Blood & Marrow Transplantation

 kschmit 

Welcome everyone! I'm Kim Schmit-Pokorny and hosting the chat today! Do you have any burning questions or issues!

 kschmit 

Where is everyone from? And what sort of practice setting do you work in?

 sgoshert 

Hi. Just wondering what your average collection parameters are for each transplant.

 sgoshert 

How many stem cells do you collect?

 kschmit 

For autologous patients - we collect a minimum of 1.5 × 10e6 (ten exponential 6th)/kg CD34+ cells - and

 sgoshert 

We have a small, outpatient transplant program...autos only.

 kschmit 

Our target is 5.0 × 10e6/kg CD34+ cells.

 nursenow 

Has anyone seen a change in the ability to collect Multiple Myeloma pt since Revlimid?

 kschmit 

Allos - we collect a minimum of 3.0 × 10e6/kg CD34+ cells.

 sgoshert 

Yes, we have trouble collecting if they have been previously treated with Revlimid.

 kschmit 

I have found that our minimum target for autos is low - most centers have at least 2.0.

 nursenow 

Our goal is 5 for NHL ( Non-Hodgkin’s lymphoma) and 10 for MM (multiple myeloma) -5 now 5 later.

 sgoshert 

We try to save Revlimid for after transplant at 2nd relapse.

 kschmit 

Same here with the MM and Revlimid.

 sgoshert 

Our center still has a target of 10 × 10e6 per transplant.

 kschmit 

Is the 10 × 10e6 for autos? - One transplant?

 sgoshert 

Yes, one transplant. We have a goal of 20 × 10e6 for MM for two transplants.

 sgoshert 

Some patients are having to apheresis for multiple days causing fluid overload, electrolyte imbalance, etc.

 kschmit 

For those who don't know - 1.5 × 10e6/kg is 1,500,000 CD34+ cell/kg - or the stem cells.

 kschmit 

Why so many cells - 10 × 10e6?

 nursenow 

Do you see infusion complications with the higher dose?

 sgoshert 

Our director has been burned in the past with pts not engrafting platelets for many months.

 sgoshert 

Yes, we are seeing a higher incidence of engraftment syndrome.

 kschmit 

Are the fluid overload and electrolyte imbalance happening during the collection or infusion?

 sgoshert 

 We are also seeing auto graft vs. host in the gut.

 sgoshert 

RE: fluid overload/electrolyte imbal: during collection.

 sgoshert 

How many days do you collect on average?

 kschmit 

Help us understand the auto graft vs. host in the gut - do you mean allo?

 sgoshert 

No, I mean with autos.....they have delayed n/v ( nausea/vomiting), sometimes 40 or 50 days out

 kschmit 

Our average number of days collection is 2 - but as noted, we are collecting a lesser number of cells.

 sgoshert 

Re: n/v: IV steroids followed by a steroid taper usually does the trick.

 nursenow 

Does anyone use Mozobil as a standard for mobilization?

 kschmit 

Did you biopsy and find GVH ( Graft vs. Host)?

 sgoshert 

We’ve biopsied one, but mostly just clinical presentation.

 kschmit 

We use Mozobil if a patient doesn't collect well after 1-2 days. Not upfront use.

 nursenow 

Are facilities still using chemo mobilization?

 sgoshert 

We still use cytoxan for mobilization quite a bit, and occasionally VP-16.

 kschmit 

We use cytoxan and G-CSF for mobilizing our Multiple myeloma patients.

 nursenow 

How about Rituxan in DLBCL?

 nursenow 

RE: Rituxan: We are talking about adding it just to ensure the NHL pts receive it.

 kschmit 

Do you mean Rituxan for mobilization? Or as an in vivo purging agent?

 sgoshert 

Yes, we use Rituxan for cell purging until they collect.

 kschmit 

DLBCL = Diffuse Large B-Cell Lymphoma, NHL = Non-Hodgkin’s lymphoma  Just FYI…

 nursenow 

We receive a lot of external referrals and not all have received Rituxan up front.

 kschmit 

We give our patients Rituxan before and after collection if appropriate.

 sgoshert 

How many liters do you cycle on the pheresis machine during collection?

 kschmit 

We process 15 liters for autos. And 12 liters for allo donors.

 kschmit 

Some people are doing higher volume for autos - in the 20 - 25 liters - that I have heard.

 sgoshert 

We process 26L per collection.

 kschmit 

How long per day does 26 L take?

 nursenow 

I think we use 22L for our autos

 sgoshert 

RE: how long it takes: Usually 4-6 hours depending on how they tolerate.

