Inpatient Hematopoietic Cell Transplant Research Articles

Family Caregiver Experiences in the Inpatient and Outpatient Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation Settings: A Qualitative Study

Caregivers (ie, family and friends) are essential in providing care and support for patients undergoing hematopoietic cell transplantation (HCT) and throughout their recovery. Traditionally delivered in the hospital, HCT is being increasingly provided in the outpatient setting, potentially heightening the burden on caregivers. Extensive work has examined the inpatient HCT caregiving experience, yet little is known about how caregiver experiences may differ based on whether the HCT was delivered on an inpatient or outpatient basis, particularly during the acute recovery period post-HCT. This study explored the similarities and differences in caregiver experiences in the inpatient and outpatient settings during the early recovery from reduced-intensity conditioning (RIC) allogeneic HCT. We conducted semistructured interviews (n = 15) with caregivers of adults undergoing RIC allogeneic HCT as either an inpatient (n = 7) or an outpatient (n = 8). We recruited caregivers using purposeful criterion sampling, based on the HCT setting, until thematic saturation occurred. Interview recordings were transcribed and coded through thematic analysis using Dedoose v.9.0. The study analysis was guided by the transactional model of stress and coping and the model of adaptation of family caregivers during the acute phase of BMT. Three themes emerged to describe similar experiences for HCT caregivers regardless of setting: (1) caregivers reported feeling like they were a necessary yet invisible part of the care team; (2) caregivers described learning to adapt to changing situations and varying patient needs; and (3) caregivers recounted how the uncertainty following HCT felt like existing between life and death while also maintaining a sense of gratitude and hope for the future. Caregivers also reported distinct experiences based on the transplantation setting and 4 themes emerged: (1) disrupted routines: inpatient caregivers reported disrupted routines when caring for the HCT recipient while simultaneously trying to manage non-caregiving responsibilities at home and work, and outpatient caregivers reported having to establish new routines that included frequent clinic visits with the patient while altering or pausing home and work responsibilities; (2) timing of caregiver involvement: inpatient caregivers felt more involved in care after the patient was discharged from the HCT hospitalization, whereas outpatient caregivers were already providing the majority of care earlier in the post-transplantation period; (3) fear of missing vital information: inpatient caregivers worried about missing vital information about the patient's care and progress if not physically present in the hospital, whereas outpatient caregivers feared overlooking vital information that may warrant contacting the care team as they monitored the patient at home; and (4) perceived adequacy of resources to meet psychosocial and practical needs: inpatient caregivers reported having adequate access to resources (ie, hospital-based services), whereas outpatient caregivers felt they had more limited access and needed to be resourceful in seeking out assistance. Inpatient and outpatient HCT caregivers described both similar and distinct experiences during the acute recovery period post-HCT. Specific interventions should address caregiver psychosocial needs (ie, distress, illness uncertainty, communication, and coping) and practical needs (ie, community resource referral, preparedness for home-based caregiving, and transplantation education) of HCT caregivers based on setting.

Comparing Outcomes of Outpatient Vs. Inpatient High-Dose Melphalan Based Conditioning Regimens Followed By Autologous Hematopoietic Cell Transplantation in Myeloma

