Mucositis Prevention:

An Evidenced-Based Protocol!

Prophylactic Cryotherapy Treatment Protocol

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Jacob N. Qurashi - 6 November 2013"

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Introduction!
Mucositis, a painful inflammation and ulceration of the gastrointestinal mucosa, is a reality for patients receiving chemotherapy and radiotherapy treatment as part of their myeloablative treatment before haematopoietic stem cell transplantation. In respect of the principle of nonmaleficence, which obliges clinicians to minimise inevitable harm patients endure when receiving cancer treatment, clinicians must find ways to help decrease the severity or eliminate mucositis and the sequelae that follows in its wake. With greater than three fourths of stem cell transplant patients suffering from mucositis, an alternative to traditional treatment is needed:

cryotherapy. The pathophysiology supporting cryotherapy centres on the vasoconstrictive property of cold; just as epinephrine prevents local lidocaine from entering the vasculature and spreading systemically; so, too, cryotherapy prevents systemic chemotherapy treatment from leaving the vasculature and attacking the mucosa (Svanberg, hrn, & & Birgegrd, 2010).

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Population, Intervention, Comparison, Outcome! The clinical question was posed: in patients receiving myeloablative (chemo/ radiotherapy) treatment, does prophylactic oral care prior to and status post chemo/ radiotherapy treatment decrease cases of mucositis as compared to patients who do not receive oral care prior to and status post chemo/radiotherapy? A review of literature

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identies cryotherapy as an effective collaborative intervention to prevent mucositis without adverse long term effects (Svanberg et al., 2010; Svanberg et al., 2012). This document outlines the clinical protocol for prophylactic cryotherapy, education for nursing and medical staff, education for patients, and a timeline for the implementation of this new procedure. Additional references and an assessment algorithm follow this document. This protocol is currently a proposal, pending approval from both the clinical nursing director and the medical director. While cryotherapy is a collaborative intervention, one requiring a physician or an advanced practise providers order, the assessment of potential clients who may benet from this therapy and the recommendation to initiate are responsibilities of the bedside and charge nurse and fall under their role as both clinician and advocate.!

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Protocol!
! The Prophylactic Cryotherapy Treatment Protocol (PCTP) begins with screening

patients who could potential benet from cryotherapy: any patient receiving chemo/ radiotherapy treatment. After an initial screening, the nurse will complete a focused assessment. If the patient is not a candidate for PCTP, the nurse will submit the assessment to the advanced practise provider (APP) who will determine which alternative therapy will be initiated. In the two weeks to follow myeloablative treatment the patient will be closely monitored for severity of mucositis using the World Health Organisation Mucositis Grading Scale (Svanberg et al., 2010).!

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Screening and Assessment! ! Upon admission, all patients will be screened by the nurse to determine if PCTP is

warranted. The initial screening will have both a subjective and objective component. In the subjective portion of the questionnaire, the client will describe if they have ever received cryotherapy treatment before, and elaborate on their experience including, tolerance, sensation, and preference. The component completed by the nurses reviews the clients admitting diagnosis, cancer diagnosis, type of transplantation, and an evaluation of clientss competence as a requirement of completing the regimen. If the client passes the initial screening, a focused assessment will be conducted to determine if the client meets any exclusion criteria which would contraindicate PCTP. Exclusion criteria includes: sensitivity or allergy to cold, diagnosis of Raynauds Disease, cryoglobulinaemia, cold haemoglobinuria, those cognitively unable to comply with treatment (Chailler, Ellis, Stolarik, & Woodend, 2010). If the client meets any of the exclusion criteria, the APP should be notied and an alternative therapy may be initiated for the clients mucosoitis prophylaxis.!

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Intervention! ! If the client passes the screening and assessment, the client will be scheduled for

cryotherapy education to begin one day before myeloablative therapy. Education will include the purpose of the therapy, the importance of compliance, duration, and potential

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complications. On the day of myeloablative therapy, the patient will be reminded of the regimen and will begin cryotherapy treatment:!

Client will perform oral hygiene one hour before start of myeloablative treatment!
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Rationale: cleaning the mouth removes debris and promotes oral hygiene; this study is ranked level 4B on the Johns Hopkins Scale of non research articles (Sargeant & Chamley, 2013; Nursing World, 2013)!

Client will thoroughly rinse mouth with sterile water!

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Rationale: cleaning the mouth removes debris and promotes oral hygiene.(Sargeant & Chamley, 2013)!

Nurse will provide ice chips and ice cold water to the client and commence myeloablative treatment!

Client will pack and hold ice chips in mouth for twenty minutes then swish cold water around oral cavity for ve minutes repeating ice and cold water cycles throughout chemo/radiotherapy treatment.!
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Rationale: the oral cavity must remain cool throughout treatment to constrict blood ow to oral mucosa thus limiting myeloablative treatment circulation; twenty minute periods are used for patient comfort and cold tolerance; a study of this calibre ranks as Level B evidence, cryotherapy for mucositis prophylaxis is level 1B evidence on the Johns Hopkins scale and the cyclic use of cold to reduce pain ranks B,the second highest rank of evidence available for clinicians, on the AACN scale (Svanberg et al., 2010; Chailler et al., 2010; Nursing World, 2013; Armola et al., 2009).!

