S174 Abstracts / Biol Blood Marrow Transplant 19 (2013) S167eS177
and nutritional factors. Hypophosphatemia, has been re- 118 ported to precede engraftment (Raanani, et al.). Nurses have Clabsi Reduction: No Longer Just an Inpatient Initiative noted and we therefore hypothesized that phosphorous, Jessica Vega 1, Stacey Knight 1, Kay Sams 2, Amy E. Patterson 3. calcium, and potassium values would drop 2-4 days pre- 1 BMT Treatment Center, Moffitt Cancer Center, Tampa, FL; engraftment, when compared to either admission for 2 Infection Prevention & Control, Moffitt Cancer Center, Tampa, conditioning (time point A) or day of transplant (time point FL; 3 Nursing Professional Development, Moffitt Cancer Center, B). Being able to predict neutrophil recovery helps nurses be Tampa, FL alert for clinical signs and symptoms of complications such as cytokine storm/engraftment syndrome, serious infection, Significance and Background: BMT patients are frequently and hyperacute graft versus host disease. discharged to outpatient care with a central line catheter in Methods: We retrospectively reviewed records of 244 place. These patients are at increased risk for developing patients who underwent hematopoietic SCT from January a central line- associated bloodstream infection (CLABSI). A 2005 through May 2006. Electrolyte values were collected at review of literature and comparison CLABSI rates showed the time of admission for conditioning (time point A); a paucity of studies in the outpatient population. An outpa- transplant day (+/- 1 day; time point B); and 2-4 days prior to tient who develops a CLABSI usually requires admission to engraftment. Two-sided paired t-tests were conducted the hospital, where treatment costs may range from comparing levels for each of the time points A and B $35,000-53,000. CLABSI surveillance began in January 2009 compared to pre-engraftment. For comparison between for our outpatient BMT population utilizing the same NHSN groups, two-sided two-sample t-tests were conducted. No definition used for inpatients. An analysis of data collected adjustment was made for the multiplicity of testing. Patients over 18 months prompted nursing staff to implement a plan were grouped as follows: overall, by stem cell source to target reduction of CLABSIs. (apheresis, bone marrow, or cord), transplant type (alloge- > 6 Interventions: BMT Treatment Center nurses were educated neic or autologous), and CD 34 cell dose ( 5or 5x10 /kg, on CLABSI, current rates, and implications for patients as well for apheresis products only). Patients had their electrolyte as the department. The nurses researched ways to reduce levels measured while in the hospital, and received stan- CLABSIs and developed a post-insertion bundle for central dardized electrolyte replacements. line care utilizing CDC CLABSI prevention strategies and other Results: Overall, the values for all the electrolytes two to four fi evidence-based practices. Patient education materials were days before engraftment were signi cantly lower than at < e developed and a post-line insertion patient education plan time points A or B (P-value range .001 to .01 Table 1). We was initiated. Nursing compliance with the bundle is concluded that drops in electrolyte levels precede neutrophil continually monitored by retrospective reviews of central line engraftment after peripheral blood SCT. Being able to predict charting, monthly central line audits, and review of electronic neutrophil engraftment will help nurses be more aware of patient education tools. CLABSI surveillance is ongoing with possible SCT complications that may occur with an in-depth review of all CLABSIs for defects in nursing care. engraftment, and allow the nurses to work with the Results: The 18 month pre-bundle CLABSI rate was 1.66 per medical team to intervene quickly. 1000 patient visits. The 18 month post-bundle rate fell to Table 1 0.88 per 1000 patient visits. The actual number of CLABSIs Overall change from admission and transplant to pre-engraftment fell by 30. This resulted in 30 fewer hospital admissions and a minimal savings of over $1,000,000 dollars to the facility. Electrolyte N Timepoint Average change to SD P-value Pre-Engraftment (change) Specifically, the number of coagulase-negative staph infec- < tions, frequently associated with indwelling devices, drop- Phosphorous 244 Admission (A) -0.6836 0.9956 .001 Transplant (B) -0.4012 1.0076 <.001 ped from 32 pre bundle to 7 post bundle implementation. Calcium 242 Admission (A) -0.5851 0.7192 <.001 Nursing compliance with CLABSI prevention strategies Transplant (B) -0.0971 0.6008 .0126 continues to be well over 90%. Potassium 244 Admission (A) -0.2947 0.5642 <.001 Transplant (B) -0.2279 0.5967 <.001