Background: Multiple myeloma (MM) is an incurable plasma cell malignancy and high-dose melphalan followed by autologous hematopoietic cell transplantation (HCT) plays a pivotal role in consolidation of response after initial anti-myeloma therapy. High-dose therapy has been historically applied in the inpatient setting, but some centers have shifted autologous HCT to outpatient setting due to various reasons including health care cost. Here, we compared the survival outcomes of high-dose melphalan followed by autologous HCT at a tertiary referral transplant center since its inception of formal outpatient HCT program. Methods: Clinical transplant data on MM patients who underwent high-dose melphalan at Moffitt Cancer Center (MCC) between 2013 and 2021 were retrospectively reviewed. BMT Research Analysis Information Network (BRAIN) database was used for querying the data. The study population consists of those MM patient who received their first autologous HCT with high-dose melphalan based conditioning regimens. HCT outcomes were compared based on the location of transplant (inpatient vs. outpatient) with the outpatient BMT program officially launching in 2013. Autologous HCT was prescribed as an outpatient by default unless there were reasons such as renal failure requiring dialysis, cardiovascular complications requiring inpatient monitoring, psychosocial concerns, patient refusal for outpatient, or physician discretion. HCT for amyloidosis was excluded from this study. Outpatient HCT team consists of a dedicated transplant faculty member and an advanced practice professional who make daily round on outpatient HCT. Patients are seen in the outpatient BMT treatment center during the day and the arrangements have been made to directly admit to inpatient BMT unit when clinical indications arise. Overall survival (OS) and progression-free survival (PFS) were calculated using Kaplan-Meier method and compared with log-rank testing. Cumulative incidence function was compared with Gray's test. Results: There were 1349 MM patients who underwent autologous HCT with high-dose melphalan-based regimen at MCC from 2013 to 2021. There were 670 patients in the inpatient group and 679 in the outpatient. The number of autologous HCT performed in the outpatient setting has increased overtime and surpassed the inpatient in 2018 with 74.6% of HCT performed as outpatient in 2021. Median age for both groups were 63 years and the median KPS of 90. Median HCT-CI was 3 for both groups. Median serum creatinine was 0.9 (range, 0.4-11.9) for inpatient, and 0.8 (range, 0.4-3.8) for outpatient. Within 30 days from HCT, 57.1% of outpatient MM HCT recipients were admitted to the hospital. Median length of stay for inpatient group was 14 days. Univariate analysis showed that the 5-year OS for outpatient vs. inpatient HCT was 80.6% (95% confidence interval (CI): 76.0-84.3) and 71.0% (95%CI: 66.6-74.8), respectively (Log rank, p=0.0009, Figure). The 5-year PFS for outpatient vs. inpatient HCT was 58.0% (95%CI: 52.6-63.0) and 50.7% (95%CI: 46.2-55.1), respectively (Log rank, p=0.012). The 5-year cumulative incidence of relapse for outpatient vs. inpatient HCT was 34.6% (95%CI: 29.7-39.5) and 39.8% (95%CI: 35.6-44.1), respectively (Gray's test, p=0.046). The 5-year cumulative incidence of nonrelapse mortality (NRM) for outpatient vs. inpatient was 7.3% (95%CI: 4.9-10.3) and 9.3% (95%CI: 6.9-12.1), respectively (Gray's test, p=0.25). Additional multivariate analysis will be provided at the presentation. Conclusions: Since the inception, the volume of outpatient HCT has steadily increased at our institution. In our retrospective analysis, outpatient MM HCT patients had better OS, PFS, with decreased risk of MM relapse compared to inpatient group. However, NRM was similar between the group. These survival differences may be due to patient selection and early period for inpatient HCT. Outpatient HCT is safe and appropriate transplant modality in the majority of MM patients who are candidate for such intervention. Further analysis to evaluate disease related prognostic factors is planned. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Usability and Acceptability of the QuestLeukemia Mobile Application: A Pilot Study for An Educational and Psychological Intervention for Children with Chronic Illnesses.

It is widely accepted that educational interventions benefit children with chronic diseases (disease awareness and autonomy) or those undergoing medical procedures (decreased anxiety and improved satisfaction). Hematopoietic cell transplantation (HCT) is an intensive procedure to treat life-threatening diseases but is associated with multiple adverse medical experiences. QuestLeukemia (QuestED, Durham, NC) is a mobile app designed to educate pediatric patients preparing for HCT through age-appropriate videos and quizzes. Here we describe the results of the initial pilot study assessing acceptability and feasibility of QuestLeukemia app. Eligible participants were selected from a convenience sample (inpatient HCT unit and outpatient clinic). Participants spent 30-60 min using the app then completed a survey assessing the app for usability, accessibility, and user satisfaction. Participants identified the app as a useful tool for gaining disease-related knowledge and reported greater autonomy over their disease process. On average, patients indicated that the app was easy to use (M = 4.93), enjoyable (M = 4.79), and comprehensive (M = 4.71). Parents followed similar trends of satisfaction with the app. Pediatric HCT providers likewise reported that the app was easy to use (M = 4.22), enjoyable (M = 4.85), and educationally comprehensive (M = 4.77). The QuestLeukemia mobile application prototype provides an easy, enjoyable, and educational tool for pediatric patients undergoing HCT. This application was well received by patients, parents, and providers. These findings will be used to design future iterations of the game in clinical care.

