Advanced Practice Nurse, Pharmacist Collaboration Leads to Improved Outcomes on HSCT Unit

A new initiative within an interdisciplinary team led to effective collaboration that improved the quality of care for patients with hematologic cancer undergoing hematopoietic stem cell transplantation (HSCT). These results were reported in a project presentation at the 48th Annual Oncology Nursing Society (ONS) Congress.

“Interdisciplinary collaboration between pharmacy and advanced practice nursing can improve clinical practice,” Shivani Gopalsami, RN, MSN, ANP-BC, AOCNP, and colleagues at UCLA Health stated in their abstract. The goal of this project was to strengthen the collaboration between the pharmacy and the nurses on the HSCT unit.

HSCT management is complex, and collaboration ensures a multidisciplinary team develops an understanding of the roles and responsibilities of each team member as their roles intersect throughout the inpatient trajectory. Within the HSCT team, the nurse practitioner provides a comprehensive view of patient medical needs; the pharmacist oversees medication management; and the clinical nurse specialist provides nursing practice insight.

For this project, the team members conducted daily patient rounds then discussed relevant workflow and practice issues on the unit, resulting in real-time assessments of patient needs. Engaging the unique perspective of each role, the following initiatives, and their results, were presented:

Electrolyte replacement protocol (ERP) Incidents of repletion noncompliance decreased from more than 18 prior to implementing ERP to 4 after implementation of this initiative. In addition, the average time of magnesium and potassium repletion was reduced from 6 hours to 1.5 hours.

Oral care bundle Incorporating an oral care regimen consisting of toothbrushing with a soft bristle toothbrush at least twice daily, Biotene oral rinse after meals and at bedtime, use of MuGard in patients undergoing total body irradiation, and cryotherapy for patients receiving melphalan-containing regimens resulted in a 56% reduction in grade 3 mucositis.

Reduction of fluids Prior to implementation, patients experienced chemotherapy delays, fluid overload, and hyperglycemia. This initiative included eliminating prehydration, reducing maintenance hydration fluid rate, and changing fluids from D5NS to NS for all HSCT conditioning regimens. Preliminary analysis of weight gain and diuresis frequency showed a decrease in incidence of fluid overload.

Hyperhydration and diuresis protocol High-dose cyclophosphamide can cause hemorrhagic cystitis. To prevent fluid overload, scheduled hyperhydration and diuresis, performed as needed based on nursing evaluation, was implemented.

Antiemetic guidelines This initiative consisted of assessment of the patient’s emetogenic risk level and evaluation for grade of chemotherapy-induced nausea and vomiting (CINV). Pharmacologic agents for management of CINV included 5-HT3 receptor agonists, neurokinin-1 receptor antagonists, glucocorticoids, benzodiazepines, dopamine antagonists, prokinetic GI agents, and miscellaneous agents.

Infusion reaction mediation guidelines Potential adverse events and emergency medications were identified, including Demerol for sustained rigors; epinephrine for anaphylaxis, including hypotension, swelling of the throat, difficulty breathing, and feeling of impending doom; and first- and second-line treatments for rash, itching, and flushing/hives.

Ongoing collaboration provides regular updates to the HSCT admission order sets, incorporating best practice recommendations that ensure consistent patient care delivery.

Reference

Gopalsami S, Wheatley T, Kim C. Improving hematopoietic stem cell transplant patient outcomes utilizing interdisciplinary collaboration between pharmacy and advanced practice nursing. Oral presentation at: 48th Annual ONS Congress; April 26-30, 2023; San Antonio, TX.