TRANSPLANT NURSING-RESEARCH ORAL 120 119 Impact of Palifermin On Incidence of Mucositis and Predicting Neutrophil Recovery by Changes in Serum Length of Hospitalization in Children Undergoing Electrolyte Levels of Stem Cell Transplantation (SCT) Autologous Hematopoietic Stem-Cell Transplant for Patients Malignant Disorders 1 2 3 4 Zandra Rivera 1, Alison Gulbis 2, Marcos de Lima 1, Leah Violago , Paige Cofnas , Kelly Vitale , Jacquelyn Bishop , 5 5 5 1 Gabriela Rondon 1, Patricia S. Fox 3, Roland Bassett Jr. 4, Yasmin Elsayed , Zhezhen Jin , Prakash Satwani . Children's 2 Mihir Raval 5. 1 Stem Cell Transplantation and Cellular Therapy, Hospital of New York Presbyterian, New York, NY; Master of The University of Texas MD Anderson Cancer Center, Houston, science in nursing, Pediatric Blood and Marrow Transplant, 3 TX; 2 Division of Pharmacy, The University of Texas MD New York Presbyterian Hospital, New York, NY; Morgan Anderson Cancer Center, Houston, TX; 3 Department of Stanley Children`s Hospital, New York Presbyterian-Columbia, 4 Biostatistics, The University of Texas MD Anderson Cancer New York, NY; Pediatrics, New York Presbyterian Hospital, 5 Center, Houston, UT; 4 Department of Biostatistics, The NewYork; Pediatrics, Columbia University, New York, NY University of Texas MD Anderson Cancer Center, Houston, TX; 5 Department of Hospital Internal Medicine, Affiliation - Myeloablative chemotherapy/radiotherapy prior to Essentia Health, Fargo, ND autologous hematopoietic stem cell transplant (AHSCT) is a leading cause of mucositis associated with significant Background: The rapid hematopoietic cell expansion that morbidity. Palifermin has been demonstrated to decrease the leads to engraftment after SCT requires variety of metabolic incidence of severe mucositis in adults following total body Abstracts / Biol Blood Marrow Transplant 19 (2013) S167eS177 S175
irradiation (TBI) conditioning prior to AHSCT. The impact of University of North Carolina Hospitals, Chapel Hill, NC; palifermin on the incidence of mucositis in children 3 Pharmacy, University of North Carolina, Chapel Hill, NC; following AHSCT has never been studied. In this retrospec- 4 UNC Hospitals, Chapel Hill, NC; 5 Department of Medicine, tive study, we compared the incidence of mucositis and UNC Lineberger Comprehensive Cancer Center, University of supportive care required in children who received palifermin North Carolina at Chapel Hill, Chapel Hill, NC; 6 Pharmacy, vs. controls (no palifermin) during non-TBI AHSCT. Mucositis University of North Carolina Hospitals and Clinics, Chapel Hill, was graded as per WHO criteria. The continuous variables NC were summarized by the mean and standard deviation; the categorical variables were summarized by percentage. The Background: The use of filgrastim with or without plerixafor palifermin vs. control group were compared by two-sided t- has been shown to be an effective modality for the mobili- test for continuous measurements and by Chi-square test for zation of peripheral blood stem cells. However, questions categorical measurements. From 2005-2011, 58 patients remain as to the CD34+ count that would best predict for received myeloablative AHSCT, of which n¼25 were in the efficient collection. We developed a filgrastim-based mobi- palifermin group and n¼33 were in the control group. lization algorithm with a predetermined decision point for Demographic characteristics are presented in Table. the inclusion of plerixafor and a CD34+ count of 20 cells/uL as Comparing palifermin vs. the control group: the average time the trigger for collection. The purpose of our evaluation was for neutrophil engraftment was 12.16 3.21 days vs. 11.5 to determine the efficacy of this algorithm, as well as the 1.68 (P¼.127), the incidence of grade I and III-IV mucositis impact on plerixafor use, in patients undergoing mobiliza- was 80% vs. 90.9%, and 20% (P¼ .02) vs. 42.4% (P¼.07), the tion with filgrastim prior to autologous