Correlates and Outcomes of Early Acute Kidney Injury after Hematopoietic Cell Transplantation

BackgroundPatients undergoing hematopoietic cell transplantation (HCT) are at high risk for acute kidney injury (AKI). The etiology of AKI is often multifactorial and includes exposure to antibiotics and calcineurin inhibitors (CNI) for prevention of graft versus host disease. MethodsThis is a retrospective, single center study which evaluated patients undergoing inpatient HCT at Froedtert Memorial Hospital, Milwaukee, Wisconsin from Jan 1 to Dec 31, 2016. AKI was defined as an increase in serum creatinine > 0.3 mg/dL from baseline value. ResultsThe total number of patients included in the study was 280, 64 had AKI and 216 were in the non-AKI group. AKI was noted in 23% patients. Exposure to CNI or vancomycin accounted for the majority of the cases (82%). The median pre-AKI vancomycin trough was elevated in the AKI group at 21.3 mcg/mL (range: 17.4–24.4 mcg/mL) while the pre-AKI CNI trough was lower in the AKI group at 12.3 ng/mL (range: 8.7–14.7 ng/mL).There were also a higher number of ICU transfers (19%) and higher 100 day mortality (15.6%) in the AKI group. ConclusionAKI is a frequent complication following HCT and is associated with a higher risk of ICU transfer and higher mortality post HCT. While a higher vancomycin trough level may be indicative of a higher risk of AKI, the risk following CNI exposure may not be related to trough levels alone. There may be underlying pharmacogenetic factors which may alter the risk of AKI with CNI use.

Chlorhexidine Gluconate Bathing Reduces the Incidence of Bloodstream Infections in Adults Undergoing Inpatient Hematopoietic Cell Transplantation

Bloodstream infections (BSIs) occur in 20% to 45% of inpatient autologous and allogeneic hematopoietic cell transplant (HCT) patients. Daily bathing with the antiseptic chlorhexidine gluconate (CHG) has been shown to reduce the incidence of BSIs in critically ill patients, although very few studies include HCT patients or have evaluated the impact of compliance on effectiveness. We conducted a prospective cohort study with historical controls to assess the impact of CHG bathing on the rate of BSIs and gut microbiota composition among adults undergoing inpatient HCT at the Duke University Medical Center. We present 1 year of data without CHG bathing (2016) and 2 years of data when CHG was used on the HCT unit (2017 and 2018). Because not all patients adhered to CHG, patients were grouped into four categories by rate of daily CHG usage: high (>75%), medium (50% to 75%), low (1% to 49%), and none (0%). Among 192 patients, univariate trend analysis demonstrated that increased CHG usage was associated with decreased incidence of clinically significant BSI, defined as any BSI requiring treatment by the medical team (high, 8% BSI; medium, 15.2%; low, 15.6%; no CHG, 30.3%; P = .003), laboratory-confirmed BSI (LCBI; P = .03), central line-associated BSI (P = .04), and mucosal barrier injury LCBI (MBI-LCBI; P = .002). Multivariate analysis confirmed a significant effect of CHG bathing on clinically significant BSI (P = .023) and MBI-LCBI (P = .007), without consistently impacting gut microbial diversity. Benefits of CHG bathing were most pronounced with >75% daily usage, and there were no adverse effects attributable to CHG. Adherence to daily CHG bathing significantly decreases the rate of bloodstream infection following HCT.

