Background: The alkylating agent busulfan (BU) is frequently used in hematopoietic cell transplantation (HCT) conditioning regimens. The Medical University of South Carolina (MUSC) predominantly administers oral BU to their adult patients. BU has a narrow therapeutic range, thus, to optimize safe and accurate BU administration and pharmacokinetic (PK) monitoring, numerous processes and educational efforts were implemented. Objectives: The aims of the project were to: 1) Ensure accurate ordering in the electronic medical record (EMR), 2) Ensure safe administration of oral BU, 3)Accurate BU PK level collection, 4) Assess outcomes (engraftment and sinusoidal obstructive syndrome (SOS) and track errors related to PK collection or administration, and 5) Compare cost savings of oral BU versus IV BU. Method: First, order sets were created in the EMR with detailed instructions for dosing, with separate orders for pre- and post- PK results. Second, to increase accurate PK level collection, the BU levels policy was revised to include a tip sheet for PK collection reminders, with specific instructions regarding the collection process and a picture of the dark green sodium heparin lab tube. The process is reviewed and assessed annually during the BMT nursing education conference with assessment questions. Third, data is collected on each of our patients receiving BU for platelet and absolute neutrophil count (ANC) engraftment and SOS. Errors are tracked through MUSC's Patient Safety Intelligence reporting system and are reviewed during the monthly HCT quality meeting. Results: From January 2010 to April 2016, 50 patients received oral BU. Approximately 73 BMT nurses attended the annual BMT education conference and reported an increased understanding of BU PK level collection after assessment. Although not eliminated, PK timing and collection deviations have been minimized. No errors have been reported in administration with separate pre- and post- PK level BU order forms. The average time to platelet and ANC engraftment was 22 and 14 days, respectively and SOS was evident in 6% of patients. The cost savings based on current inpatient acquisition cost for a typical patient, less than or equal to 75 kg, is approximately $14,000 per patient. Conclusion: By implementation of a multidisciplinary, comprehensive program for the safe and accurate administration of PO BU, our program has optimized outcomes with oral BU with an additional benefit of cost savings.
Background: Prevention of Central Line-Associated Blood Stream Infection (CLABSI) is of utmost importance in health care and particularly in Hematopoietic Stem Cell Transplant (HSCT) Programs. Autologous Stem Cell Transplant (ASCT) patients are at particular risk because of the length of time their central venous line (CVL) is in place and the prolonged period of neutropenia after chemotherapy. Objective: To decrease the CLABSI rate in ASCT patients by changing the way education of CVL care is performed and by whom it is performed. Method: It was determined that ASCT patients would only have nurses trained in CVL care perform the required weekly sterile dressing changes. A BMT Guideline for CVL Care was created which contained a standard list of mandatory supplies and dressing change instructions. Each patient was made a home health referral for line care following the placement of the CVL. The BMT Guideline for CVL Care was disseminated to all the referring home health agencies. Caregivers were no longer required to perform sterile dressing changes weekly, but were still instructed on performing daily flushing with saline and heparin. Findings: Implemented the above method in September of 2016, and examined data one year prior and one year after implementation. There were 2 CLABSI/50 ASCT transplants excluding mucosal barrier injury (MBI) and 0 CLABSI/62 ASCT transplants respectively. Cost analysis showed decrease from about $93,628 (Home Health visits $2,000 + CLABSI costs $91,628) before implementation to $0 after implementation. Conclusion: New process appears cost effective and improves overall infection rates. Quality of life and overall patient satisfaction is better as well as improved morbity and mortality.
Background: Pulmonary complications remain a significant cause of morbidity and mortality after hematopoietic stem cell transplant (HSCT). Methods: We conducted a retrospective review of the pediatric HSCT database from July 2007-July 2015 to identify the yield of pre-HSCT screening chest high resolution computed tomography (HRCT) and targeted bronchoalveolar lavages (BAL) along with their relationship to pulmonary complications and survival. Cox proportional hazards model was used to analyze association with survival outcomes. Chi-square test was used to assess relationships with pulmonary complications with correlations examined by the Pearson model. Results: We identified 139 patients (97 allogeneic, 42 autologous) who underwent a first HSCT. Mean age was 8.48 years (range 1-23). HRCT was abnormal for possible infection in 20 (21%) allo patients and 7 (17%) auto patients. Among abnormal HRCT patients, no auto patients but 4 allo patients (20%) had more than one type of abnormality. Possible infectious findings in the allo group included a single nodule (1), multiple nodules (3), ground glass opacities/air space disease (14), pleural effusion (3), and bronchiectasis (1). Possible infectious findings in the auto group included single nodular opacities (4) and ground glass opacities (3). Ten (50%) of the allo patients with abnormal HRCT underwent BAL. Five patients (50%) had a positive BAL, including HHV-6 (2), Prevotella melaninogenica (1), parainfluenza and Mycobacterium gordonae (1), and Streptococcus pneumoniae (1). One patient with multiple nodules underwent lung biopsy instead of BAL with negative results. Only 1 auto patient with an abnormal HRCT underwent BAL and it was negative. Survival rates at day +100 and +365 were 82.5% and 64% in the allogenic group 95% and 88% in the autologous group, respectively. No significant association was found between chest HRCT abnormalities and pulmonary complications requiring intubation (allo P = .64; auto P = .38) or day +365 survival (allo P = .57; auto p = 1). BAL results were unrelated to abnormal findings on chest HRCT (P = .33), post-transplant pulmonary complications (P = .67) and survival outcomes (P = .87). Intubation strongly correlated (Pearson r) with overall survival outcomes in both groups (P < .05). Conclusion: BAL yield was similar to previously published results. The lack of association between chest HRCT abnormalities and outcomes suggests that management strategies were able to ameliorate a potentially negative effect of pulmonary abnormalities on transplant outcomes.
