Before 2013, if patients with certain cancers or immune deficiency disorders at NewYork-Presbyterian Hospital/Columbia were in need of a bone marrow or stem cell transplant, they would have needed a referral for this portion of their care.
Patients may have received chemotherapy, radiation or other therapies for leukemia, lymphoma, multiple myeloma, myelodysplastic syndrome, or aplastic anemia at NYP/Columbia and could have received an autologous transplant, one where the patient's previously removed stem cells are restored back to him or her.
However, if they needed an allogeneic bone marrow transplant (receiving bone marrow from a donor), they were often transferred to NewYork-Presbyterian/Weill Cornell or another provider. Transferring the patients disrupted the continuity of care.
As of March 2013, however, the referrals have stopped when the hospital recruited clinicians with years of experience in the field, including Jennifer Giannini, MSN, RN, NP-C, CNS, to begin its own Blood and Marrow Transplant Program. Giannini joined the hospital in April as the new Patient Care director of the Blood and Marrow Transplantation.
Bone marrow and stem cell transplantation is the standard of care for patients who have been treated for blood-related diseases and cancer. Bone marrow - soft, sponge-like material found in bones - contains hematopoietic stem cells. Stem cells - undifferentiated cells found in the human body that have the potential to develop into many different cell types that carry out different functions.
According to the National Cancer Institute at the National Institutes of Health, unlike embryonic stem cells that can form into any type of cell, hematopoietic stem cells divide to form more hematopoietic cells, or they mature into white blood cells to fight infection; red blood cells to carry oxygen; and platelets, to help the blood to clot. Cells a lot of patients are in need of following treatment.
POWERFUL PAIR: Linda Valentino, MSN, RN, director of nursing, Neuroscience & Specialty Services, NYP Nursing Administration (left), shares a moment with Jennifer Giannini, MSN, RN, NP-C, CNS, who joined NewYork Presbyterian/Columbia hospital in April as patient care director of its new Blood and Marrow Transplant Program.
The program at NYP/Columbia, under the direction of Markus Y. Mapara, MD, PhD, recently completed its first allogeneic bone marrow transplant. The nursing care the donor and recipient received contributed to the successful outcome-care that begins weeks ahead of the transplantation date.
"The nurses do so much on the unit," Giannini said. "They care for the patient in their entirety, doing daily assessments, administering medications, creating the care of plan for the patient and post-care education. They're really their biggest advocate."
Patients are admitted to the unit for typically more than 21 days for the transplant. The procedure begins weeks before that to identify a donor, most likely a sibling with matching human leukocyte antigens (protein molecules inherited from parents). The sibling will undergo various tests during pre-evaluation - blood work, cardiac testing and a physical evaluation. Once cleared for donation, for 5 consecutive days, the donor receives Neupogen (Filgrastim).
"This stimulates the bone marrow and allows for replication of stem cells in the bone marrow in overabundance," Giannini explained. After the donor has plenty of stem cells to donate, he is hooked up to an apheresis machine, which kind of looks like a "washing machine on spin cycle," she said. An IV is placed in either arm of the donor, and the machine spins off stem cells for collection (like in a centrifuge), then returns remaining blood and plasma to the other arm.
The collection process, which takes one or two days, coincides with what is going on with the recipient. They have already undergone testing, which is more intensive than the donor experienced. Extensive laboratory, cardiac and pulmonary tests are completed. They receive a physical examination, review pre-procedure testing, and talk with a social worker to ensure they are physically and emotionally prepared for the transplant.
Recipients also are given a high dose of chemotherapy, with or without radiation, before the transplant. "This allows for the existing bone marrow to be wiped out, to allow space for new stem cells to grow and remove any lingering cancer cells," Giannini explained.
When it's time for the actual transfusion, Day 0, as they call it, nurses remain on the alert.
"During this time, there is a 1:1 nurse-to-patient ratio," Giannini said. "The patient can have adverse reactions, and the stem cell infusion may need to be slowed. The stem cell infusion can take anywhere from 15-20 minutes to two or three hours.
"These patients can be highly acute and change on a dime," she said. "Nurses really have to have a keen eye and look at the trends to catch a fever early or notice if their blood pressure starts to drop which could be early signs of sepsis. We don't have patients on monitors like a telemetry unit, so we really have to be very aware of what is going on."
On the unit, as well as the rest of NYP, nurses apply the Primary Nursing Care Model, which allows for patients who are admitted and readmitted to have the same nurse. This allows for continuity for the staff and patients and provides better patient care, Giannini said.
The transplantation program currently is occupying a medical oncology unit but will move into its own unit in February 2014, Giannini said.
The 18-bed state-of-the-art unit will accommodate allogeneic and autologous bone marrow transplant patients. Each room will have its own computer work station to update and access the patient's records and its own vital signs machine.
"Everything will be at the patient's bedside, which helps in time management so nurses don't have to scramble to find things, and for infection control," Giannini said.
NYP/Columbia is still looking for nurses to join the unit. Nurses with experience in oncology or critical care are encouraged to apply, Giannini said, but those who have worked in other bone marrow transplant programs would be ideal candidates.
Nurses looking to find out more about the program are encouraged to attend the Fist Annual Blood and Marrow Transplantation Continuing Education Event on Oct. 25. The event will engage and enhance the knowledge base of RNs with emphasis on multidisciplinary care of the Blood and Marrow Transplant patient.
"This is a rare opportunity for nurses to be involved with something that is opening for the first time," Giannini said. "That's what motivated me to come here. It's unique to watch a program grow from the ground up. Nurses can help shape the program and drive its success."
Stacey Miller is a freelance writer.