Czerlanis C

Background: Hematology/Oncology patients represent a complex population that requires timely follow- up to prevent clinical decompensation and delays in treatment. Previous reports have demonstrated that follow-up within 14 days is associated with decreased 30-day readmissions, and the magnitude of this impact is greater in higher risk patients. This project was designed to standardize the discharge process with the primary goal to reduce average time to hematology/oncology follow-up to 14 days.

Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team of hematology/oncology staff developed and implemented a standardized discharge process. Rotating resident physicians were trained through online and inperson orientation. Additional interventions included the development of a discharge checklist handout and clinical decision support tool including a note template and embedded order set. All patients discharged during the two-month period prior to and discharged after the implementation of the standardized process were reviewed. Patients who followed with hematology/oncology at another facility, enrolled in hospice, or died during admission were excluded. Follow-up appointment scheduling data and communication between inpatient and outpatient providers were reviewed. Data was analyzed using XmR statistical process control chart and Fisher’s Exact Test using GraphPad.

Results: One hundred forty-two consecutive patients were reviewed between May - August 2018 and January - April 2019. The primary endpoint of time to hematology/ oncology follow up appointment improved from a baseline average of 17 days prior to intervention to 13 days in PDSA cycles 1 and 2 and 10 days in PDSA cycle 3. The target of 14 day average time to follow up was achieved. Furthermore, the upper control limit decreased from 58 days at baseline to 21 days in PDSA cycle 3 suggesting a decrease in variation. Outpatient hematology/oncology provider co-signature to discharge summary increased from 20% to 54% after intervention (P=0.01).

Conclusion: Our quality initiative to standardize the discharge process for the hematology & oncology service decreased time to hematology/oncology follow up appointment, improved communication between inpatient and outpatient teams, and decreased process variation. Timelier follow-up for this complex patient population will prevent clinical decompensation and delays in treatment.

Background: Hematology/Oncology patients represent a complex population that requires timely follow- up to prevent clinical decompensation and delays in treatment. Previous reports have demonstrated that follow-up within 14 days is associated with decreased 30-day readmissions, and the magnitude of this impact is greater in higher risk patients. This project was designed to standardize the discharge process with the primary goal to reduce average time to hematology/oncology follow-up to 14 days.

Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team of hematology/oncology staff developed and implemented a standardized discharge process. Rotating resident physicians were trained through online and inperson orientation. Additional interventions included the development of a discharge checklist handout and clinical decision support tool including a note template and embedded order set. All patients discharged during the two-month period prior to and discharged after the implementation of the standardized process were reviewed. Patients who followed with hematology/oncology at another facility, enrolled in hospice, or died during admission were excluded. Follow-up appointment scheduling data and communication between inpatient and outpatient providers were reviewed. Data was analyzed using XmR statistical process control chart and Fisher’s Exact Test using GraphPad.

Results: One hundred forty-two consecutive patients were reviewed between May - August 2018 and January - April 2019. The primary endpoint of time to hematology/ oncology follow up appointment improved from a baseline average of 17 days prior to intervention to 13 days in PDSA cycles 1 and 2 and 10 days in PDSA cycle 3. The target of 14 day average time to follow up was achieved. Furthermore, the upper control limit decreased from 58 days at baseline to 21 days in PDSA cycle 3 suggesting a decrease in variation. Outpatient hematology/oncology provider co-signature to discharge summary increased from 20% to 54% after intervention (P=0.01).

Conclusion: Our quality initiative to standardize the discharge process for the hematology & oncology service decreased time to hematology/oncology follow up appointment, improved communication between inpatient and outpatient teams, and decreased process variation. Timelier follow-up for this complex patient population will prevent clinical decompensation and delays in treatment.

Background: Hematology/Oncology patients represent a complex population that requires timely follow- up to prevent clinical decompensation and delays in treatment. Previous reports have demonstrated that follow-up within 14 days is associated with decreased 30-day readmissions, and the magnitude of this impact is greater in higher risk patients. This project was designed to standardize the discharge process with the primary goal to reduce average time to hematology/oncology follow-up to 14 days.

Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team of hematology/oncology staff developed and implemented a standardized discharge process. Rotating resident physicians were trained through online and inperson orientation. Additional interventions included the development of a discharge checklist handout and clinical decision support tool including a note template and embedded order set. All patients discharged during the two-month period prior to and discharged after the implementation of the standardized process were reviewed. Patients who followed with hematology/oncology at another facility, enrolled in hospice, or died during admission were excluded. Follow-up appointment scheduling data and communication between inpatient and outpatient providers were reviewed. Data was analyzed using XmR statistical process control chart and Fisher’s Exact Test using GraphPad.

