Bone Marrow Transplant Fast Track Clinic Bridges Care for RUSH Patients

Aney Abraham, DNP, RN NE-BC; Erin Dowding, MSN, APRN, ACNS-BC, OCN; Diane Jakubik, BSN, RN, CMSRN, MA; Hayley Lesnik, BSN, RN, BMTCN; Katie Quinlan, BSN, RN, BMTCN ; Jamie Schanz, BSN, RN, BMTCN; Eric Zack, DNP, RN, ACNP-BC, AOCN, BMTCN

Improving patient outcomes, the efficiency of workflows and patient and staff satisfaction are top priorities in the ever-changing landscape of health care. The Bone Marrow Transplant Fast Track (BMT FT) Clinic on 14 East Tower is a RUSH program meant to improve all these areas and is built out of an interdisciplinary team with strong collaboration between nurses and physicians. The clinic opened in August 2018. It has logged approximately 1,000 patient visits per year. The 32-bed inpatient hematology/bone marrow transplant unit converted two inpatient rooms to make space for four outpatient chairs to better serve patients after stem cell transplants (SCT).

BMT FT was created to provide care for discharged patients moving from inpatient settings where daily transfusions and electrolyte administrations were necessary. These patients often require four to 10 hours of infusions. They must be admitted if they become hemodynamically unstable. After creating the clinic, four patients each morning and up to eight daily can be seen. If a lab, symptom or vital sign gets flagged as too critical, an algorithm is used to admit the patient to inpatient status. The BMT FT nurse works in close communication with the advance practice provider (APP), the charge nurse and RUSH patient placement to facilitate quick admission to an open inpatient room, maintaining patient safety. If the unit census is high and there are emerging needs for inpatient beds, an algorithm is employed to convert the BMT FT unit back into two inpatient beds.

An interdisciplinary care team was assembled to develop workflows for SCT patients. The team defined criteria for the skills needed by nurses who could work in both the BMT FT and the inpatient setting. The BMT FT team is staffed with attending physicians, APPs, a pharmacist, designated staff nurses, an inpatient nursing unit director, an assistant nursing unit director, an oncology clinical nurse specialist and support staff for additional hospital services.

Discharged inpatients are scheduled in the BMT FT clinic for multiple appointments in the weeks after discharge for close follow-up. The clinic is open from 7 a.m. to 5 p.m. Nurse-driven replacement protocols were developed for treatments, such as potassium and magnesium supplementation, as well as packed red blood cell and platelet transfusions. Ambulatory infusion guidelines and practices also were adopted for faster potassium and magnesium IV infusion.

The Joint Commission and the Foundation for the Accreditation of Cellular Therapy guidelines were utilized as the standards for the safe and expert care found in the BMT FT. Given the improvements noted after the clinic was created, in fiscal year 2022 (FY22) care was expanded to include emergent treatment related to CAR-T cell therapy mobilization chemotherapy and colony-stimulating factor administration and teaching have been mobilized.

Several key outcomes that continue into FY22 from this clinic include the reduction in the average length of stay for patients undergoing autologous and allogeneic transplantation. The team reported a decrease in the 30-day readmission rate for patients undergoing autologous and allogeneic transplantation and fewer intensive care unit visits. The clinic also has generated better outcomes for patients and has had a positive impact on RUSH nurses, including an increase in job satisfaction. Nurses see former inpatients successfully transition to ambulatory care, observing them recover and return to their former selves.

The BMT FT clinic has created an easier transition for patients and their caregivers and has improved the patient experience. In addition to the positive impact on patient care, this project provided nursing at all levels the opportunity to support and collaborate on an innovative care team model.