hematopoietic stem number of days with fever were 4.92 3.49 vs. 7.09 4.86 cell transplant (HSCT). (P¼.063), the number of days patients received PCA were Methods: Patients received filgrastim 10 mcg/kg SC once 8.80 8.39 vs. 8.30 8.54 (P¼.826), and the number of days daily for 4 days. If the day 5 CD34+ count was > 20/ul, patients were on TPN were 13.52 11.32 vs. 11.55 9.63 apheresis was started and filgrastim was continued until the (P¼.484), respectively. The incidence of blood stream and collection goal was met. If the day 5 CD34+ count was <10, Clostridium difficile infection was 36% vs. 27.3% (P¼.4) and plerixafor was started, and if the day 5 CD34+ count was 10- 24% vs. 18.2% (P¼.5), respectively. The average length of 20, filgrastim was continued for 1 day with plerixafor added hospital stay 31.44 7.42 vs. 28.61 10.38 (P¼.252) was not if the day 6 CD34+ count remained <20/uL. Mobilization statistically different between the palifermin and control efforts were stopped if the blood CD34+ count remained < groups. In summary, we were unable to demonstrate that 10. The CD34+ cell collection goal was 4 x 106 cells/kg, with there was a statistical difference with incidence of mucositis a minimum requirement of 2 x 106 to proceed to HSCT. and other supportive care needs or a decrease in hospital Results: To date, 21 patients (18 multiple myeloma and 3 stay in the palifermin group. In children receiving AHSCT, other) have been treated. Fifteen of 18 myeloma patients palifermin should only be used in the setting of a large received prior lenalidomide therapy. Eleven of the 21 prospective study. patients were successfully mobilized using filgrastim alone. Nine patients who had inadequate CD34+ mobilization with filgrastim alone responded to the addition of plerixafor. Patients requiring plerixafor received an average of 1.56 Variable Control group Palifermin group P-value doses. One patient with non-Hodgkin's lymphoma had no (No Palifermin, (n¼25)Mean (SD) response to filgrastim and therefore mobilization attempts ¼ n 33) Mean (SD) were halted. Seventeen of the 21 patients have successfully Age 6.85 (5.49) 7.96 (6.19) .473 proceeded to transplant, with 3 of the remaining 4 expected Gender: to be admitted for HSCT within the next month. Patients Male 20 (60.6%) 14 (56%) .724 collected in an average of 1.7 apheresis sessions and collected Female 13 (39.4%) 11 (44%) 6 Weight 30.62 (27.08) 35.02 (25.95) .535 an average of 5.15 x 10 CD34+ cells/kg. BSA 0.98 (0.55) 1.05 (0.51) .580 Conclusion: We demonstrate here a successful and cost- Brain Tumor 15 (45.5%) 3 (12%) .024 effective algorithm-based approach to mobilization, Solid Tumor 11 (33.3%) 14 (56%) including a predetermined strategy to include plerixafor for Lymphoma 7 (21.2%) 8 (32%) poor mobilizers. By using a decision point for the inclusion or Disease Status .671 exclusion of plerixafor, we avoided use of the agent in CR/PR 29 (87.9%) 21 (84.0%) SD/PD 4 (16%) 4 (12.1%) patients unlikely to need it for successful collection. Prior Radiation: .120 Yes 3 (9.1%) 6 (24%) No 30 (90.9%) 19 (76%) 122 HSV serostatus: .330 Utilization of an Algorithm for Chemomobilization Positive 25 (75.8%) 16 (64%) Including the Use of Plerixafor in Poor Mobilizers Negative 8 (24.2%) 9 (36%) 1 2 3 Creatinine clearance 118.1 (42.55) 134.8 (49.31) .176 Eric Chow , Andrea E. Faison , Tippu Khan , Deborah Covington 4, Thomas C. Shea 5, Kamakshi V. Rao 6. 1 Pharmacy, University of North Carolina Hospitals, Chapel Hill, 2 3 TRANSPLANT PHARMACY ORAL NC; University of North Carolina Hospitals, NC; Pharmacy, University of North Carolina, Chapel Hill, NC; 4 UNC Hospitals, Chapel Hill, NC; 5 Department of Medicine, UNC Lineberger 121 Comprehensive Cancer Center, University of North Carolina at Effectiveness of an Algorithm-Based Approach to Chapel Hill, Chapel Hill, NC; 6 Pharmacy, University of North Filgrastim-Based Mobilization Using Predetermined Carolina Hospitals and Clinics, Chapel Hill, NC Decision Points for the Inclusion of Plerixafor Andrea E. Faison 1, Eric Chow 2, Tippu Khan 3, Background: Chemotherapy plus GCSF has been an effective Deborah Covington 4, Thomas C. Shea 5, Kamakshi V. Rao 6. modality for the mobilization of peripheral blood stem cells. 1 University of North Carolina Hospitals, NC; 2 Pharmacy, However, the optimal drug, dose, and schedule have not