Nurse will provide client with support and additional ice chips as needed!

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Nurse and client will repeat process for every round of myeloablative treatment!

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Implementation!
! After approval, clinical managers, clinical educators, charge nurses, three

staff nurses from each shift, one APP, and a supportive care physician will attend a Mucositis Champions class where they will receive PCTP education focusing on client preparation and education, nurse colleague education, physician and APP education, and information on where to nd a hard copy of the protocol as well as contact information for the protocols administrator. After the Mucositis Champions are trained, general education will start for the remaining staff nurses, APPs, and medical staff. Staff nurses responsible for administering cryotherapy treatment will be checked off prior to administration. Once all staff, APPs, and physicians are on board, PCTP can be used to treat patients.!

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Mucositis Champions! ! Mucositis Champions (MC) will be selected to facilitate initiation of PCTP.

Staff nurses selected will be those already approved to precept new employees, having demonstrated their competence to mentor and teach. An MC will be present with a staff nurse for their rst education and initiation of PCTP.

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Additionally, MCs will serve as advocates for clients if providers are disinclined to initiate cryotherapy treatment for their patients. A monthly MC meeting will occur to discuss challenges to implementation, solutions, and progress reports.!

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Nursing Education! ! All staff nurses will attend an PCTP inservice and sign off on their

understanding of the new process. Afterwards, they will work with the clinical educator or an MC to provide patient education for cryotherapy treatment. Additionally, PCTP will be added to the shift huddle announcements and reminders will be added to the bulletin boards and On the John training memorandums in the staff restrooms. Nurses will have a MC present for their rst cryotherapy treatment administration.!

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Physician and APP Education! ! The protocol administrator along with the APP representative MC will

provide education and training for the physicians and APPs. Physicians will be briefed on the APPs role in identifying alternative therapies if the patient does not meet criteria for PCTP. Additionally, they will be informed that PTCP is a standing protocol, one that must have an explicit signed physician order to prevent initiation by the bedside nurse. Both providers will be encouraged to support this evidencebased protocol. !

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Patient Education! ! Patients will receive information about PTCP at three different times: upon

admission, the day prior to administration, and the day of administration. All patients are educated about expectations and practises upon admission; PCTP will be included in the material given while discussing myeloablative treatment. The day before and the day of treatment, patients will receive in depth teaching about PCTP, their role in their treatment, what they can expect of staff, and the importance of compliance. MCs are available to assist with education as needed.!

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Approval!
! The Evidence-Based Practise Committee (EBPC) developed and approved

this protocol for use in the inpatient Haematopoietic Stem Cell and Bone Marrow Transplantation Unit (SCU). This protocol is pending approval from the Transplantation Services Clinical Director and the Medical Director of the SCU. An implementation timeline can be found in Appendix.!

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References!
Armola, R.R., Bourgault, A.M., Halm, M.A., Board, R.M., Bucher, L., Harrington, L., ! ! ! Medina, J. (2009). AACN levels of evidence: Whats new. Critical Care Nurse, 29(4), 70-73.!

Chailler, M., Ellis, J., Stolarik, A., & Woodend, K. (2010). Cold therapy for the management of pain associated with deep breathing and coughing post-cardiac surgery. Canadian Journal Of Cardiovascular Nursing, 20(2), 18-24.! Nursing World. (2013). Retrieved from American Nurses Association: http:// www.nursingworld.org/DocumentVault/NursingPractice/Research-Toolkit/ JHNEBP-Research-Evidence-Appraisal.pdf Sargeant, S., & Chamley, C. (2013). Oral health assessment and mouth care for children and young people receiving palliative care. Part two. Nursing Children & Young People, 25(3), 30-33.! Svanberg, A., hrn, K., & Birgegrd, G. (2012). Five-year follow-up of survival and relapse in patients who received cryotherapy during high-dose chemotherapy for stem cell transplantation shows no safety concerns. European Journal Of Cancer Care, 21(6), 822-828. doi:10.1111/ecc.12009 ! Svanberg, A., hrn, K., & Birgegrd, G. (2010). Oral"cryotherapy reduces"mucositis and improves nutrition -- a randomised controlled trial. Journal of Clinical Nursing, 19(15-16), 2146-2151. doi:10.1111/j.1365-2702.2010.03255.x

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Appendix!

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11/8/2013 PCTP approved by Clinical Director

11/6/2013 PCTP approved by EBPC

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11/26/2013 PCTP Go Live! Day 11/21/2013 Nursing Staff Training 11/18/2013 PCTP approved by Medical Director

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11/19/2013 First Mucositis Champions Meeting and training

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11/22/2013 Medical Staff Training

12/26/2013 MC Monthly Eval Meeting

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