Results: One hundred forty-two consecutive patients were reviewed between May - August 2018 and January - April 2019. The primary endpoint of time to hematology/ oncology follow up appointment improved from a baseline average of 17 days prior to intervention to 13 days in PDSA cycles 1 and 2 and 10 days in PDSA cycle 3. The target of 14 day average time to follow up was achieved. Furthermore, the upper control limit decreased from 58 days at baseline to 21 days in PDSA cycle 3 suggesting a decrease in variation. Outpatient hematology/oncology provider co-signature to discharge summary increased from 20% to 54% after intervention (P=0.01).

Conclusion: Our quality initiative to standardize the discharge process for the hematology & oncology service decreased time to hematology/oncology follow up appointment, improved communication between inpatient and outpatient teams, and decreased process variation. Timelier follow-up for this complex patient population will prevent clinical decompensation and delays in treatment.

Background: A growing body of evidence suggests that palliative care is an important element of comprehensive cancer treatment by assisting with symptom management and establishing goals of care. Research suggests that enhanced integration of palliative care and oncology medicine has a positive effect on mortality and quality of life outcomes, and integration of the two is now considered standard care. However, there are no standard models for how this integration might occur. At our facility, there was no formal connection between the Oncology service and the Palliative Care Team.

Methods: The interdisciplinary Palliative Care Consult Team established weekly “Lightning Rounds” with Heme-Onc trainees, in which trainees answered questions about each patient regarding symptoms, prognosis, goals of care, and whether Palliative Care support was needed. In addition, trainees received brief didactics—“ teaching pearls”—that addressed components of palliative medicine (eg, use of opioids).

Trainees completed surveys Pre- and Post- Lightning Rounds, rating on a scale of 1 to 5 (Not at all to Very Much) how much they understand about, how confident they are in explaining, and how supported they feel by Palliative Care.

Results: From November 2017 – April 2019, we rounded on 105 unique patients in 26 Lightning Rounds sessions. Pre- and Post- samples are not paired. Average ratings of Pre- (n=18) and Post- (n=14) data show an increase in Understanding (4.2 to 4.6 on a 5-point scale); Confidence (4.0 to 4.6) and Support (4.8 to 5).

Conclusions: The current project sought to enhance integration between Oncology and Palliative Care by establishing a brief weekly Lightning Rounds in which Oncology trainees met with Palliative Care team members. We found that trainees’ understanding in what a Palliative Care consult can provide; their confidence in knowing when to offer a Palliative Care consult, and how supported they feel by our Palliative Care team, all increased from pre- to post-Lightning Rounds. These findings support our initial hypotheses and are encouraging continued involvement via this medium.

Background: A growing body of evidence suggests that palliative care is an important element of comprehensive cancer treatment by assisting with symptom management and establishing goals of care. Research suggests that enhanced integration of palliative care and oncology medicine has a positive effect on mortality and quality of life outcomes, and integration of the two is now considered standard care. However, there are no standard models for how this integration might occur. At our facility, there was no formal connection between the Oncology service and the Palliative Care Team.

Methods: The interdisciplinary Palliative Care Consult Team established weekly “Lightning Rounds” with Heme-Onc trainees, in which trainees answered questions about each patient regarding symptoms, prognosis, goals of care, and whether Palliative Care support was needed. In addition, trainees received brief didactics—“ teaching pearls”—that addressed components of palliative medicine (eg, use of opioids).

Trainees completed surveys Pre- and Post- Lightning Rounds, rating on a scale of 1 to 5 (Not at all to Very Much) how much they understand about, how confident they are in explaining, and how supported they feel by Palliative Care.

Results: From November 2017 – April 2019, we rounded on 105 unique patients in 26 Lightning Rounds sessions. Pre- and Post- samples are not paired. Average ratings of Pre- (n=18) and Post- (n=14) data show an increase in Understanding (4.2 to 4.6 on a 5-point scale); Confidence (4.0 to 4.6) and Support (4.8 to 5).