An Interdisciplinary Team Decreases Hospital Acquired Infections in HCT Patients

Topic Significance & Study Purpose/Background/Rationale Prevention of healthcare-associated infections (HAI) is a priority of regulatory and national agencies and CMS implemented payment reductions for HAIs as of 2015. Central Line Associated Blood Stream Infections (CLABSI) in hospitalized patients are challenging HAIs that are known to increase lengths of stay, financial burdens, and overall mortality. HAI definitions are based on non-immunocompromised patient populations and immunocompromised patients often have increased reporting for these infections. Our NCCN hospital sought to better describe CLABSIs in our hematopoietic cell transplant (HCT) population to assure appropriate reporting of HAIs and to identify opportunities for quality improvement. Methods, Intervention, & Analysis An interdisciplinary team including the Infection Prevention Medical Director, Infection Preventionists and Physicians, Pharmacist, inpatient Nurse Manager and a Clinical Nurse Specialist met monthly to perform intensive reviews of CLABSI events that occurred on an inpatient HCT unit. The review included patient risk factors for infection and the degree to which nurses followed the central line care bundle. As a result of these reviews, a Staff RN group was formed who were educated to became unit experts on CLABSI and central line care. Subsequently, CLABSI rates reduced by 30%. Findings & Interpretation CLABSI reviews found common organisms across cases, opportunities for improvement in nursing practice as well as trends in patient characteristics where gaps in care may exist. By expanding these reviews to other HAIs, situations where standard definitions may not directly apply were identified, particularly with Clostridium Difficile Infection (CDI). The interdisciplinary CDI review focused on common causes of diarrhea which were then categorized and shared with staff to aid in patient care decisions. Discussion & Implications Intensive review of HAI events and identification of trends in the immunocompromised patient population assures accurate reporting of these cases. Reviews also allow for development of internal classifications of causes and ongoing process improvement in patient care by identifying unique situations leading to those infections. While this process requires resources to perform data collection and to review cases, the subsequent potential improvement in patient care may offset those. Multidisciplinary case review can help to improve practice, decrease infections, and potentially decrease the cost of patient care.

Identifying Fall Risk of Patients Receiving Hematopoietic Cell Transplant

Background and Purpose/Objective: Few studies have examined the efficacy of fall risk assessment tools for patients undergoing hematopoietic cell transplant (HCT). The purpose of this study was to determine whether the Hendrich II Fall Risk Model (HFRM II) can distinguish patients who fell from those who did not fall in the inpatient HCT population. Methods: Observational study. Design: Retrospective chart review. Setting: Academic medical center. Patients: Patients undergoing HCT who fell during the first 100 days posttransplant. Intervention: None. Measurements: Independent-sample t tests were performed to determine differences in HFRM II score, age, pulse, systolic and diastolic blood pressure, platelet count, hemoglobin concentration, and hematocrit for fallers compared with nonfallers. Chi-square tests of independence determined differences regarding sex, assistive device used on the day of fall, transplant type, and physical therapy. Logistic regression analysis detected odds of falling dependent on transplant type, pulse rate, and HFRM II score. Results: Forty-seven patients who fell within 100 days after HCT were control matched by transplant date with 2 nonfallers each. Significant differences included HFRM II mean score (5.36 for fallers vs 3.41 for nonfallers; t = 4.510, P < .001) and mean pulse rates (100.09 vs 88.70 bpm; t = 3.398, P = .001). Patients with allogeneic HCT were 3.46 times more likely to have fallen than those with autologous HCT (P = .007). Limitations: Potential selection bias of retrospective review. Conclusions: HCT patients with higher HFRM II scores, greater pulse rate, or allogeneic transplant were more likely to fall.

Melphalan desensitization following immediate hypersensitivity in a patient undergoing conditioning for autologous hematopoietic cell transplantation

