Standardized Workflow for Rituximab Priming and Infusing

“Rituximab, a monoclonal antibody, has the potential to cause a wide range of infusion reactions, which can be distressing to patients and alarm nurses,” Flora Kechedjian, MSN, RN, OCN^®, CNL, BMTCN^®, said. “Minimizing potential risks can offer a safer way to provide care to patients.”

She and Lauren Giordano, RN, BSN, OCN^®, both of Stanford Health Care in California, examined techniques nurses at their institution used to prime rituximab lines—and whether the process leads to hypersensitivity reactions. They identified inconsistencies, a lack of standard operating procedures, poorly defined workflows, and a need for guidelines for nursing staff.

The nurses developed a project to educate nurses and create a standard workflow for rituximab priming and infusing to reduce the incidence of hypersensitivity reactions.

They performed a literature search, consulted the manufacturer’s nurse educator, and reviewed the manufacturer’s administration and priming guidelines. They also consulted national safety organizations to confirm that rituximab priming would not pose any exposure risk for nursing staff.

Based on the information they discovered, they created three distinct standardized order sets for subsequent rituximab infusions. They also are working on establishing a platform in the electronic medical record system, which healthcare professionals soon will be able to use to document graded hypersensitivity reactions.

From 2018 (before the workflow was implemented) to 2019 (after implementation), they observed a 50% reduction in the use of hypersensitivity rescue medications. In addition to improving patient outcomes and experiences, the standard workflow alleviated nurses’ stress around rituximab infusions, ultimately increasing nursing practice.

Reduced Time to Treatment for Febrile Neutropenia

Febrile neutropenia can be life threatening if not addressed quickly, Sarah Dean, BSN, RN, OCN^®, of Wentworth-Douglass Hospital in Dover, NH, said. Furthermore, she added, it may lead to prolonged hospital stays, treatment delays, and dose reductions. 

The first dose of antibiotics should be administered within one hour of onset of febrile neutropenia, Dean said, but her institution lacked an optimal process to recognize the condition in a timely manner and move patients quickly from triage to antibiotic administration.

She and a team that included a pharmacist, physician, infectious disease specialist, project manager, and clinical educator developed an order set for empiric management of suspected febrile neutropenia. They created a detailed algorithm for initial empiric antimicrobial therapy in patients with febrile neutropenia (temperature ≥ 38°C and absolute neutrophil count < 500) as well as a new nursing process flow. After implementing the algorithm, they observed decreased time to antibiotic administration, Dean said.

Another team of nurses continues to meet and refine and improve the process, including the following challenges:

• Getting provider buy-in
• Coordinating among departments (emergency department to cancer center, pharmacy to pharmacy)
• Reducing time for laboratory results
• Reporting critical laboratory results to the infusion RN, not the primary RN
• Educating patients to call ahead rather than report to the emergency department
• Educating staff institution-wide, including the front desk
• Ensuring the antibiotics are ready for administration, but not hanging them before laboratory results are received

“Persistence in helping to be the change is an important part of the process,” Dean said.