Preparing Nurses on an Intermediate Care Unit to Assess and Manage Patients Undergoing Chimeric Antigen Receptor Therapy (CAR T) at an NCI Designated Academic Cancer Center

Abstract

Topic Significance & Study Purpose/Background/Rationale Chimeric Antigen Receptor Therapy (CAR T) is a dynamic rapidly developing area of cancer treatment. The delivery of this therapy is complex and many centers struggle with operationalizing the various phases of this treatment, including which specialty area is best equipped to administer, monitor and safely manage the patient for potentially life threatening side effects during each phase of therapy. Without a dedicated CAR T service, it was the determined that adult patients receiving this treatment would be best managed on our intermediate care leukemia/lymphoma unit. Methods, Intervention, & Analysis Prior to treating our first commercial patient, a multidisciplinary team met biweekly to outline a process diagram delineating phases of treatment, team member responsibilities, and SOPs for monitoring and administration of therapy. The inpatient nursing leadership team quickly recognized the need for education and standardization to adequately prepare staff and create a safe patient environment. After an extensive literature search looking at various CAR T programs throughout the country, the nursing leadership team identified a list of high priority action items to develop before the first patient was treated. Using functionality within the EMR, a directed neurologic assessment tool was developed for CAR T patients, order sets for admission, Cytokine Release Syndrome (CRS), and neurotoxicity were implemented, and a best practice advisory (BPA) was created to ensure team members knew the patient was getting CAR T therapy no matter where they were located within our center. A process was developed for nursing to verify sufficient doses of tocilizumab were available in advance of administration of CAR T cells, and a very specific after-hours coverage plan was implemented that bypassed the standard hierarchy for notification of abnormal findings and allowed nursing staff to directly the established APP team during the week and the attending physician on call over the weekend and holidays. Findings & Interpretation Between 04/01/2018 and 10/1/2019 there were 17 adult patients treated with a commercial CAR T product. The average length of stay for patients was 15 days. 11 of 17 (65%) of patients developed some degree of CRS and 7 of 17 (41%) of patients developed some degree of neurotoxicity. Only one patient required a transfer to our neuro ICU. Despite having limited experience with assessment and monitoring of these complex side effects, nurses on the intermediate care unit report a high degree of satisfaction with delivering care to CAR T patients. Discussion & Implications With adequate preparation and an engaged multidisciplinary team, CAR T therapy can safely be administered on a non-BMT intermediate care unit. Efforts to streamline and standardize nursing assessment and documentation are essential and help create an environment founded in safety for nurses and patients alike.