Guidelines, Protocols Described for Outpatient BMT Program

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 Center’s Bone Marrow Transplant Program at University Hospitals of Cleveland, described their program’s guidelines at a transplant conference, sponsored by IBC/Infoline.

The program’s 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:
University Hospitals of Cleveland

Diagnosis of breast cancer, lymphoma, or multiple myeloma

Performance status of 0 or 1

Tolerant of previous chemotherapy

Compliant with previous treatment

Designated caregiver

Psychosocial assessment of both patient and caregiver

Residence within 50-mile radius or 1 hour’s drive of the facility, or arrangements to stay at a specialized residence for cancer patients and their families in the area (Hope Lodge)

Insurance preapproved

Organ function assessment adequate

The Protocol

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 a PharmD.

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 physician’s 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.