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.
Few case studies exist of applying a sustainable livelihoods approach in Europe or North America. Those that do, suggest that the approach can significantly contribute to community development in a Northern context. This paper describes work in progress in an English market town and looks at differences and commonalities between a sustainable livelihoods approach and the method currently employed by the Countryside Agency. Early lessons indicate that a sustainable livelihoods approach can contribute by building on current methods, including for example, the development of greater understanding of the make‐up of a community. Shared learning from both approaches can play a part in building best practice in North and South.
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.
Marked by Good AttendanceI HE official registration of the Institute's 1934 winter convention recently held in New York, Ν. Y., Jan. 23-26, totaled 1,227 persons.This attendance was particularly gratifying to all who had worked to make the convention a success, as it is an appreciable increase over last year's registration.Also, there was a notable increase in out-of-town attendance.
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.