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome is a paraneoplastic disorder associated with an underlying plasma cell neoplasm. High-dose melphalan followed by autologous hematopoietic cell transplantation (HCT) is considered to confer the highest likelihood for achieving durable responses resulting in long-term survival. We describe the case of a 55-year-old man with POEMS syndrome who developed an immediate hypersensitivity reaction to high-dose melphalan during conditioning for autologous HCT and subsequently underwent successful melphalan desensitization. A 55-year-old man was diagnosed with POEMS syndrome after presenting with polyneuropathy, IgA lambda paraproteinemia, elevated vascular endothelial growth factor, organomegaly, and thrombocytosis. While arrangements for autologous HCT were being made, induction therapy with cyclophosphamide and prednisone was started. The patient underwent successful stem cell mobilization with filgrastim and plerixafor and was subsequently admitted to the inpatient HCT Unit. He was prescribed melphalan at a dose of 200 mg/m (total dose 1⁄4 400 mg) administered intravenously over 30 minutes, which was to be followed by reinfusion of autologous stem cells 2 days later. Dexamethasone 20 mg and ondansetron 24 mg were administered orally 30 minutes before melphalan for antiemetic prophylaxis. Three minutes after starting the melphalan infusion, which resulted in approximately 60 mg administered, he developed severe head and chest pressure, mild shortness of breath, cough, and facial flushing. His blood pressure remained stable and heart rate increased from a baseline of 82 to 97 beats per minute. A pulse oximeter measured a SpO2 of 96%, slightly below his baseline of 100%. An electrocardiogram revealed normal sinus rhythm. A chest X-ray was unremarkable. No fever was noted. The melphalan infusion was stopped and symptoms resolved after a single dose of intravenous diphenhydramine 25 mg. The autologous HCT was aborted. The following day, the Allergy and Immunology team evaluated the patient. A tryptase level obtained approximately 15 hours after the reaction was noted to be within normal limits at 10.8 mg/L. The patient was discharged home 2 days after the event. Notably, this was the patient’s first exposure to melphalan. Prior reports have suggested that melphalan hypersensitivity, an IgE-mediated process with an incidence of approximately 5%, occurs after several courses of intravenous therapy. Given the severity of the initial hypersensitivity reaction to melphalan, a 4-bag 16-step desensitization protocol was indicated. However, we were unable to use the standard 4-bag 16step approach because of the unique physical and chemical properties of melphalan. Melphalan is stable for only 60 minutes after reconstitution, thus making it logistically infeasible to complete all of the components of each step within an hour time frame, which include preparation of the intravenous admixture, delivery of drug to the floor, and infusion of the dilution. In addition, melphalan is required to be diluted in normal saline to a concentration 0.45 mg/mL, creating a substantial challenge in finding the appropriate volume that would adhere to the infusion and stability properties. To circumvent the logistical issues related to melphalan’s short stability and concentration requirements, we designed a novel 5-bag 17-step melphalan desensitization protocol, as shown in Table I. Melphalan is classified as a strong irritant and may cause skin necrosis and ulceration and is not amenable to skin testing. Four weeks after the initial incident, the patient was admitted directly to the Medical Intensive Care Unit for close observation during the planned desensitization. A tryptase level drawn before the procedure was mildly elevated at 15.3 mg/L, likely attributed in part to a delay in normalization from the intensity of the initial reaction as well as the patient’s mild renal dysfunction. He was premedicated with orally administered cetirizine 10 mg, montelukast 10 mg, and aspirin 325 mg (given history of flushing during reaction) 60 minutes before initiation of desensitization. In addition, he received diphenhydramine 25 mg and famotidine 20 mg intravenously 20 minutes before the start of desensitization. He received dexamethasone 20 mg and ondansetron 24 mg orally 30 minutes before administration of melphalan for antiemetic prophylaxis. An allergic reaction desensitization kit was brought to bedside, which contained epinephrine, diphenhydramine, methylprednisolone, peak flow meter, and blood pressure cuff. Vital signs were taken and recorded every 10 minutes. A nurse observed the patient throughout the entire protocol in a one-to-one fashion. The patient tolerated the desensitization procedure without any reaction. The patient’s required level of care was subsequently downgraded and he was transferred to the inpatient HCT Unit. Two days later he successfully received 4.3 10/kg of CD34þ peripheral blood mononuclear cells. Neutrophil engraftment occurred on day þ13 and platelet engraftment on day þ15. Hypersensitivity reactions to chemotherapy often preclude administration of potentially curative therapy for patients with

