Multidisciplinary Teamwork Yields Improvements in HSCT Workflow and Care

A multidisciplinary collaboration between a nurse practitioner, doctor of pharmacy, and clinical nurse specialist improved workflow and care delivery for patients receiving hematopoietic stem cell transplantation (HSCT) at UCLA Health. Findings were presented at the 48th Annual Oncology Nursing Society (ONS) Congress.

One area that was improved through this collaboration was what the team referred to as the “electrolyte replacement protocol.” Previously, when patients required replacements for their medications, the nurses needed to reach out to providers for the orders. However, the electrolyte replacement protocol allowed for the nurses to provide these medications when clinically indicated.

Shivani Gopalsami, RN, MSN, ANP-BC, AOCNP

“We were able to use the electrolyte protocol to reduce the hours from laboratory result to administration of the medication from 5.9 hours to 1.7 hours,” Shivani Gopalsami, RN, MSN, ANP-BC, AOCNP, said in an interview with Oncology Nursing News®. “That was critical in ensuring that we’re optimizing our electrolyte balance and some preliminary data showed we were able to reduce adverse cardiac events as well.”

Other areas that were improved through multidisciplinary collaboration included an oral care regimen and cryotherapy with melphalan (Evomela) as well as a reduction of fluids with all HSCT conditioning regimens, to name a few.

Tia Wheatley, DNP, RN, AOCNS, BMTCN

In an interview, Tia Wheatley, DNP, RN, AOCNS, BMTCN, a certified clinical nurse specialist, and Gopalsami, an adult nurse practitioner at UCLA Health, highlighted the importance of multidisciplinary care and how incorporating it in their clinic’s initiatives demonstrated benefits.

Oncology Nursing News: What was a multidisciplinary initiative you implemented that demonstrated improvements for patients?

Gopalsami: One of the most impactful interventions that we used a collaborative approach to develop is our inpatient electrolyte replacement protocol. Previously, when patients required replacements of medications, the laboratory [results] would come in and nurses would have to reach out to providers for orders. This electrolyte replacement protocol not only improved timely administration of magnesium and potassium, but it also increased the nursing autonomy to give these medications when indicated.

From a collaborative approach, our clinical nurse specialist looked at a lot of the prior protocols that were in the literature related to outpatient oncology setting or the intensive care unit. We took that framework and I, as a nurse practitioner, put that framework into our own patient population, [to ask] what dose do they need [and] what parameters do we want to do for this oncology population that may need to have levels a bit higher than other patient populations? We also collaborated with the pharmacist to ensure what medications were available readily to the nurses via the [BD] Pyxis [management software] so that they wouldn’t have to go to the pharmacy which could delay timely medication delivery.

Why is multidisciplinary collaboration important and what are some of the barriers that occur with it?

Wheatley: Multidisciplinary collaboration is very important because not one person has the answers to everything, and you do not want to assume how your best practice initiative will impact other disciplines. [For me], getting [everyone] to the table in the beginning and the planning stages [is important], especially when I am coming forth with new ideas and wanting to translate them into clinical practice. [I want to] understand how that [approach] might impact the workflow of my colleagues, whether that be the nurse practitioner team, our provider colleagues with our physicians, or even our pharmacy. [It is necessary to] have that input upfront is very important.

Also, having those different pieces of expertise is very important. As an evidence-based practice clinician, we know that we want to have the latest research and evidence, but we also put that in conjunction with our clinical expertise. My lens is going to be very different from the nursing point of view as to the medical model, the pharmaceutical model, and [or] our ancillary partners. Having all those perspectives makes us more comprehensive in the care that we're providing.

There are a lot of barriers to that—it’s not something that happens overnight—it takes a lot of time to implement some of these initiatives, get everybody at the table, make sure that their points are heard, and that we are compromising to the best of our abilities [and] paying attention to evidence. Some providers [in and out of the department] might not be as gung-ho to change practice as we are. But, as we’ve gotten more of a hang on it and shown how this collaborative work is impacting patient outcomes, we’ve had a lot of buy-in for other initiatives to where a lot of those barriers have been mitigated now that we have data [to] backup some of the things that we’re trying to do going forward.

What additional initiatives did you work together on?

Gopalsami: One of the other initiatives that Tia, I, and the pharmacists, collaborated on was regarding [the] hyperhydration protocol and diuresis when giving high-dose cyclophosphamide. In the stem cell transplant setting, there is an increased use of posttransplant high-dose cyclophosphamide, though this can result in an increased morbidity of hemorrhagic cystitis.

With this, we worked together to create a protocol where we not only increased the hydration these patients are getting to increase the flow with the bladder, but also diuresis, so we are not fluid overloading our patients and causing other downstream sequela. Partnering together, we created this protocol, got buy in from our physician colleagues, and were able to prevent fluid overload and downstream sequela.

What is a main takeaway from this collaborative effort?

Wheatley: The main takeaway here is to know that the collaboration between advanced practice nursing with nurse practitioners and clinical nurse specialists is very powerful. [It is important to be] looking at who on your team you need to get involved [and because] you never want to assume workflows of other disciplines. So making those connections upfront, [and] getting them involved as a team [is key]. We round every day for our patients as a collaborative team and it is a great environment to have that open door first name policy—everybody’s collaborating and practicing together for that central theme of the patient.

Hopefully our initiatives and outcomes that we have had with that collaboration inspire other institutions to do the same and have those daily interdisciplinary rounds and open conversations. We have done amazing work for our patients, but it has also solidified our relationships as colleagues as well. We are always calling each other, we are always consulting each other for things, and I hope that is something that other people can take away from the work that we've done.

Gopalsami: It is so important to get buy-in, involvement, and engagement from every single interdisciplinary member of the team, whether it’s a pharmacist, clinical nurse specialist, nurse practitioner, physician, [or] nursing staff, they are at the bedside implementing these protocols. Getting that collaborative team mindset is probably the most impactful thing to make an initiative successful.

Reference

Gopalsami S, Wheatley T, and Kim C. Improving hematopoietic stem cell transplant patient outcomes utilizing interdisciplinary collaboration between pharmacy and advanced practice nursing. Poster presented at: 48th Annual Oncology Nursing Society Congress; April 26-30, 2023; San Antonio, TX. Accessed May 24, 2023. https://ons.confex.com/ons/2023/meetingapp.cgi/Paper/13235