CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 1

Improving the Reliability of Immunosuppressant Drug Levels

Michelle Kosik, Carrie Zeh, Trista Carelock, Penny Odem, Chrissy Boyd, & Kelly Hill Rose

February, 2013

CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 2

PROBLEM

The Colorado Blood Cancer Institute BMT Program at Presbyterian/St. Luke’s Medical Center, a member of the Sarah Cannon Blood Cancer Network, had 14 confirmed TAC/CSA lumen contaminations in 2010. In March 2011, auditing revealed 5 additional contaminations. This prompted a process improvement initiative.

The goals of the process improvement were to:

1.Improve the reliability of TAC/CSA levels and resulting dose adjustments

2.Improve patient satisfaction with the process (lumen contamination necessitates peripheral sampling causing increased discomfort and risk for patients)

CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 3

DEFINITIONS

Contaminate: Immunosuppressive agents (TAC/CSA) adhere to the inner aspect of the patient’s central access device. If a nurse inadvertently withdraws blood from the lumen that TAC/CSA has infused into, the resultant drug level will be higher than the actual circulating blood drug level.

TAC/CSA: Tacrolimus and cyclosporine are immunosuppressive agents that are administered after allogeneic transplant to reduce the activity of the patient’s immune system to lower the risk of rejection.

Float Pool Staff: a centralized hospital based pool of nursing staff who have been trained to work in specialty areas.

Contract RNs: nursing staff contracted for  13 week assignments and designated to the Blood and Marrow Transplant Units.

UBC: Unit Based Councils provide the opportunity for frontline nursing staff to have a voice in their nursing practice and patient care using evidence based practice. The council is actively engaged in creating solutions to problems in our care areas.

RN Resource: Dedicated BMT nurse with 2 years experience who is assigned to resource/mentor float pool or contract nursing staff unfamiliar with BMT processes and medications.

Healthstream: internet-based education program that documents compliance with assigned learning modules.

Meditech: (Medical Information Technology) The healthcare information system utilized at our facility.

CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 4

POTENTIAL CAUSES FOR INCREASED CONTAMINATED BLOOD DRAWS

Forty new staff hired in a 24 month period

Census and acuity were higher than had been previously sustained

An increased number of contract RNs (travelers) had been hired

Float pool staff were being cross-trained to the BMT units.

CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 5

INTERVENTION

Immediate efforts focused on nursing staff re-education

The Unit-Based Council (UBC) led this process improvement initiative

The UBC recommended the following alerts:

– At allogeneic patient admission, nurse to dedicate lumen for TAC/CSA infusion using light green colored tape

– No TAC/CSA sampling to be performed from designated lumen

– TAC/CSA Infusion to be primary line into dedicated lumen

– TAC/CSA infusion to be turned off for 10 minutes prior to blood sampling

CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 6

ADDITIONAL RECOMMENDATIONS

During the review process, another contamination occurred

The UBC made additional recommendations:

– BMT Unit Float Guidelines were reviewed and the updated TAC/CSA process added.

– The updated TAC/CSA process was added to traveler orientation

– A RN resource was assigned to all new hires, float staff and travelers

– A TAC/CSA process education poster was created and posted on the BMT units

CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 7

ANOTHER CONTAMINATION

In February, 2012, another contamination was noted. The leadership team and the UBC convened to review and identify additional opportunities.

A mandatory Healthstream module for nursing was developed on the topic of immunosuppressant medications.

It was determined that all lumens other than the one being used to obtain the blood sample should be clamped during the blood sampling process.

Multiple disciplines (nursing, pharmacy and informatics) collaborated to create a pop-up screen in Meditech that appears when immunosuppressant medications are scanned – “Infuse via designated lumen ONLY. For help, see your charge nurse.”

CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 8

RESULTS

CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 9

DISCUSSION

Ongoing review continues.

2013 Skills labs – mandatory review of TAC/CSA process

New TAC/CSA process competency required of all BMT staff within 3 months of hire

Added to High dose Chemotherapy Checklist- “Designate white lumen with green tape if the patient will receive TAC/CSA.”