North Carolina Cancer Hospital Located on the Campus of UNC Chapel - PDF document

Bone Marrow and Stem Cell Transplant Program University of North Carolina Improving the Quality of Care Delivered to  FACT accredited Adult and Pediatric Transplant, Healthy Related Donors: Collection and Processing Center  NMDP Marrow and Apheresis Collection Center Implementation of a Related Donor Team  16 ‐ bed Hepa ‐ filtered unit  Adult and Pediatric combined inpatient BMTU S. Elizabeth “Sam” Sharf  Outpatient (OP) BMT Clinic/Infusion areas Clinical Director  Pediatric patients seen in OP Peds Hem/Onc Adult and Pediatric Bone Marrow and Stem Cell Transplant Program clinic University of North Carolina at Chapel Hill North Carolina Cancer Hospital Located on the Campus of UNC ‐ Chapel Hill Yearly Transplants 2006 ‐ 2011 UNC ‐ CH BMT Program Staffing Allo Auto  7 Adult and 2 Pediatric BMT Physicians 20 0 18 0  5 Adult Advanced Practice Professionals (APPs)/ 16 0 1 Pediatric APP 63 14 0  7 Transplant Nurse Coordinators 55 12 0 42  3 Data Managers 10 0 29 41 39 80  1 Financial Coordinator 121 60  3 Administrative Personnel 93 84 80 40 72 62  9 OP Clinic RNs 20 0 2006 2007 2008 2009 2010 2011

Related Donor Dilemma ‐ Transplant Nurse Coordinators They’re a patient, too!  Each Adult Nurse Coordinator is paired with  2009 – 17 related donors a specific physician (or physicians)  2010 – 28 related donors  One specific Pediatric BMT Nurse Coordinator  2011 – 17 related donors*  Coordinates all pre ‐ transplant functions  Total 2009  Sept 2011 = 62 related donors  Further therapy as required audited  Pre ‐ admission work ‐ up  Clearance/regulatory documentation * 11 more related donors were collected in the  Historically provided coordination of care for 4 th quarter of 2011. Total related donors their recipient’s related donor as well processed through the program for 2011 = 28 Related Donor Audits Inconsistent Compliance  All related donor charts since 2009 audited for:  IDMs and appropriate lab work – 100%  Blood Transfusion or other pertinent medical history –  Completed HHQ (including significant PMH, reviewed by a provider and documented in EMR) 76%  Required laboratory studies including IDMs  Signing of Release of Medical Records ‐ 11%  Documentation of potential venous access  Donor Consent documentation in EMR – 70%  “Release of Medical Records” form signed/on file  Documentation of donor clearance in both recipient’s  Pregnancy assessment(s) as applicable and donor’s EMR (41% and 29% respectively)  Donor suitability documented in both donor’s and recipient’s EMR  Documentation of review of abnormal results with f/u  Review of abnormal results w/donor documented recommendations – 25%  f/u recommendations documented as well  Follow ‐ up phone call w/donor within 72 hours of donation Interventions Factors Affecting Compliance  Detailed checklist to help seven (7)  Some improvement ‐ compliance Transplant Coordinators (TCs) navigate decreased as donor numbers increased institutional and regulatory requirements  Inconsistencies from Coordinator to  Scripted documentation to ascertain Coordinator compliance in the appropriate EMRs  Inconsistencies from Provider to Provider  One ‐ on ‐ one coaching with each TC  Small number of donor work ‐ ups per  Scripted coaching with each APP & MD Coordinator providing donor evaluation/clearance services  Cryopreservation prior to admission

Interventions Related Donor Coordinator  Dedicated Donor Advocacy Model developed  Registered Nurse / Transplant  Implementation January 2011 Coordinator Role  Separate Donor Medical Team  Quality Management Nurse Coordinator  Related Donor Nurse Coordinator role established separate  FACT Nurse Coordinator from recipient’s primary Transplant Coordinator  Separate BMT Physician from recipient’s primary BMT  Safety Coordinator Physician  RITN Coordinator Purpose:  To avoid conflict of interest, provide unbiased care to the donor and provide one dedicated Transplant Nurse Coordinator to care for ALL related donors. Improvement in Medical and Medical Clearance/Compliance Medical/Regulatory Compliance from 2009 to 2011 Regulatory and Institutional Compliance CONCLUSIONS  The creation of a separate Related Donor Coordinator role had a significant impact on compliance improvement in all areas.  Donor advocacy has risen to a new level.  Seen privately without family members present  Opportunity provided for one ‐ on ‐ one assessment without additional pressure  Separate team focuses solely on donor

