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February, 2013

Improving the Reliability of Immunosuppressant Drug Levels Michelle Kosik, Carrie Zeh, Trista Carelock, Penny Odem, Chrissy Boyd, & Kelly Hill Rose. February, 2013. Problem.

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February, 2013

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  1. Improving the Reliability of Immunosuppressant Drug LevelsMichelle Kosik, Carrie Zeh, Trista Carelock, Penny Odem, Chrissy Boyd, & Kelly Hill Rose February, 2013

  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: • Improve the reliability of TAC/CSA levels and resulting dose adjustments • Improve patient satisfaction with the process (lumen contamination necessitates peripheral sampling causing increased discomfort and risk for patients)

  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.

  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.

  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

  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

  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.”

  8. Results

  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.”

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