1. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 1 Improving the Reliability of Immunosuppressant Drug Levels Michelle Kosik, Carrie Zeh, Trista Carelock, Penny Odem, Chrissy Boyd, & Kelly Hill Rose February, 2013

2. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 2 P ROBLEM 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: 1. Improve the reliability of TAC/CSA levels and resulting dose adjustments 2. Improve patient satisfaction with the process (lumen contamination necessitates peripheral sampling causing increased discomfort and risk for patients)

3. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 3 D EFINITIONS  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. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 4 P OTENTIAL 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. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 5 I NTERVENTION 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. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 6 A DDITIONAL 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. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 7 A NOTHER 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. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 8 R ESULTS

9. CONFIDENTIAL AND PROPRIETARY © 2012 Sarah Cannon. 9 D ISCUSSION 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.”