Is there still an indication for nursing patients with prolonged neutropenia in protective isolation?: An evidence-based nursing and medical study of 4 years experience for nursing patients with neutropenia without isolation

doi:10.1054/ejon.2002.0216

European Journal of Oncology Nursing

Volume 7, Issue 1, March 2003, Pages 17-23

https://doi.org/10.1054/ejon.2002.0216 Get rights and content

Abstract

Patients with severe neutropenia due to high-dose chemotherapy and/or total-body irradiation are at risk of serious infections and are frequently nursed in strict protective isolation. This is a costly procedure and results in a psychological burden for the patient and its significance has been debated for a long time. The introduction of very potent systemic antibiotics, antibiotic prophylaxis, haematopoietic growth factors and peripheral stem cell transplantation might have decreased the need for it. We performed a systematic literature review and conducted a medical/nursing guideline study. In the literature we searched especially for prospective randomised studies. Only six were found, these were prospective randomised studies and contradicted each other on the usefulness of protective isolation.

In an initiative aimed at promoting evidence-based care, we conducted a combined medical and nursing guideline study consisting of three parts: (1) inventory of (inter) national guidelines; (2) analysis of potential sources of infection; and (3) follow-up study post-implementation of new guidelines.

Results: (1) The practices in different centres in Europe appeared to vary widely. (2) Micro-organisms spread easily, especially if hands are not adequately dried. Isolation does not prevent this. Based on these findings we decided to stop protective isolation. This change of policy was combined with a campaign for optimal hygiene and introduction of hand alcohol. (3) We monitored the incidence of febrile neutropenia, infections and use of systemic antibiotics and antifungals in a 3-year period without protective isolation and compared this with the findings in the preceding 3 years with isolation. No significant differences in infections and mortality were found. We concluded that abandoning protective isolation combined with increased hygienic measures in nursing of patients with severe neutropenia does not increase the risk of infections, but improves the quality of care and patient satisfaction and reduces costs.