 nursenow 

Same here

 kschmit 

What type of catheters do you use to maintain the high flow rates?

 nursenow 

Apheresis here

 sgoshert 

Triple lumen tunneled cath

 kschmit 

A practical question - do you unhook the patient to go to the bathroom?

 nursenow 

I wish we used triple lumen.

 sgoshert 

 RE: Unhook? No, they are in a private room with enough slack to reach the bathroom.

 nursenow 

We do not unhook, BSC ( bed side commode) or urinal.

 sgoshert 

How often are you flushing your lines, and with what solution? We use NS ( normal saline) only 3xweek.

 kschmit 

We use NS = normal saline every day.

 kschmit 

There are ONS guidelines - but they vary depending on the type of cath.

 sgoshert 

Do you do outpatient or inpatient?

 kschmit 

We have a Cooperative Care Model that we use for outpatient transplants.

 kschmit 

In the Coop model, the patient and care partner are in a hotel like setting - in our Transplant Building. They go down to our Treatment Center and Clinic.

 kschmit 

Our Treatment Center is open 24/7. At night there are 2 nurses/1tech.

 nursenow 

Nice to have 24/7 coverage outpatient

 nursenow 

We do all of our transplants inpatient.

 kschmit 

The care partner is taught to observe for side effects, give meds, take temps and blood pressures, etc.

 kschmit 

The 24/7 is very nice - no need to send patients to the ER, they see us if they need to.

 sgoshert 

How many transplants do you do a year?

 nursenow 

Our Chief gives her patients her pager number for 24/7 coverage but she is heading for retirement.

 kschmit 

We do about 150 - 175 per year. How about you?

 sgoshert 

We do about 20-25 per year, but that number is going up; we only have 2 coordinators.

 nursenow 

We are small -10-20 allos and about 30 autos

 sgoshert 

All outpatient, all autos

 kschmit 

Where do your outpts stay?

 nursenow 

We have 3 coordinators

 kschmit 

We have 7.5 FTE for coordinators.

 sgoshert 

RE: where pts stay: At home if they have good caregiver support and live within 1hr. Otherwise, at a hospitality house or hotel or are admitted right after transplant.

 sgoshert 

They come to the clinic everyday for f/u.

 kschmit 

We have a transplant insurance coordinator - who works with the clinical team, and interprets the 'insurance' lingo for us. Does anyone else have that role?

 nursenow 

We have a “Principle access assistant”. Same idea but not efficient.

 sgoshert 

Our data manager has just recently taken on that role. Our program manager/coordinator does all of the insurance letters.

 nursenow 

It is easier to investigate ourselves.

 nursenow 

We do our own letters.

 kschmit 

Does "Principle" mean associated with the insurance company by that name?

 nursenow 

We also do our own drug authorizations.

 nursenow 

"principle" = The main access point

 kschmit 

Ok - got it!

 nursenow 

It isn't working well but we keep adjusting the position

 sgoshert 

Do you have an orientation program for either nurse coordinators or the transplant nurses?

 kschmit 

Our insurance person has a background from the insurance industry and in the BMT arena.

 nursenow 

Can we steal them?

 sgoshert 

Our transplant nurses also work in the hem/onc treatment area, so they find it's difficult to wear both hats.

 kschmit 

The insurance person is a nurse. No - can't steal - but we can talk more!

 nursenow 

RE: orientation: Our transplant nurses (all inpatient) must have 1 year oncology experience and take a one day class

 kschmit 

Orientation program for nurse coordinators - we have the new person follow others for 6-8 weeks.

 nursenow 

They then shadow an experienced transplant nurse for 2-4 weeks.

 nursenow 

New oncology nurses shadow an experienced RN for 4-8 weeks.

 kschmit 

Then the new coordinator is assigned several patients - and we help her walk thru the work.

 sgoshert 

So does the coordinator do any of the physical patient care, or just coordinate?

 nursenow 

Is it possible for a nurse from an outside program to shadow your coordinators?

 nursenow 

With our program being so small it is hard to do the work and teach.

 kschmit 

Yes - we have had people from the outside shadow - email Laurl @ lmatey@ONS.org  and she will get us in touch.

 kschmit 

Coordinator roles at our center are overall coordination of care, most of the education, we infuse the cells, follow the patient thru the entire process - referral to long term follow-up.

 kschmit 

We have a very clinical role - follow all the test/procedures, get the first calls from patients on issues, etc.

 nursenow 

7.5 FTE for 150-175 patients- WOW that is a lot

 kschmit 

Are you saying a lot of FTEs - or a lot of patients to handle?

