Patients who receive bone marrow transplantations (BMT) require vigilance for complications such as graft versus host disease (GVHD), opportunistic infections, and febrile neutropenia. During a presentation for the inaugural ONS Bridge™ virtual conference, Barbara E. Wenger, DNP, APRN, AOCNS®, CRNI, of UCHealth Metro, and Stephanie Armstrong, DNP, AGNP, NP-C, of Froedtert Hospital Clinical Cancer Center, described interventions to improve care quality in the BMT population.

Medication Adherence in Adult BMT Care

Medication nonadherence presents special challenges in BMT recipients. Wenger discussed how patients are seen preadmission, potentially for multiple week admissions, and then followed up postdischarge.

“For some transplants, allogeneic in particular, they may be sent home with as many as 5–10 different medications with various schedules and tapering doses,” Wenger explained. “Medication adherence and patient education regarding their medication can help to prevent emergency department visits, clinic visits, or even hospitalizations due to potential non-adherence complications.”

Wenger’s practice implemented an intervention to decrease incidence of GVHD and opportunistic infections through improved medication adherence practices. In the care transition process, nurses reviewed common medications, a self-report adherence survey, and pill box filling with patients.

Wenger said that time was one of the biggest barriers to successful implementation. Medication education in the inpatient and outpatient areas takes extra time. Knowing it is the right thing to do was the impetus that helped us overcome many of these barriers,” she said.

Overall, rates of GVHD and infections decreased during the intervention, and nurses reported improved patient communication and comfort. “Teamwork and stakeholder buy-in are crucial for these projects,” Wenger said. “If the group has a common aim, they have a better chance to work collaboratively to meet goals, deal with barriers, and improve outcomes.”

“Engaging the patients and watching them take part in this process was inspiring to the team,” Wenger said.

Nurse-Driven Interventions for Suspected Febrile Neutropenia

Febrile neutropenia is associated with high levels of morbidity and mortality when not treated promptly. Armstrong described how her 24-hour clinic practice developed a plan to decrease response times while also improving nurse satisfaction through increased autonomy.

“We saw a need that nursing could directly impact care quality, elevating the nursing scope of practice and supporting the interprofessional team to elevate their scope of practice as well,” Armstrong said.

“BMT patients today are too complex for a single person to manage on their own. It takes a village with everyone’s expertise functioning at the top level to support the patient at that biopsychosocial level,” Armstrong said.

Nurses at Armstrong’s practice were empowered to triage patients who call reporting a fever to either the emergency department or the 24-hour clinic, based on ONS guidelines. Previously, patients had to wait about an hour for the provider to call back. In addition, the clinic implemented a protocol based on National Comprehensive Cancer Network guidelines so nurses could expedite fever work-up and start antibiotics before the provider came in to see the patient. Postintervention, time to antibiotic treatment decreased while overall staff satisfaction increased.

Armstrong advised nurses seeking to increase autonomy in their own practices to find what motivates them. “Innovative ideas come from nurses across the spectrum,” she said. “You don’t have to be an expert to have a good idea. Sometimes the new nurse is the one with the best idea because they do not have the history to say the old adage of that’s how it has always been done.

“Support each other and be your best advocates. Internal motivation drives autonomy and innovation,” Armstrong said.