.

 nursenow 

I would love some input on orientation. I have been in the outpatient setting as a Coordinator for about 2 years and have so much to learn.

 kschmit 

The new case mgr also spends time with all the other areas involved in BMT.

 kschmit 

I heard an abstract at Tandem. They had new RNs - and case managers follow several patients.

 kschmit 

They said it really worked well to have the new staff see the process from the patient’s point of view.

 kschmit 

Nursenow - do you have current coordinators that the new person can follow?

 nursenow 

We are small. We started with one coordinator and one physician. We have now expanded to 3 and 3.

 nursenow 

I was able to follow a coordinator when I started but only for autologous.

 kschmit 

I think it is hard to have a new person shadow the current coordinator - and try to do all the work. But that does seem to help with the orientation.

 nursenow 

With us now hiring a 3rd RN I have started a transition to Allo patients and need training.

 nursenow 

I understand NMDP has a coordinator training session has anyone been?

 kschmit 

We have found that after a 6-8 week shadowing helps - but then it is on the job training - trying to take it slow.

 stenstrup 

We have our NCs attend our "BMT Cluster Classes" as well as shadow other NCs and the patient experience. It puts many of the pieces together for them.

 kschmit 

Re: Training for coordinators: I haven't had any one go thru the NMDP for training - however, that training might be directed at the coordination of all the NMDP stuff - not sure.

 nursenow 

We do everything in our facility.

 kschmit 

The BMSCT SIG (ONS SIG) is developing an on-line course for BMT that might help.

 kschmit 

I think they are close to having it available.

 nursenow 

I am looking forward to the online training and hopefully an eventual BMT certification.

 kschmit 

Good to hear!

 stenstrup 

What types of line are you using in your facility? We are still using a double lumen power Hickman (or PICC). Would love to move to a triple Hickman for our allos that we know will get very sick.

 kschmit 

We still use a double lumen Hickman - for apheresis. Autos and Allos get it. If allos have a port - we put a PICC in. We haven't tried the triple or more lumen caths. Anyone else?

 kschmit 

Yesterdays chat - there were a couple of people who used triple and even 4 lumen caths.

 stenstrup 

Sounds like heaven to me!!!

 nursenow 

Me too

 kschmit 

Does sound good! I wonder if they draw for apheresis?

 nursenow 

We use Hickman for allo or Power Piccs and apheresis caths for our autos.

 kschmit 

Have you ever used a PICC for apheresis - we haven't had any luck when we tried.

 stenstrup 

I don't think we've had luck, either. I believe they put in a temporary cath or, if pt does not have PICC, will do the typical peripheral apheresis.

 kschmit 

Yes that's about what we do.

 stenstrup 

We are close to zero BSI rates, so I want to take the leap forward and ask the docs if they would consider triple lumens...

 kschmit 

Ok - can't remember BSI...

 stenstrup 

Blood stream infections

 stenstrup 

Is that what you meant?

 kschmit 

Wow that is great! Zero! What is your trick?

 stenstrup 

Lots and lots of work!! When I got here at Univ of Minn, took apart the policy and went to work on the drsg change part, competencies, got our Infx Dept involved, etc.

 kschmit 

Did it involve working with the people who put the caths in, too?

 oncnurse 

Stenstup, what is your dsg change policy?

 stenstrup 

I did not directly influence them, but the Infx Dept did. They use "bundles" which has really helped us out!

 stenstrup 

Policy: tegaderm (or transparent) = 72 hours, Primapore = 48 hours. No Biopatch. We added mask to drsg change - they were not doing that. Also, our techs do 90% of the drsg changes. They must demonstrate competency every year.

 kschmit 

Wow!

 oncnurse 

Wow, very interesting - thanks!

 kschmit 

What is your flushing policy? Does that make a difference?

 stenstrup 

I have heard many places do 96 hour drsg changes, but I guess I am not ready to go there yet. We are doing so well right now.

 stenstrup 

Flushing: We are flushing with 10ml NS after every blood draw (if not on fluid restriction) and 50 units heparin when HL'd (heparin locked).

 kschmit 

We use only 10 ml NS. No heparin. And, at least each lumen every day.

 stenstrup 

I think we will be going to NS only very soon. Our ICUs have a no heparin policy and lit supports that...so will look into that soon.

 kschmit 

We have been doing only NS for at least 5 years - ok - maybe longer, time flies. And, it seems to work pretty well.

 kschmit 

I almost think we had more clot problems when we used heparin.

 stenstrup 

Wow. This university is behind your university...I need to get up to speed!

 kschmit 

We haven't fixed the infections yet!

 oncnurse 

How do you preserve your stem cells?

 kschmit 

We use 10% DMSO and put in a controlled rate freezer for a fast freeze. Then put in -196 degrees freezer for long term storage.

 kschmit 

At one time we used 5% DMSO and 5% Hydroxeythel starch. But they stopped making the starch - much less side effects.

 kschmit 

Does anyone use something different?

 kschmit 

I have heard that MD Anderson has a different procedure - but I don't know the details.

 oncnurse 

What kind of side effects do you see?

 kschmit 

With the infusion - possibly related to the DMSO...

 kschmit 

We see Nausea/Vomiting/Diarrhea; there is a bad smell/taste - like garlic.

 kschmit 

They can get fluid overloaded, have allergic reactions, and have rxn to the breakdown of red cells in the product.

 kschmit 

I have seen anaphylactic rxn - very quick and only an epinephrine drip allowed us to get the cells in.

 kschmit 

Also, hard on the kidneys - they need lots of fluid to flush the broken down cells thru - they may even have red urine!

 oncnurse 

Anaphylactic rxn like that - that had to be really scary.

 kschmit 

Shortness of breath, chest pain - probably related to the red cell break down.

 kschmit 

Yes - scary - if someone starts to complain of itching - just get the epi out right away!

 kschmit 

We have found with the better drugs for mobilization and lesser number of collections (of course) the patients have less side effects. So, we try to collect in about 5 or less collections

 kschmit 

However, I have given at least 2 patients 28 bags of cells - and many 24, 25 or so bag transplants

 kschmit 

Those we have done over 2 days. Makes me sick too!

 kschmit 

I should say - those large transplants were at least 5-10 years ago.

 kschmit 

With Neupogen, plerixafor, etc. patients collect better. Or they possibly should not be having an auto txplant.

 Laurl at ONS 

It’s about five minutes before the end of our chat- please don’t stop asking questions! However, when you can, please take a moment after the chat to cut and paste this URL into a browser window and take our very brief survey – we’d love to hear what you think of these chats! The URL is http://research.zarca.com/k/RsTUTRsSWPsXYTYUsPsP

 kschmit 

Good to talk to you both!

 stenstrup 

Thanks, Kim!

 Laurl at ONS 

Welcome! We are just actually ending this hour's chat, but if you have a quick question we'd love to hear it!

 Laurl at ONS 

The next chat on this topic is tomorrow AM at 8:30 am EASTERN time.

 kschmit 

A great place to ask questions and get answers from all over is our ONS BMSCT SIG website - Discussion forum

 kschmit 

You can go to the SIG website - and post a question - or answer - or view previous answers

 Laurl at ONS 

Well, what a great discussion - thanks to all participants, and especially to Kim!

 Laurl at ONS 

We hope you'll come to another chat soon - please tell your coworkers about them! There are two more in this series - check the ONS website for more info.

 kschmit 

Thanks to all! Have a great evening!

 Laurl at ONS 

Thank you Kim!

 oncnurse 

Thanks