Safely Provide Outpatient Care to Patients Receiving Hematopoietic Stem Cell Transplantations
By Martha Lassiter, MSN, AOCNS®, BMTCN
High-dose chemotherapy with hematopoietic stem cell support is a well-established treatment (http://legeforeningen.no/PageFiles/218929/2015GraffBMT%20Saf%20of%20outpat%20auto%20hem%20cell%20tx%20for%20mm%20and%20lymphoma.pdf) for many hematologic malignancies. This treatment can be a difficult journey for patients and families. Historically, patients have been treated in a traditional hospital setting in anticipation of severe side effects, including mucositis, febrile neutropenia, thrombocytopenia, and pulmonary, renal, and hepatic complications. Patients can remain profoundly immunosuppressed for months while recovering from transplant. However, better supportive care in recent years has allowed many centers to move all or a portion of their transplant care into an outpatient setting.
In 2012, the Center for International Blood and Marrow Transplant Research (https://www.cibmtr.org/pages/index.aspx) conducted a survey of hematopoietic stem cell transplant (HSCT) centers in the United States that revealed 54 of 85 (64%) centers were supported (http://www.bbmt.org/article/S1083-8791(15)00220-7/pdf) by a separate outpatient clinic dedicated to the care of HSCT recipients. Forty-eight (57%) centers reported that they performed outpatient transplants for some or part of treatment, including the conditioning regimen, infusion of stem cells, supportive care, and care of patients with febrile neutropenia.
Components of Care
To provide safe care to HSCT recipients in an outpatient setting, many supports must be in place. In addition to the physical infrastructure needed, a dedicated team is necessary to care for patients and provide support to caregivers. The team includes physicians, advanced practice providers, social workers, registered dietitians, physical therapists, occupational therapists, and nurses. Outpatient HSCT nurses must have a strong knowledge base in oncology and transplant expertise. Being able to identify potential problems early is vital to minimizing complications. Expertise in chemotherapy administration, toxicity management, blood product administration, patient education, and caregiver support is necessary to be successful.
While receiving outpatient care, patients must have a competent caregiver with them at all times. This may be a team of rotating caregivers or a single family member. Caregiver responsibilities include:
- Manage medications.
- Provide reliable transportation.
- Provide nourishment and hydration.
- Report side effects.
- Check vital signs.
- Provide psychosocial support.
Prior to beginning the transplant journey, a psychosocial assessment is completed to ensure patients have the necessary resources in place prior to treatment. Rigorous education occurs in multiple forms to accommodate individual learning needs and is reinforced daily.
For successful outpatient care for patients and caregivers, transplant centers provide support in a variety of ways. This may include consultative services with behavioral medicine and palliative care team members along with transplant social worker support. The cancer center’s patient support services may be used as well.
One Model of Outpatient Care
At our institution, we are in our 25th year of providing outpatient care to HSCT recipients. Patients are up and dressed in street clothes every day to come to the clinic as opposed to being confined in an isolating hospital room. They can walk outside, eat food prepared by a caregiver, and sleep in more comfortable accommodations. Patients receive daily treatment, including weekends, at our clinic. Our inpatient HSCT unit provides after-hours coverage. If a patient has an issue at night, the inpatient charge nurse and covering medical staff provide support.
Although our model of outpatient transplant care has been successful for many years, other outpatient HSCT programs may look very different. No matter the model, HSCT nurses strive to provide safe evidence-based care to transplant recipients.