Clinical depression and anxiety are reported in approximately 30% of stem cell transplant patients prior to their transplant. This distress is also similar to that of patients diagnosed with post-traumatic stress disorder, according to Shannon Farley, MN-NP Adult, BScN, CCRP, CON(C).
Farley, an adult medical oncology nurse practitioner in the William Osler Health System, demonstrated that institutions must take into consideration a patient’s mental health prior to stem cell transplants in her presentation on improving inpatient outcomes at the 37th Annual Chemotherapy Foundation Symposium Nursing Track.
Patients stay with Farley’s clinic in Brampton, Canada, a smaller city compared to the like of Toronto, for 2-3 weeks. This was where Farely encountered patients displaying complications and a readmission rate atypical of 23% versus an average oncology readmission rate of 7%-9%. This led Farely to take a closer look at some of the behaviors of her patients.
The 2 example cases presented were given the nicknames “Mr. No Thanks” and “Mr. Silent”. “Mr. No Thanks”, often refused palliative measures and advice from his care team while “Mr. Silent”, pre-screened prior to his transplant treatment, came in wearing diapers and did not discuss his treatment. Both developed complications that Farely had to find novel treatments for, and in the case of “Mr. Silent” he developed diarrhea requiring IV replacement, Lomotil, and loperamide.
Diarrhea was not a complication previously disclosed in any pre-screening, and based on these examples, Farely wanted to see other possible factors that might impact her patient’s quality of life and behavior, leading her to investigate clinical depression and anxiety in patients undergoing stem cell transplant therapy. In her findings, she found that after patients undergo stem cell transplant patients have higher depression 3 times that of their oncological survivor peers.
Identifying this depression also showed how depression impacted the quality of life (QoL) of patients recovering from stem cell transplant therapy. These include common adverse events like stress, nausea, and pain, but also a strong association with distress and inflamed cytokines that can delay engraftment and make patients more prone to infection.
“What I was finding with my patients was that depression was predictive of how long they were going to be hospital, it was predictive of the morbidity of the treatment, and of how they were going to do afterward,” said Farley. Armed with this information Farley and her team worked on solutions to help their patients prior to experience distress from their treatment without the care team realizing.
The solutions began with screening for depression utilizing validated distress tools, such as the Edmonton Symptom Assessment System (ESAS) and the Distress Thermometer, to screen for depression in all patients that came in for recovery. Her team also developed a distress management team of experts that could work with every patient, with the goal in mind to refer patients that need this distress care at admission, and not later on in their recovery.
Farley’s small team created a triage referral system for psychosocial distress prior to their stem cell transplant based on the ESAS test. Any patient with a score greater of 4 was given psychosocial treatment upon their admission. Patients with a score reporting between 0-3 worked with their nurse and social worker, per the standard care at the hospital. Patients reporting score 4-6 saw social work, spiritual care, and art therapy experts come on board. Patients with higher scores of 6-8 had psycho and pharmacotherapy, and any patients reporting scores 8-10 were given referrals to psychiatry outside of the clinic.
This program has only recently been implemented and has just begun collecting data to see if their interventions can change the length of stay and readmission rates of their patients. Describing their “homemade” solution Farley said, “inspiration can come in really surprising places, no idea is too small anybody can make a difference.”
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