Background: Blood and Marrow Transplant (BMT) centers must maintain less than a 3% error rate to maintain a good standing with the Center for International Blood and Marrow Transplantation Research (CIBMTR). Creating specific electronic health records (EHR) tools for accurate and efficient data management for CIBMTR is complex. The CIBMTR staging forms in an electronic format can enable efficient and accurate entry of the required patient data during patient visits. Objective: The objective was to design an electronic reporting tool for CIBMTR data and integrate it with the EHR in order to provide a high quality of accurate and efficient data management for BMT centers. Methods: A performance improvement project was designed and implemented using a multidisciplinary approach to create a CIBMTR electronic staging tool in the EHR. The Medical University of South Carolina (MUSC) Information Solutions Team and MUSC BMT Team collaboratively designed a specific activity labeled "CIBMTR Staging" that any BMT provider could access during a patient encounter and record the disease staging. Multiple CIBMTR staging forms were created in an electronic format. A quality assurance process was completed to verify the information was correct once the templates were built. Access rights for staging were restricted to the BMT Attending Physicians and Advance Practice Providers to improve the reporting quality. The multidisciplinary BMT team received education from the MUSC Information Solutions Team on the new process before implementation. The new tool was shared with the EHR vendor research and development team. Results: The electronic completion rate for the electronic CIBMTR staging tools was 61% in May 2016 at implementation and the results improved by 3-5% each month. The final completion rate in January 2017 increased to 87% for the patients that had an electronic CIBMTR form completed in the EHR prior to reporting transplant data to the CIBMTR. Conclusion: MUSC piloted the first template of the tool built for the EHR to capture the CIBMTR staging criteria for reporting. Creating this electronic CIBMTR staging tool in an EHR will increase the overall quality of the data and improve reporting efficiency by the BMT data management team. This is one of the first tools built for electronic CIBMTR disease staging and is being discussed.
BACKGROUND: Plerixafor enhances the ability of filgrastim (FIL) to mobilize CD34+ cells but adds cost to the mobilization. We hypothesized that replacing weight‐based FIL with flat‐dose pegfilgrastim (PEG) in a validated cost‐based mobilization algorithm for patient‐adapted use of plerixafor would add convenience without increased cost. STUDY DESIGN AND METHODS: A single‐center retrospective analysis compared two consecutive cohorts undergoing FIL or PEG mobilization before autologous hematopoietic stem cell transplantation for multiple myeloma or lymphoma. FIL dose was 10 µg/kg/day continuing until completion of collection and a 12‐mg flat dose of PEG. Peripheral blood CD34+ cells (PB‐CD34+) enumeration was performed on the fourth day after initiation of growth factor. Subjects surpassing a certain target‐specific threshold of PB‐CD34+ started apheresis immediately while subjects with lower PB‐CD34+ received plerixafor with apheresis starting on the fifth day. RESULTS: Overall 68 of 74 in the FIL group and 52 of 57 patients in the PEG group met the mobilization target. Only one patient in each cohort required remobilization. Median PB‐CD34+ on Day 4 was significantly higher in patients in the PEG group (18.1 × 10 6 vs. 28.7 × 10 6 cells/L, p = 0.01). Consequently, patients in the PEG group were less likely to require administration of plerixafor (67.5% vs. 45.6%, p = 0.01). Cohorts had near identical mean number of apheresis sessions and comparable CD34+ yield. The estimated cost associated with growth factor was higher in patients in the PEG group, but it was counterbalanced by lower cost associated with use of plerixafor. CONCLUSION: Single administration of 12 mg of PEG is associated with better CD34+ mobilization than FIL allowing for effective, convenient mobilization with less frequent use of plerixafor.