Successful Transitions in Transplant Between Hospitalization and Outpatient Care

Topic Significance & Study Purpose/Background/Rationale: Hematopoietic Cell Transplant (HCT) patient care has increasingly shifted from inpatient (IP) to outpatient (OP) care as transplant centers consider cost containment, outcomes, and patient satisfaction. Approximately 500 transplants (autologous and allogeneic) a year are performed at our academic medical center and outpatient clinic. Patients admitted to the IP HCT services reflect all phases of transplant care, including mobilization, conditioning, stem cell infusion, and management of acute and chronic post-transplant complications. The care needs for HCT patients at time of discharge are complex due to infection risk, transfusions, vascular access device care, medication regimens, financial constraints, and the shift in caregiving responsibilities from hospital staff to the patient, caregiver, and outpatient medical providers. The transition to OP HCT care is facilitated by Transition Nurses (TN) working with multidisciplinary teams in both the IP and OP departments. Methods, Intervention, & Analysis: Daily, the TN bridge the gap of approximately 6miles between two different IP hospital settings (adultandpediatric)andtheOPclinic toprovidepatient and caregiver education, care coordination, and discharge planning. TN participate in IP interdisciplinary rounds to assess care needs and resolve barriers to discharge. Requisite skills are providing education on insulin, hyperglycemia management, subcutaneous injections, home infusion, central venous catheter care, management of symptoms, infection prevention, and navigating the OP clinic. TN assist patients with deciphering insurance benefits, initiate referrals to vendors for home care needs, and provide nursing hand-off communication to the OP clinic. Transfers to SNFs for patients that require additional post HCT care are also facilitated. Data collection is ongoing for quality indicators of transitions such as rates of readmissions, length of stay, patient satisfaction, and infection rates. Findings & Interpretation: The TN provide crucial complex care planning and education to support transfers of care from the IP to the OP. Initial data results shows high patient satisfaction and adult HCT IP length of stay an average of 2 days less than other academic medical centers. Discussion & Implications: Transition Nurses demonstrate an exemplar model of coordination of care delivery integral to HCT patients achieving the highest quality outcomes in all clinical settings.

Outpatient High-Dose Chemotherapy and Autologous Hematopoietic Cell Transplantation for Multiple Myeloma Is Associated with a Low Infection Safety Profile.

High-dose melphalan (MEL) and autologous hematopoietic cell transplantation (HCT) is now a standard therapy in patients (pts) with multiple myeloma (MM). This HCT procedure is sufficiently tolerable to be performed on either an outpatient (OP) or inpatient (IP) basis. We compared the infection profiles in 16 consecutive pts who underwent OP HCT and 31 consecutive pts who underwent IP HCT for MM over a 24-month period. The median age of each group was comparable (OP 58 yr, range 33–72 yr; IP 59 yr, range 32–74 yr). All pts received MEL 200 mg/m2 before HCT and anti-infective prophylaxis with oral acyclovir, fluconazole and levofloxacin. Empiric treatment of first neutropenic fever in the OP group was imipenem and vancomycin (VAN) and in the IP group was cefepime with addition of VAN for persistent fever and/or positive cultures with VAN-sensitive bacteria. Median time to neutrophils >0.5 x 109/L after HCT was 10 days in both groups (range 8–12 days for OP and 9–12 days for IP). Fever during neutropenia occurred in 7/16 (43.8%) of OP and 16/31 (51.6%) of IP HCT pts. Positive blood cultures (BCs) were identified in 3/7 (42.9%) of the febrile OP and 5/16 (31.3%) of the febrile IP HCT pts. Positive BCs in febrile OP HCT pts were coagulase-negative Staphylococcus (CNS) (2 pts) and Pseudomonas (1 pt). Positive BCs in febrile IP HSCT pts were CNS (2 pts), Streptococcus viridans (1 pt), Enterococcus (1 pt) and Bacillus (1 pt). One febrile OP HCT pt had cytomegalovirus pneumonia, and one afebrile IP HCT pt had a positive BC for CNS. Four febrile IP HCT pts with negative BCs had other infections, including cellulitis (2), facial abscess (1), and Clostridium difficile-associated colitis (CDAC) (1). Two other IP HCT pts (1 with fever and positive BC for CNS, 1 without fever) also had CDAC, for an overall incidence of CDAC of 3/31 (9.7%) after IP HCT. In contrast, no OP HCT pts had CDAC. Overall, the incidence of infections was 4/16 (25%) after OP HCT and 11/31 (35.5%) after IP HCT. We conclude that the infection profile of OP HCT compares favorably with that of IP HCT in pts with MM and is associated with a lower incidence of CDAC.