 nursenow 

A lot of patients

 kschmit 

It can be a lot of patients - we do have to work to make sure the coordinators aren't overloaded.

 nursenow 

We have separate inpatient and outpatient nurses. Outpatient is 3 RNs and 30-40 patients a year

 nursenow 

We continue to follow all of our Allos who are on immunosuppression so our patient load continues to grow.

 kschmit 

And, sometimes we have to spread out the autos and allos.

 sgoshert 

Are they dedicated stem cell transplant nurses? Or do they also do other chemo treatment?

 kschmit 

Yes - we do the same - follow all allos while on immunosuppression.

 kschmit 

The coordinators are dedicated to stem cell txplant and high dose acute leukemia pts. They are assigned by diagnosis.

 kschmit 

So, a coordinator who has been assigned a new acute leukemia pt, will follow that patient thru transplant - and long term.

 nursenow 

Are you treating your acute Leukemia pts outpatient?

 kschmit 

Some of our acute leukemia pts are outpt, most are inpatient.

 kristie 

We are treating them with consolidation therapies here in the office.

 kristie 

We are treating many of ours outpatient with the plan to do more.

 sgoshert 

Induction therapy inpatient, consolidation outpatient

 nursenow 

Financially we all need to move in that direction.

 kschmit 

That is what we will do - if the induction goes well.

 nursenow 

Same here

 kristie 

What therapies are you doing in the outpatient setting (in terms of consolidations and other high dose regimens)?

 kschmit 

Transplant regimens - BEAM, melphalan, and a few leukemia protocols.

 kristie 

How many of you guys are doing outpatient transplants?

 sgoshert 

We use busulfan, cytoxan, vp-16 for NHL, hodgkins, AML and melphalan for myeloma and amyloid

 nursenow 

Inpatient

 kristie 

We are doing re-infusions in the office

 sgoshert 

We do all outpatient, all autos (about 25 per year)

 kschmit 

Kristie, I know you came in a little late - we did talk about outpatient previously, check the transcript too,

 kristie 

Sorry, transcript unavailable to me

 kschmit 

What are you doing?

 Laurl at ONS 

Sorry, Kristie, we aren't clear - yes, transcript will be available after today's chat-sometime tomorrow....when you come in you can't see what was written prior to entering chat...but good info re: outpt transplants in this transcript, available tomorrow...

 kristie 

We just started doing outpatient transplants in January and have done 9 since then, including one mini-allo using FCR

 kschmit 

FCR?

 kristie 

Fludarabine, cytoxan, rituxan

 kschmit 

Also, the BMT SIG  ( ONS) is developing an on-line course. Hopefully ready soon!

 kschmit 

Do your outpatients stay close by?

 kristie 

Yes, I am anxiously awaiting that as I am the nurse manager here.

 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

 sgoshert 

We like them to be within 30min. but no more than 1hr away.

 kristie 

Yes, they have to stay within 30 minutes drive time. If their home is farther away than that, they stay in a couple of designated hotels close by.

 nursenow 

We require that after D/C from inpatient transplant

 kristie 

Same here until they are d/c from ATC.

 kschmit 

Just for the transcript - what is ATC? Thanks!

 kristie 

Ambulatory treatment center or clinic, whatever you like at the end.

 kschmit 

Just curious - what are your hours?

 sgoshert 

7am-6pm Monday-Friday. Makes timing of transplant difficult sometimes.

 sgoshert 

Especially now using Mozobil

 kschmit 

Have you had patients give their own Mozobil?

 nursenow 

Do your patients self inject Mozobil?

 nursenow 

We do

 kschmit 

How is that working - giving their own? We haven't had a need yet.....but it is coming!

 kristie 

We have not allowed that as of now but we are giving it at 6pm and getting them on the machine at 7am.

 sgoshert 

We've talked about it, but haven't tried it yet due to the cost.

 nursenow 

Seems to work OK.

 kristie 

Works very well. Have collected all our previously failed collections after using it.

 nursenow 

We had one failure with mcg G and Mozobil.

 kschmit 

I agree Mozobil works very well! Though, we have had a few Mozobiil failures!

 kschmit 

Thanks to everyone for joining! It's been a fun 'chat!'

 Laurl at ONS 

I hate to interrupt this great discussion but unfortunately we are out of time! Thank you for a great discussion today. This transcript will be available sometime tomorrow. Please be sure to check out the next topics coming up - they are all great- Caregiver stress; Complimentary and Integrative therapies. Infectious Complications coming up soon.

 Laurl at ONS 

Thanks for your time and expertise Kim!

 sgoshert 

Thanks!

 kristie 

Thanks!