The The UNC Bone Marrow and Stem Cell Transplant Program Future  Inclusion of UNC Comprehensive Cancer Support Program in evaluation  Clinical Psychologist to be included as part of the donor evaluation process  Fresh products  Higher donor awareness  Donor appreciation Questions? Acknowledgements Thank you to Please feel free to contact: Sam Sharf, Clinical Director UNC Bone Marrow & Stem Cell Transplant Program ssharf@unch.unc.edu (919) 966 ‐ 7516 (work phone) (919) 408 ‐ 1809 (text) (919) 216 ‐ 9824 (pager) for their collaboration and tireless support of this project.

Objectives Using Skin Rounds to Enhance the Care of the Integumentary System in a • Understand why skin care is critical in a BMT BMT Population within an Urban population Adult Teaching Hospital • Obtain knowledge of how the skin rounds Elise Frans, BSN, RN program was developed University of Washington Medical Center in partnership with the Seattle Cancer Care Alliance • Evaluate outcomes from the program and future objectives Background Evaluate the Need • UWMC is an urban adult teaching hospital • This unit has 22 BMT acute care beds and 6 oncology ICU beds • Aggressive skin care in BMT patients is critical • One of four units that provides • Chemotherapy/radiation and graft-versus-host disease inpatient care for the SCCA/FHCRC change skin integrity • Only adult ICU unit within the • Damage to skin integrity can cause increased risk of alliance infection and prolonged care of these patients Evaluate the Need Develop a Plan • Skin Assessment Rounds • Lack of awareness and knowledge regarding skin • Done once a week by two unit based RNs care • Perform head to toe skin assessments • Two reportable pressure ulcers in last year • Discuss findings with RN and help complete necessary • Misidentification and documentation of skin issues tasks • Few standard interventions established • Identify skin issues early and establish correct • Increased anxiety among staff and patients regarding documentation and care skin care

Develop a Plan Implementation • Collaborate with multidisciplinary team, patients, and • Recruit unit based RN’s who are interested in skin care family about skin care • Initial training • Be a resource to help provide exceptional skin care to • Attend a wound care workshop provided by the hospital all patients • Round with Wound Ostomy Resource Nurse and • Provide continuing education to nurses who perform experienced “Skin Rounds” nurses skin rounds • Weekly rounds on both day and night shifts performed • Prioritize patients based on acuity and Braden Scale Implementation Outcomes • Continuing Education • Difficult to initially evaluate program based on • Quarterly skin team meetings with “Skin Rounds” incidence of wounds nurses from all units and Wound CNS • Formal survey of staff nurses showed increase in staff • Dedicated wound workshops satisfaction and skin awareness • Wound care and “Skin Rounds” binders • Feedback from patients and family showed • Resource for unit decreased stress and increased satisfaction • Work with unit based and local practice councils • Address issues at education days Outcomes Future Steps • Continue to build skin care team • Increased accurate • Develop tool to identify high risk patients identification and • Further evaluate effectiveness of skin rounds documentation of skin issues • Expand skin rounds to other BMT units in UWMC • Increased initiation of • Partner with outpatient BMT clinics to provide prevention measures continuum of skin care • Increased awareness of skin • Utilize skin team to help implement other care unit wide interventions that affect skin

Acknowledgements • Wound and Ostomy CNS: Colleen Karvonen, MN, RN, CMSRN and CWON • Hematologic Malignancies/BMT Clinical Nurse Specialist: Lenise Taylor, MN, RN, AOCNS • 8NE Nurse Manager: Timothy Ehling, MN, RN • 8NE RN3: Jocelyne Wahl, RN, OCN Thank You