Conclusions: The current project sought to enhance integration between Oncology and Palliative Care by establishing a brief weekly Lightning Rounds in which Oncology trainees met with Palliative Care team members. We found that trainees’ understanding in what a Palliative Care consult can provide; their confidence in knowing when to offer a Palliative Care consult, and how supported they feel by our Palliative Care team, all increased from pre- to post-Lightning Rounds. These findings support our initial hypotheses and are encouraging continued involvement via this medium.

Background: A growing body of evidence suggests that palliative care is an important element of comprehensive cancer treatment by assisting with symptom management and establishing goals of care. Research suggests that enhanced integration of palliative care and oncology medicine has a positive effect on mortality and quality of life outcomes, and integration of the two is now considered standard care. However, there are no standard models for how this integration might occur. At our facility, there was no formal connection between the Oncology service and the Palliative Care Team.

Methods: The interdisciplinary Palliative Care Consult Team established weekly “Lightning Rounds” with Heme-Onc trainees, in which trainees answered questions about each patient regarding symptoms, prognosis, goals of care, and whether Palliative Care support was needed. In addition, trainees received brief didactics—“ teaching pearls”—that addressed components of palliative medicine (eg, use of opioids).

Trainees completed surveys Pre- and Post- Lightning Rounds, rating on a scale of 1 to 5 (Not at all to Very Much) how much they understand about, how confident they are in explaining, and how supported they feel by Palliative Care.

Results: From November 2017 – April 2019, we rounded on 105 unique patients in 26 Lightning Rounds sessions. Pre- and Post- samples are not paired. Average ratings of Pre- (n=18) and Post- (n=14) data show an increase in Understanding (4.2 to 4.6 on a 5-point scale); Confidence (4.0 to 4.6) and Support (4.8 to 5).

Conclusions: The current project sought to enhance integration between Oncology and Palliative Care by establishing a brief weekly Lightning Rounds in which Oncology trainees met with Palliative Care team members. We found that trainees’ understanding in what a Palliative Care consult can provide; their confidence in knowing when to offer a Palliative Care consult, and how supported they feel by our Palliative Care team, all increased from pre- to post-Lightning Rounds. These findings support our initial hypotheses and are encouraging continued involvement via this medium.

Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care

Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.

Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.

Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.

Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care

Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.

Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.

Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.

Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care

Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.

Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.

Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.

Backround: Mastocytosis is a rare disease with a variable clinical course. Pure red cell aplasia has not been frequently reported in association with aggressive systemic mastocytosis. CD30 is often expressed on mast cells in systemic mastocytosis. The CD30-directed antibody-drug conjugate brentuximab vedotin has shown in vitro activity against CD30-positive neoplastic mast cells. We describe a case of systemic mastocytosis with the development of severe hemolytic anemia, pure red cell aplasia, and evidence of weak bone marrow CD30 positivity. Brentuximab vedotin was administered with some evidence of clinical benefit.

Patient: A 64-year-old man presented with fatigue and a 20 pound weight loss. He was found to have transfusion-dependent anemia, a low reticulocyte count, and splenomegaly. Evaluation for gastrointestinal blood loss was unremarkable. Bone marrow biopsy showed mast cell aggregates, spindle-shaped mast cells, CD-2 and CD25-positivity, increased myelopoiesis and dysmegakaryopoiesis, red cell aplasia, eosinophilia, and increased reticulin fibrosis. The D816V c-kit mutation was present, and serum tryptase level was elevated at 114 ng/mL. He later developed Coombs-positive hemolysis and direct hyperbilirubinemia, concerning for mast cell liver infiltration.

Intervention: The patient received high-dose steroids and red blood cell transfusions. Interferon alpha and cladribine were contraindicated, given severe liver dysfunction. He was started on hydroxyurea. He received a dose of brentuximab vedotin 1.8 mg/kg IV. Thirteen days after starting steroids and 10 days after brentuximab, haptoglobin became detectable, and total bilirubin decreased to 18.4 mg/dL from 40.5 mg/dL. Red blood cell transfusion requirements decreased. He then developed severe neutropenia, pneumonia with sepsis, and respiratory failure, requiring intubation, maximal pressor support, and broad-spectrum antibiotics. Despite these measures, he expired.

Discussion/Conclusion: This is a rare case of pure red cellaplasia in the setting of aggressive systemic mastocytosis. Therapeutic options were limited in the setting of liver dysfunction, and therapy with brentuximab vedotin resulted in initial clinical benefit. Brentuximab vedotin is being investigated in patients with advanced systemic mastocytosis or mast cell leukemia.

