Implementation of a Standardized Assessment for Neurotoxicity in Patients Receiving Chimeric Antigen Receptor (CAR) T-Cell Therapies on an Inpatient Hematology Unit

Abstract

Topic Significance & Study Purpose/Background/Rationale An inpatient hematology unit at a NCCN designated cancer center experienced a dramatic increase in patients receiving a chimeric antigen receptor (CAR) T-cell therapy in 2018. Neurologic toxicity at any grade is observed in most patients receiving a CAR T-cell therapy, with more than 58% of patients who received Kymriah™ (1) and 87% of patients who received Yescarta® (2). Although nursing staff was completing a neurologic assessment each shift to identify neurologic toxicity, the assessment and documentation by each nurse varied considerably. Nurses were also having difficulty identifying clear and concrete assessment changes to report to physicians. As the neurologic changes observed in this population can initially be subtle, a tool to accurately and consistently identify changes is vital. A request was made by nursing leadership in May 2018 to create a standardized neurological assessment for patients receiving a CAR T-cell therapy. Methods, Intervention, & Analysis Unit leadership and the unit based practice council collaborated to create a standardized CAR T-cell neurotoxicity assessment tool for nurses. A review of the literature was completed, and the CAR T-cell therapy associated TOXicity (CARTOX) 10-point neurological assessment tool was reviewed. An adapted version of the CARTOX-10 was agreed upon by unit staff, nursing leadership and the CAR T-cell working group. The final version consists of a verbal and writing assessment. The UBPC is presently in the process of educating all nursing staff on how to complete this tool and notify physicians when changes are assessed. Staff are educated during staff huddles, shift handoff, staff meetings, and can view literature on a unit education board. Findings & Interpretation While the implementation of this new tool is currently ongoing, the feedback from nursing staff has been positive and the reception from patients and caregivers has been enthusiastic. Discussion & Implications Implementing a practice change must be interdisciplinary and requires close collaboration amongst frontline nurses, nursing leadership, and physicians. As nursing practice becomes standardized with the development and implementation of this neurotoxicity assessment, we will assess nurse's perception of its feasibility in practice. An accurate neurologic assessment in CAR T-cell recipients is vital and we will validate its effectiveness in identifying neurologic conditions that warrant intervention. 1. Novartis Pharmaceuticals Corporation. (2018). Kymriah™ (tisagenlecleucel) [Package Insert]. East Hanover, NJ: Author. 2. Kite Pharma Inc. (2017). Yescarta® (axicabtagene ciloleucel) [Package Insert]. Santa Monica, CA: Author.