Improving Reliability of Immunosuppressant Sampling Techniques

Problem: The Colorado Blood Cancer Institute BMT Program at Presbyterian/St. Luke’s Medical Center, a member of the Sarah Cannon Blood Cancer Network, performed 242 hematopoietic cell transplants in 2011. The program noted 14 confirmed TAC/CSA lumen contaminations in 2010. In March 2011, auditing revealed 5 additional contaminations. This prompted a process improvement initiative. Goals were to improve quality outcomes by increasing reliability of TAC/CSA levels and resulting dose adjustments and improve patient satisfaction with the process (lumen contamination necessitates peripheral sampling causing increased discomfort and risk for patients).

The BMT Leadership team reviewed potential causes: Forty new staff hired; census and acuity were higher; Travelers and float staff were utilized. A process was needed to ensure TAC/CSA levels were reliable and bedside caregivers had appropriate knowledge to manage TAC/CSA infusions and samplings.

Intervention: Immediate efforts focused on nursing staff re-education.

1. Upon admission, nursing to designate a lumen for TAC/CSA infusion
2. No TAC/CSA sampling will be drawn from designated lumen.
3. TAC/CSA infusion is primary line infusing into dedicated port.
4. TAC/CSA infusion turned off 10 minutes prior to level sampling.

The unit-based council led this initiative. They recommended alerts to the special nature of these drugs. While under review, another contamination occurred. Additional recommendations made:

1. BMT Float guidelines reviewed -TAC/CSA process added
2. TAC/CSA process included in traveler orientation
3. RN Resource assigned to new hires, floats, and travelers
4. TAC/CSA education poster displayed on BMT units

In February 2012, another contamination was noted.  The BMT Leadership team and unit-based council convened to review additional opportunities.

1. Mandatory Healthstream education developed. Healthstream is an electronic education system which includes documentation of compliance.  
2. Clamp unused lumens during sampling process.
3. Interdisciplinary collaboration to create a pop up screen when medication is scanned-”Infuse in designated lumen ONLY. For help, see your charge nurse.”

Results: Significant reduction in lumen contamination; enhanced patient satisfaction. No contaminations since February 2012.

Discussion: Ongoing review and process improvements needed. In 2013 - mandatory review of TAC/CSA process in skills lab;   new TAC/CSA competency required for all BMT staff within 3 months of hire.