Backround: Mastocytosis is a rare disease with a variable clinical course. Pure red cell aplasia has not been frequently reported in association with aggressive systemic mastocytosis. CD30 is often expressed on mast cells in systemic mastocytosis. The CD30-directed antibody-drug conjugate brentuximab vedotin has shown in vitro activity against CD30-positive neoplastic mast cells. We describe a case of systemic mastocytosis with the development of severe hemolytic anemia, pure red cell aplasia, and evidence of weak bone marrow CD30 positivity. Brentuximab vedotin was administered with some evidence of clinical benefit.

Patient: A 64-year-old man presented with fatigue and a 20 pound weight loss. He was found to have transfusion-dependent anemia, a low reticulocyte count, and splenomegaly. Evaluation for gastrointestinal blood loss was unremarkable. Bone marrow biopsy showed mast cell aggregates, spindle-shaped mast cells, CD-2 and CD25-positivity, increased myelopoiesis and dysmegakaryopoiesis, red cell aplasia, eosinophilia, and increased reticulin fibrosis. The D816V c-kit mutation was present, and serum tryptase level was elevated at 114 ng/mL. He later developed Coombs-positive hemolysis and direct hyperbilirubinemia, concerning for mast cell liver infiltration.

Intervention: The patient received high-dose steroids and red blood cell transfusions. Interferon alpha and cladribine were contraindicated, given severe liver dysfunction. He was started on hydroxyurea. He received a dose of brentuximab vedotin 1.8 mg/kg IV. Thirteen days after starting steroids and 10 days after brentuximab, haptoglobin became detectable, and total bilirubin decreased to 18.4 mg/dL from 40.5 mg/dL. Red blood cell transfusion requirements decreased. He then developed severe neutropenia, pneumonia with sepsis, and respiratory failure, requiring intubation, maximal pressor support, and broad-spectrum antibiotics. Despite these measures, he expired.

Discussion/Conclusion: This is a rare case of pure red cellaplasia in the setting of aggressive systemic mastocytosis. Therapeutic options were limited in the setting of liver dysfunction, and therapy with brentuximab vedotin resulted in initial clinical benefit. Brentuximab vedotin is being investigated in patients with advanced systemic mastocytosis or mast cell leukemia.

Backround: Mastocytosis is a rare disease with a variable clinical course. Pure red cell aplasia has not been frequently reported in association with aggressive systemic mastocytosis. CD30 is often expressed on mast cells in systemic mastocytosis. The CD30-directed antibody-drug conjugate brentuximab vedotin has shown in vitro activity against CD30-positive neoplastic mast cells. We describe a case of systemic mastocytosis with the development of severe hemolytic anemia, pure red cell aplasia, and evidence of weak bone marrow CD30 positivity. Brentuximab vedotin was administered with some evidence of clinical benefit.

Patient: A 64-year-old man presented with fatigue and a 20 pound weight loss. He was found to have transfusion-dependent anemia, a low reticulocyte count, and splenomegaly. Evaluation for gastrointestinal blood loss was unremarkable. Bone marrow biopsy showed mast cell aggregates, spindle-shaped mast cells, CD-2 and CD25-positivity, increased myelopoiesis and dysmegakaryopoiesis, red cell aplasia, eosinophilia, and increased reticulin fibrosis. The D816V c-kit mutation was present, and serum tryptase level was elevated at 114 ng/mL. He later developed Coombs-positive hemolysis and direct hyperbilirubinemia, concerning for mast cell liver infiltration.

Intervention: The patient received high-dose steroids and red blood cell transfusions. Interferon alpha and cladribine were contraindicated, given severe liver dysfunction. He was started on hydroxyurea. He received a dose of brentuximab vedotin 1.8 mg/kg IV. Thirteen days after starting steroids and 10 days after brentuximab, haptoglobin became detectable, and total bilirubin decreased to 18.4 mg/dL from 40.5 mg/dL. Red blood cell transfusion requirements decreased. He then developed severe neutropenia, pneumonia with sepsis, and respiratory failure, requiring intubation, maximal pressor support, and broad-spectrum antibiotics. Despite these measures, he expired.

Discussion/Conclusion: This is a rare case of pure red cellaplasia in the setting of aggressive systemic mastocytosis. Therapeutic options were limited in the setting of liver dysfunction, and therapy with brentuximab vedotin resulted in initial clinical benefit. Brentuximab vedotin is being investigated in patients with advanced systemic mastocytosis or mast cell leukemia.