The Royal Marsden 1 Nursing and Service Aspects of Extracorporeal Photopheresis ( ECP) Janet Baker (Sister-Haem-Onc Daycare/Outpts/Apheresis) Royal Marsden NHS Foundation Trust EBMT NAP UK 5/10/2012
The Royal Marsden
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Nursing and Service Aspects of Extracorporeal Photopheresis ( ECP)
Janet Baker (Sister-Haem-Onc Daycare/Outpts/Apheresis)Royal Marsden NHS Foundation Trust
EBMT NAP UK 5/10/2012
The Royal Marsden2
Background Opportunity to deliver ECP at RMH
Commercially sponsored clinical trial: ECP for 1st line Chronic GvHD
Provision of CellEx™ Photopheresis system
Charity funded programme for Acute GvHD
Development of an ECP service
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Discussion Points Clinical Governance Issues
Management, Organisation, and Personnel
Training and Supervision
Premises-Space-Storage
Key Documentation
Quality Assurance/ Standards
Patient Management
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Clinical Governance Issues Service Objectives / Outcome Service Agreements/ Maintenance
New Equipment User Group Drug and Therapeutics Committee-Approval
for 8-Methoxypsoralen (Uvadex™)
Risk Assessment Incident Reporting System
Procurement Finance Reporting- updates to Charity Fund
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Management, Organisation, and Personnel ? Extension / Integration of Apheresis service
Inpatient / outpatient service
Designated leads/ Keyworkers: Nursing and Medical
Accountability / Responsibility
Skill mix / Experience: Apheresis + Transplant
Resources: Nursing Staff and Time
Institutional / Department support
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Training Requirements Technical Competency Certificate from Company
Trainer – ‘water treatment’ and patient treatments
Theoretical component- workbook
Arranged observational visit to Nottingham -ECP
Strasbourg- Company HQ, and clinical observational visit
On- the – job training / learning….ongoing
Instruction Manual
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Premises – Space - Storage
CellEx™
Location of procedure – Inpt/ Outpt/ Apheresis
Therapeutic environment
Service is portable
Storage of kits
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Key Documentation Standard Operating Procedure ( SOP) for ECP
Patient Consent Form Patient Information Leaflet
Photopheresis Procedure record Prescription/ Proforma -Uvadex™ / Heparin GvHD monitoring/ assessment form FACT-BMT Quality of Life questionnaire
Reporting forms for System failures/Incidents Maintenance and Cleaning records
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Quality Assurance / Standards
SOP policy for ECP and associated policies JACIE accredited centre
JACIE 5th edn standards B7.2 acknowledge: - “Inspectors are encountering ECP processes during inspection-if part of therapy for GvHD- must comply with JACIE standards-performed according to policies for safe administration of ECP”
UK Photopheresis Society (UKPS) advocates ECP accreditation in UK / Europe by external assessment
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Patient Management Patient selection / Eligibility for treatment – SOP ‘ to ECP or not to ECP?’
Further consensus guidelines for acute GvHD needed
Scheduling –treatment efficacy -Acute –twice weekly-8 wks
- Chronic- per trial / 2x week every 2 weeks
- logistics and practicalities
Clinical pre-assessment criteria-blood values (Fbc, Coag, U&es, Lfts, lipids) / Weight
Baseline GvHD assessment and I/S medication review
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Patient Consent / Information Commitment / Compliance Repeat hospital visits Inpt/ Outpt Realistic aims and timeframes- not ‘quick fix’ Support / Reassurance Low fat diet- ( lipids) UVA protection skin / eyes - dark glasses Contraception – (Uvadex ™) Good oral hydration Acute/ Chronic GvHD pts… different needs
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Side –effect profile
Fatigue Hypotension / dizziness/ syncope - ECV Increased sensitivity to sunlight- skin / eyes Pain, anxiety, bruising – peripheral
cannulation Infection- central access lines Bleeding/ bruising – anticoagulation
Metallic taste in mouth , ‘sparkly’ sensation in eyes during re-infusion
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Venous access - vein assessment Peripheral Access– Kimal needle size 16/17 - 17/18 g cannula Return - 18/ 20 g cannula
Central Line –Double lumen - LTS line(long term
silicone,tunnelled) - 12 French ( 5.5 mm per lumen) - > 3 French per lumen - provide flow rates > 15 ml/ min
CellEx™ - Single or Double lumen procedure
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Transfusion Requirements pre ECP
Institutional Parameters
Hct > 27 %
Platelets > 25,ooo
Blood results < 48 hours pre procedure
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Anticoagualtion System licensed for Heparin not Citrate
? Anticoagulant not anti-platelet clumping activity
10,ooo units Heparin in 500 mls / AC ratio 10:1 Adjust for high/ low platelet counts
Watch for Platelet Clumping Assess for bleeding, bruising - haematuria Patient anti-coag history- INR
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Technical problems CellEx™ Alarms
Problem solving
Technical support - Hotline / UK trainer
Kits - Reimbursement if problems
Smart Cards- send for analysis
Reporting / Documenting System and kit problems
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Assessment, Monitoring, Evaluation Efficacy v toxicity of treatment - ECP good
safety profile
GvHD assessments - who should complete these?
Record Clinical Outcomes - ? National ECP database
Quality of Life information
Financial Outcomes - Commissioners / Reimbursement and future funding
Evidence -based and cost- effective service
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Our experience so far……. 3 AGvHD patients treated- 1 in treatment
CGvHD Trial - 1 pt enrolled- not randomised to ECP
? Future after funding/ trial complete
Challenging / time-consuming
Great opportunity for us and our patients
Collaboration and networking with other ECP centres
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Acknowledgement / Thanks
Regina De Jesus - Joint ECP Key- worker - Sister, Transplant Unit,
RMH
Nurses on Bud Flanagan Ambulatory Care ( BFAC)
ECP experts, esp - Emma Luke at Nottingham - Tracy Maher and Maggie
Foster at Rotherham