ORLANDO--An increasing number of bone marrow transplants (BMTs) are
being done on an outpatient basis. According to ELM Services, Inc.,
an oncology consulting firm, the outpatient cancer market will grow
from reimbursements of $85 billion in 1990 to $290 billion in the
early part of the next century, dwarfing growth in the inpatient market.
What are the eligibility criteria and treatment protocols that a
successful outpatient program uses? Nancy Tainer, RN, MBA, associate
director of the Ireland Cancer Centers Bone Marrow Transplant
Program at University Hospitals of Cleveland, described their
programs guidelines at a transplant conference, sponsored by IBC/Infoline.
The programs eligibility criteria (see below) include a
diagnosis of breast cancer, lymphoma, or multiple myeloma. "We
assess their tolerance of previous chemotherapy and past compliance
with treatment," Ms. Tainer said. The candidate must have a
designated caregiver and must live nearby or stay during treatment at
Hope Lodge, a residence sponsored by the American Cancer Society for
cancer patients and their families.
Eligibility Criteria for Outpatient BMT:
Once a prospective patient has passed all the eligibility criteria,
all hospital areas that will be involved in the transplant process
are notified. One or two weeks before high-dose chemotherapy is
begun, the patient is seen by his or her primary transplant
physician, and 5 days before the planned therapy, the attending
physician reviews and signs preprinted physician orders written
jointly by the attending physician, a hematology-oncology fellow, and
High-dose chemotherapy is administered to transplant patients in the
ambulatory area at 8:30 am on each designated day. They are also
evaluated and have blood work done. During that time, they are the
responsibility of the attending physician and medical personnel who
supervise inpatient services.
Patients are assessed for mouth tenderness, pain, and sore throat;
instructed in a mouth care regimen; and reminded that optimal fluid
intake is 8 to 10 glasses a day. They are asked about any nausea and
vomiting and the effectiveness of any antiemetics they are using.
Patients also report on any bruising or bleeding of the nose, gums,
or rectal area, and chills or fever over 100° F, as well as
urinary output, diarrhea, and medications.
Nurses do a complete set of vital signs and inspect patients
oral mucous membranes for mucositis or Candida.
Protocol requires that patients remain in the clinic until lab
results are reviewed and the attending physician has assessed the
patient. Platelets and other blood products are transfused according
to guidelines; hematopoietic growth factors are administered as
ordered; and electrolyte replacement is given as necessary.
Outpatient bone marrow transplant patients may be admitted to the
hospital at the physicians discretion if they have fever over
100.4° F, grade 2 nausea/vomiting, grade 3 diarrhea, grade 3
mucositis, and/or platelet count <10,000/µL. If patients are
admitted with a fever, an antibiotic regimen is begun. If patients
become afebrile, are clinically stable, and have negative cultures,
they can be discharged on antibiotics.