Stem cell transplant patients have access to some non-invasive procedures. At the clinic a bone marrow biopsy and aspirate can be performed under local anesthesia or conscious sedation. A paracentesis and/or thoracentesis can be performed by the Medical Director. During these procedures non-invasive and respiratory monitoring is capable. Services provided to the hematology/oncology include all those listed above and administration of blood and blood products, injections to increase their red and white blood counts, immunizations, and platelet infusions.
Both groups of patients are privy to the services for emotional support. Services performed outside the clinic are CT scans, MRI, bronchoscopies, endoscopies, hemodialysis, and mechanical ventilation. (See Appendix A for Definition of Terms). The CAGT clinic is a 15 bed specialized care unit staffed and equipped to provide continuous life support and care to patients who are receiving stem cell transplants or other cell and gene therapies. A multidisciplinary approach to patient care is emphasized plus the availability of appropriate, sophisticated, diagnostic and therapeutic support on a 24-hour basis.
Privacy is provided, in that all rooms are for a single patient and have a private bathroom. Isolation, with controlled directional airflow, is provided. These rooms have the capacity of negative and positive pressures. All rooms are equipped with bedside monitoring which is transmitted to a central monitoring and recording center. Each room is equipped with oxygen and wall suction. A defibrillator is available and can be operated by each Registered Nurse. The CAGT clinic is jointly managed by Medicine and Nursing.
Medical management is the responsibility of the Medical Director, who in turn is responsible directly to the Chief of Medical Services for professional activities. The nursing care in the clinic is the responsibility of the Nurse Director, who in turn is responsible for the professional activities to the Medical Director of the CAGT clinic. The attending physicians as well as the stem cell transplant Fellow, assume total responsibility for the day-to-day medical management of the CAGT patients. The hematology/oncology patients are under the care of their individual Hematologist/Oncologist who has privileges to practice at TMH.
The clinic utilizes computerized care plans as a model for planning, organizing and evaluation of patient care and unit protocols to estimate length of stay. This model is used for each of the primary admitting treatment modalities, outlining medications, test, teaching and discharge planning and outcomes to be achieved. The care plans and protocols are derived from and are reflective of current Standards of Medical and Nursing practice. They incorporate the multiple components of care provided to the critically ill patient. Professional nurses assigned to the CAGT patients function as the Case Manager for the individual patient.
On a daily basis, the nurse monitors the patients’ progress for the achievement of expected outcomes and/or variance. Variances (negative or positive), when identified are viewed as possible opportunities for improvement of patient care. The nurse with the patient care team initiates analysis of variance as a collaborative effort and when possible an action plan to correct the variances is initiated. The Nursing Director and nursing staff will conduct variance analyses for groups of similar patient populations to form a database for Continuous Performance Improvement (CPI).
The staff verifies all data before it becomes a part of the patients’ permanent record. The writer’s role in the CAGT outpatient Hematology/Oncology clinic is that of staff certified oncology nurse. The writer is a current member of the national and local Oncology Nursing Society and the Association of Ambulatory Care Nursing Society. For 20 years, the writer has been certified in chemotherapy administration and has worked in the field of stem cell transplant for 12 years. Presently, at TMH for 24 years and was in the United States Navy as Training Officer for 4 years.
At TMH, the writer is the clinic’s designee on the safety, pain and palliative care committees. The writer has direct contact with all patients, their families and friends, and staff. When patients come to the CAGT clinic as potential candidates for a stem cell transplant, they are examined and enter into a discussion with the Medical Director. This discussion can take over two hours. Patients are given verbal and pre-printed information and materials by the Medical Director and other members of the multidisciplinary team.
Copious amounts of information, materials and handouts are given regarding the patients’ disease, its stage and treatment options. Patients are not retaining or recalling the information and instructions when interviewed on subsequent visits. To assist with processing the information and formulating pertinent questions and concerns, patients are asked to return with someone who will be involved in their care. This person will also be needed to care for them after the transplant once discharged to home.