A Prospective Initiative to Reduce Mucosal Barrier Injuries and Blood Stream Infections in Patients with Hematologic Malignancy Receiving Inpatient Chemotherapy
Authors: Reed Daniel R , Ruefer Katie E , Thomas Tanya D , Harr Erin L , Daniels Elizabeth R , Sen Jeremy M , Keng Michael K 
Published: October 2019

Abstract
Introduction: A dangerous consequence of chemotherapy used to treat patients with hematologic malignancy is the breakdown of intestinal and oral mucosa known as MBI (mucosal barrier injury). In the setting of neutropenia, this can lead to life-threatening laboratory confirmed blood stream infections (LCBI) from translocation of bacteria. This results in increased length of stay, ICU admissions, and decreased quality of life for patients. Sparse evidence exists to guide clinicians on interventions to help prevent and treat MBI and reduce its complications.
Methods: In an attempt to reduce MBI-LCBI events, a multidisciplinary team including oncology physicians, nurses, and pharmacists was assembled. A retrospective chart review from 1/2015 to 12/2015 was completed to establish a baseline for MBI-LCBI rate. This rate was calculated by dividing the number of MBI-LCBI events by total number of patients on the malignant hematology wards receiving inpatient chemotherapy treatment. The average MBI-LCBI rate was 0.01. While there is no published national average MBI-LCBI rate, we aimed to decrease this rate by 75%. LEAN principles were applied to approach the problem. A statistical process chart (p-chart) was used to depict rates of MBI-LCBI in baseline cohort and intervention groups.
Results: The baseline MBI-LCBI rate was found to be 0.01. Through LEAN methodology with analysis of an A3 and outlining "5 whys," a number of root causes leading to increased MBIs were identified. These included: accessibility of necessary supplies needed for compliance with standard work, availability of the oral care kits, importance of on-going education related to appropriate care and maintenance practices. The multidisciplinary team focused on 2 main interventions to improve MBI-LCBI rate. One Plan Study Do Act (PDSA) cycle was completed and post intervention data was analyzed. In March of 2016 the first intervention implemented was a robust education plan for nursing, including instructions for grading mucositis based on WHO criteria and completing through oral assessments marking the first PDSA cycle. Through further analysis of an A3, oral care was identified as a potential intervention in decreasing MBIs. A second intervention of oral care bundle, consisting of sodium bicarbonate mouth wash, artificial saliva, scheduled nursing oral assessments and teeth brushing, was implemented on May of 2016. After one year of implementation of PDSA cycle 1 the MBI rate (0.003 MBI-LCBIs per month) was reduced by 70% from baseline (Figure 1). This was not sustainable and ultimately after completion of first cycle in March of 2018 the average MBI-LCBI rate was found to be 0.009 which was still reduced from the baseline event rate of 0.01 MBI-LCBI per month.
Conclusions: Through a multidisciplinary effort, the rate of MBI-LCBIs were able to be reduced through interventions in both education of nursing and physician staff and focus on oral care in patients. While there was initially significant success, it is apparent towards the end of PDSA cycle 1 there was difficulty with sustainability. There was a reduction in the number of oral care bundle ordered and therefore currently a second PDSA cycle is underway with a nurse driven oral care order set. Further focus in prevention, sustainability support structures (nurse driven protocol implementation) and reducing MBI rate is important in decreasing morbidity and mortality in this patient population.

Disclosures
No relevant conflicts of interest to declare.