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Febrile neutropenia
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The lived experience of patients in protective isolation during their hospital stay for allogeneic haematopoietic stem cell transplantation
2016, European Journal of Oncology Nursing
Citation Excerpt :
The extent to which the isolation is implemented depends on the neutrophil count but varies drastically across centres and countries (Bevans et al., 2009; Hicheri et al., 2013; Lee et al., 2008). However, there is growing evidence showing its limited efficacy (Mank and van der Lelie, 2003; Russell et al., 2000), together with the clinical benefits for patients if cared for at home, such as lower incidence of acute graft-versus-host disease (GVHD), better nutritional status (Svahn et al., 2008), and also a higher survival rate (Bergkvist et al., 2013; Ringden et al., 2013). Thus, innovative models of outpatient care have been developed for selected transplant patients and the role of home care versus hospital care has been investigated by a growing number of studies (Cantú-Rodríguez et al., 2016; Faucher et al., 2012; Fernández-Avilés et al., 2006; Paul et al., 2015; Schlesinger et al., 2009; Solomon et al., 2010).
Patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT) usually receive hospital care in protective isolation until full neutrophil recovery. Although the aim of protective isolation is to benefit patients' health by preventing risks of infection, it could have severe psychological implications. The aim of this study was to explore the lived experiences of protective isolation in adult patients who had been treated with allogeneic HSCT.
A descriptive phenomenological inquiry based on Giorgi's approach was conducted in a university hospital in Italy. Ten patients (7 female and 3 male, age range 28–66), who had undergone allogeneic HSCT to treat a haematological malignancy, were interviewed about their hospital stay in protective isolation.
A general meaning structure was identified as being isolated to achieve transformation. The revelatory themes were as follows: (1) the special place for transformation, (2) the experience of embodied transformation, and (3) light and shade from inside and outside. Participants experienced a transformation of themselves, of their relationships with loved ones, and of the environment.
Since patients may live the experience of being treated with allogeneic HSCT in protective isolation as a transformation process, health-care providers should monitor the psychosocial implications of the isolation practice.
Infection control practices in patients with hematological malignancies and multidrug-resistant organisms: Special considerations and challenges
2014, Clinical Lymphoma, Myeloma and Leukemia
Citation Excerpt :
These reverse isolation procedures were used to protect patients from the outside environment, especially from airborne and waterborne sources of bacteria.5,6 However, because most infections in neutropenic patients are attributable to their endogenous flora, many of these practices were of no benefit in reducing infection and have been mostly abandoned,7-11 with the exception of prophylactic antibiotics,12 and the use of controlled ventilation systems with continuous pressure monitoring and high-efficiency particulate air filters.13 Standard precautions, which include hand hygiene, safe injection practices, and the use of gowns, gloves, masks, and eye protection, depending on the type of exposure, constitute the core stratagems to prevent infection.14
Infectious complications contribute greatly to morbidity and mortality in patients with hematological malignancies. As these patients undergo prolonged chemotherapy and are in frequent contact with health care settings, they are at high risk for nosocomial and health care-associated infections. This long-term relationship with the hospital setting represents a major opportunity for infection prevention. In this review, we describe several infection control strategies that are currently used to reduce the transmission of hospital-acquired infections in patients with hematological malignancies, particularly infections with multidrug-resistant organisms.
Febrile neutropenia
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Analysis of the feasibility of early hospital discharge after autologous hematopoietic stem cell transplantation and the implications to nursing care
2014, Revista Brasileira de Hematologia e Hemoterapia
Citation Excerpt :
Pancytopenia although long-lasting is restored by the HSC infusion but corresponds to from 5% to 10% of myeloablative regimen-related deaths.24 A study by Mank and Van Der Lelie25 that assessed infection and mortality, demonstrated that HSCT is possible without patients being confined to hospital and thus, early hospital discharge is possible. Febrile neutropenia often lasts for three weeks or more26 and, in this study it occurred in 58% of the patients before bone marrow engraftment.
Autologous hematopoietic stem cell transplantation is a conduct used to treat some hematologic diseases and to consolidate the treatment of others. In the field of nursing, the few published scientific studies on nursing care and early hospital discharge of transplant patients are deficient. Knowledge about the diseases treated using hematopoietic stem cell transplantation, providing guidance to patients and caregivers and patient monitoring are important nursing activities in this process. Guidance may contribute to long-term goals through patients’ short-term needs.
To analyze the results of early hospital discharge on the treatment of patients submitted to autologous transplantation and the influence of nursing care on this conduct.
A retrospective, quantitative, descriptive and transversal study was conducted. The hospital records of 112 consecutive patients submitted to autologous transplantation in the period from January to December 2009 were revisited. Of these, 12 patients, who remained in hospital for more than ten days after transplantation, were excluded from the study.
The medical records of 100 patients with a median age of 48.5 years (19–69 years) were analyzed. All patients were mobilized and hematopoietic stem cells were collected by leukapheresis. The most common conditioning regimes were BU12Mel100 and BEAM 400. Toxicity during conditioning was easily managed in the outpatient clinic. Gastrointestinal toxicity, mostly Grades I and II, was seen in 69% of the patients, 62% of patients had diarrhea, 61% of the patients had nausea and vomiting and 58% had Grade I and II mucositis. Ten patients required hospitalization due to the conditioning regimen. Febrile neutropenia was seen in 58% of patients. Two patients died before Day +60 due to infections, one with aplasia. The median times to granulocyte and platelet engraftment were 12 days and 15 days, respectively, with median red blood cell and platelet transfusions until discharge of three and four units, respectively. Twenty-three patients required rehospitalization before being discharged from the outpatient clinic.
The median time to granulocyte engraftment was 12 days and during the aplasia phase few patients were hospitalized or suffered infections. The toxicity of the conditioning was the leading cause of rehospitalization. The nursing staff participated by providing guidance to patients and during the mobilization, transplant and outpatient follow-up phases, thus helping to successfully manage toxicity.
Research priorities in haemato-oncology nursing: Results of a literature review and a Delphi study
2009, European Journal of Oncology Nursing
The study aimed to review the nursing haemato-oncology literature followed by a Delphi study to determine research priorities of UK nurses working in haemato-oncology.
The review analysed relevant literature from 1996–2008. In the Delphi study, all members of the Royal College of Nursing (UK), Haematology and Bone Marrow Transplant Forum (n = 1444) were invited to participate. Data were collected in three sequential rounds of postal questionnaires. Research topics identified in round 1 were used to compile subsequent questionnaires.
A final list of 33 research priorities was identified. Clear research themes emerged from the data including chemotherapy, psychosocial issues and information giving, psychological support needs of nurses, ethical considerations and palliative care, nurse-led services and guidelines.
Results show both similarities and differences to priorities identified in previous haemopoietic stem cell transplant and cancer nursing studies. Further exploration of priority areas is required but priorities identified in this study provide a good starting point for further exploration and development of research programmes.

View all citing articles on Scopus

^f1: Correspondence and offprint requests to: Arno Mank

^f2: Phone: 31 20 5666090

^f3: Fax: 31 20 5669030

^f4: [email protected]

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Regular ArticleIs there still an indication for nursing patients with prolonged neutropenia in protective isolation?: An evidence-based nursing and medical study of 4 years experience for nursing patients with neutropenia without isolation

Abstract

American Journal of Medicine

Journal of Hospital infection

American Journal of Medicine

Biology of Blood and Marrow Transplantation

Lancet

Feelings of oncology patients about being nursed in protective isolation as a consequence of cancer chemotherapy treatment

Journal of Advanced Nursing

Reverse isolation: what patients perceive

Oncology Nursing Forum

Psychological effects of isolation nursing (1): mood disturbance

Nursing Standard

Infection prevention in autologous bone marrow transplantation and the role of protective isolation

Bone Marrow Transplantation

Reverse barrier nursing. Care of patients with bone marrow depletion

Nursing Times

The psychological effects of isolation in protected environments

American Journal of Psychiatry

Protected environments and prophylactic antibiotics. A prospective controlled study of their utility in the therapy of acute leukemia

New England Journal of Medicine

Regular Article
Is there still an indication for nursing patients with prolonged neutropenia in protective isolation?: An evidence-based nursing and medical study of 4 years experience for nursing patients with neutropenia without isolation