Plerixafor enhances the ability of filgrastim to mobilize CD34+ cells for AHSCT in patients with lymphoma (LY) or multiple myeloma (MM). Single dose of pegfilgrastim has, in some series, been utilized for autologous mobilization for its convenience and possibly greater efficacy. We retrospectively compared two consecutive mobilization cohorts utilizing filgrastim (FIL) 10 mcg/kg/day or pegfilgrastim (PEG) 12 mg (single dose) for steady state mobilization and the same algorithm for "just in time" use of plerixafor. In both cohorts peripheral blood CD34+ cells (PB-CD34+) enumeration was performed on the 4th day after initiation of growth factor to determine the immediate initiation of apheresis or administration of plerixafor with apheresis starting in the next day. Decision to use plerixafor was determined by the same previously validated algorithm in both cohorts. Apheresis and growth factor +/- plerixafor were continued until the mobilization target was met. Analysis of estimated total cost of mobilization utilized average wholesale price (AWP) for drugs and average charges for apheresis, cryopreservation and laboratory tests from a representative sample of subjects. Seventy-four consecutive subjects were included in FIL and 57 in PEG. The two cohorts were comparable in terms of age (57.5 vs. 53.7), proportion of patients with diagnosis of MM (63.5% vs.66.7%), proportion of MM patients previously exposed to lenalidomide (63.8% vs. 50%), average body weight (82.9 vs.84 kg) and average mobilization target (4.5 vs. 5 x 106 CD34+/kg). Overall 68/74 in FIL and 52/57 patients in PEG met the mobilization target. Median PB-CD34+ on day 4 was significantly higher in PEG.TableMobilization outcomesFILPEGPN = 74N = 57Day 4 PB-CD34+18.1 (+/-19.5)28.7 (+/-27)0.01Patients requiring plerixafor50 (67.5%)26 (45.6%)0.01Number of days of apheresis1.62 (+/-0.72)1.68 (+/-0.65)0.6Number of injections13.1 (+/-3.8)2.7 (+/-0.9)0.001Number of CD34+ cells collected (x10e6/kg)7.26 (+/-3.99)7.54 (+/-3.52)0.6Patients meeting mobilization target68 (91.9%)52 (91.2%)1Mobilization failures (<2 x 10e6 CD34+/kg)1 (1.3%)1 (1.7%)1 Open table in a new tab Patients in PEG received fewer subcutaneous injections and were less likely to require administration of plerixafor. Cohorts had near identical average number of apheresis sessions and comparable CD34+ yield. The estimated cost associated with growth factor was on average US$3,069 higher in PEG, but it was counterbalanced by an estimated $3,546 saving in plerixafor, resulting in no significant difference in the estimated overall cost of mobilization. Single administration of pegfilgrastim is associated with better CD34+ mobilization than daily filgrastim in patients with MM and LY allowing for effective mobilization with less frequent use of plerixafor. Pegfilgrastin with patient adapted used of plerixafor is a reliable, convenient and cost-neutral strategy for AHSC mobilization.
Background: Blood and Marrow Transplant (BMT) centers must maintain less than an 8% error rate to maintain a good standing with the Center for International Blood and Marrow Transplantation Research (CIBMTR). Creating specific electronic health records (EHR) tools for accurate and efficient data management for CIBMTR is complex. The CIBMTR staging forms in an electronic format can enable efficient and accurate entry of the required patient data during the patients' visits. Objective: The objective was to design an electronic reporting tool for CIBMTR data and integrate it with the Epic EHR system in order to provide a high quality of accurate and efficient data management for BMT centers. Methods: A performance improvement project was designed and implemented using a multidisciplinary approach to create a CIBMTR electronic reporting tool in Epic. The Medical University of South Carolina (MUSC) Epic Informatics Team and MUSC BMT Team collaboratively designed a specific activity labeled "CIBMTR" that any BMT provider could access during a patient encounter and record the disease staging. Multiple CIBMTR staging forms were created in an electronic format. A quality assurance process was completed to verify the information was correct once the templates were built. Access rights for staging were restricted to the BMT Attending Physicians and Advance Practice Providers to improve the reporting quality. The multidisciplinary BMT team received education from the MUSC Epic Informatics Team on the new process before implementation. The new Epic tool was shared with the National Epic research and development team. Results/Conclusion: MUSC piloted the first template of the tool built for Epic EHR system to capture the CIBMTR staging criteria for reporting. Creating Epic CIBMTR staging tool in an EHR system will increase the overall quality of the data and improve reporting efficiency by the BMT data management team. This is one the first tool built for the CIBMTR disease staging by the National Epic BMT Working Group and will be added to their database so it can be utilized by other BMT centers using Epic EHR (Figure 1).
