Ambulatory care for autologous stem cell transplants

Katie McDougall, Senior Sister for Ambulatory Chemotherapy at the Northern Centre for Cancer Care, explains the ambulatory care service for autologous stem cell transplants (ASCTs). Offering the ASCT process in ambulatory care means patients can stay in their own home and familiar surroundings – with the reassurance of close monitoring through the aftercare available on the unit – and can be admitted into hospital if needed. Patients have reported that ambulatory care for ASCT has made their experience easier and less frightening.

Pictured: Katie McDougall, Senior Sister; Beth Taylor, Deputy Sister; Rhoda Nepomuceno, Staff Nurse; Anne-Marie Morel, Staff Nurse; Fiona Millar, Health Care Assistant

Why did the service start?

The service developed as result of funding for the CAR-T provision within the centre. We were prompted to consider ambulatory care by capacity issues, COVID-19, and the NHS plan to move healthcare closer to home. Our consultant had read a lot of evidence about ASCT patients having very little intervention in hospital afterwards, so we wondered if we could do some, or all, of the pathway via ambulatory care. I found articles from other countries dating back a considerable amount of time, which was reassuring even though we weren’t aware of other UK centres providing the service. We planned the new pathway with a MDT approach, as we wanted a patient-centred model that ensured patient safety. The wellbeing of patients was paramount in all of our decision-making, as we considered whether hospital-acquired infections and deconditioning could be minimised with an outpatient pathway.

How has the service developed?

The service is ever evolving. We devised the protocol in early 2021 by adapting the chemotherapy regime to fit within suitable timeframe so patients would receive treatment to fit within the department, pharmacists and consultants’ working hours. We started with a single patient who had previously had melphalan and SCT as an inpatient and lived very close to hospital. Since then, we have continued to adapt the protocol and make changes around transfusion support and using what we have learnt from our patients on the ambulatory pathway since the service started.

Protocols

Full ambulatory: patients attend as day cases for chemotherapy and cell infusion, then enter ambulatory follow-up protocol, and are only admitted into hospital if there are side effects or nursing concerns.

Partial ambulatory: as above, then planned admission on day 4-6, if at risk. This may be because they live alone or there is a language barrier for emergency phone calls.

Partial ambulatory for regional patients: the same as partial ambulatory but with planned return to regional base site. The team at base site then decides on whether patients are admitted.

Could you explain how the service runs day-to-day?

The service is split into pre-treatment and treatment phases:

Pre-treatment

In the weekly MDT with the ambulatory team, consultants and apheresis nurses, we identify patients who would be suitable for the protocol. A lot of patients have been receiving treatment up to this point in their regional base hospital. We arrange to meet patients at either the stem cell harvesting, or if patients have already had harvesting (which a lot have) then at the consent appointment. There are minimum safety criteria for ambulatory care: distance from the centre, how the patient communicates, who else is at home, and comorbidities. The criteria ensure we are not accepting patients that could be put at risk by not being in hospital, we do find that the majority of people fit for transplant are fit for ambulatory care.

We designed our own patient safety leaflet with language tailored to patients and which the team talk through with patients. Patients are given appointment times, contact numbers, and are talked through the emergency protocol. We also explain what to expect at each appointment (which is written down so patients can show family) and try and keep everything very simple. Dietary information is given at this stage. This was designed by our team of dieticians specifically for patients receiving treatment within the centre, as we identified very early on that appetite is one of biggest issues during recovery from ASCT. There is also a mouth care protocol, which we are working on with one of our palliative care consultants, and are very proud of as we’ve had no patients who have struggled with mouth care as a result.

Treatment

Day -2 for start of protocol and chemotherapy. Patients discharged after treatment, normally in the early evening. Patients told to come back if any adverse effects.

Day -1 is a rest day after the chemotherapy. Telephone call to patient to assess any adverse effects and safety net, and also to provide the appointment time to attend for cell re-infusion.

Day 0 for cell infusion with dedicated nurse. Ambulatory patients are asked to stay in the department for a minimum of 60 minutes, and then are allowed to go home if no adverse effects. We would address any nausea issues following the chemotherapy.

Day 1 is another telephone call to assess any adverse effects and safety net.

Day 2 and 3 are timed so over weekend. More telephone calls to safety net.

Day 4 would normally be a Monday and patients brought back in. If patients are feeling well and full blood count is what we expect it to be, they can go home. If they live locally (within half an hour of hospital) we allow them to go home before biochemistry results come back. We can usually tell if a patient needs to stay in.

Patients attend on alternate days until concerns arise (febrile, tiredness/lethargy, dip in mood, nursing concern etc.) so we don’t have a set day for admission. Usually by day 6 everyone’s blood count has dropped, so planned admission is between days 4 and 6. Some patients remain as outpatients for the entire protocol.

What resources are required to run the service?

We have an established team with six treatment spaces in the department for haematology and oncology. Our team is comprised of 4.7 Band 5 staff nurses, 1 Band 6, 1 Band 7, and 1 health care assistant. I am a nurse prescriber and non-medical authoriser for blood transfusions, which minimises medical input. The department is nurse-led; we do not have a medic formally attached to our service but always have medical support when required. We inform the medical team when bringing a patient into hospital, but it is usually a nurse who makes this decision.

What impact has the service had on patients, families and carers?

The feedback we have received from patients and families has been 100% positive. All patients have ticked the boxes for feeling well cared for, improved sleep, and improved food choice. Even the patients from regional base sites who had been very apprehensive have given positive feedback. This is all down to how we run the service: visitors are allowed, the team talks to relatives, appointments are tailored around patient tiredness, we try to be adaptable. The process is not an easy one and patients are appreciative of our efforts to ease their experience as much as possible.

The introductory meeting can take over an hour if the patient is nervous, and, if there is a nursing concern that ambulatory care is causing stress to a patient or their family, they will automatically receive inpatient care. Every patient is reviewed individually, and the team is very in tune with patients’ needs. We don’t want patients to feel they don’t have right to a bed because they have started ambulatory care protocol, so we ensure patients are aware that a bed is always there if they need it. Even though planned admission is between days 4 and 6, we listen to patients and would bring them in at any point if they were concerned.

What impact has the service had on colleagues?

Staff feel empowered that they can provide this service for patients. Our team feels very supported by the MDT. We know everyone is on board with the protocol and that, if the nurses call to say they are worried about a patient, the medical staff will support this. The lab staff have been wonderful, and we have worked closely with the apheresis team from the outset. The nurses have gained new skills and learnt new competencies – they have had extremely positive experiences with patients we have cared for. The team feels confident and competent with the protocol, and we provide teaching to new pharmacists on the protocol.

What advice would you give to other hospitals planning a similar project?

I have learnt in the last two years that change takes a very long time. We are very fortunate to have built very good relationships with the MDT, but it was a long process to change protocols that were designed around inpatient care to become ambulatory care.

It is essential to prepare patients very well for the protocol and ensure they are well-informed. Nurses should make themselves very available to patients. It is also important that patients realise the protocol is not about keeping them out of hospital beds. Patients should never feel any pressure to remain out of hospital if they don’t feel well. We want to facilitate quicker recovery, however that happens. We built the protocol around the patients rather than around the treatment, and the patients benefit from having a dedicated team who know them very well.