Rev4 NP

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University of Colorado Hospital Clinical Nursing Guideline

Bone Marrow Transplant Unit: Neutropenic/Immunocompromised
Management for Hematopoietic Stem Cell Transplant Patients

Related Policies and Procedures:
Standard Precautions
Hand Hygiene-Outside the Surgical Setting
Hospital Infection Control
Isolation/Transmission Based Precautions
Blood/Body Fluid Spills
Aseptic Technique in Invasive and Operative Procedures
Clean/Sterile Supply Storage in Clinical Areas
Infectious/Regulated Waste Management
Employee Work Restrictions for Infectious Diseases
Live Plant and Flower Restrictions
Diet Restrictions and Recommendations for the Hematology and Oncology
Immunocompromised Patient
Central Venous Lines
Animal Assisted Activities/Therapy Program

Approved by: .
Bone Marrow Transplant Medical Director: Clay Smith, MD
Nurse Practitioner: Glen Peterson, RN, ACNP-BC, DNP
Clinical Nurse Specialist Educator: Barbara Wenger, RN, MS, AOCNS, CRNI

Pharmacist: Jeff Kaiser, Pharm. D
Bone Marrow Transplant Outpatient Educator: Erin Stohner, RN

Effective: 5/14

Description: This guideline defines Neutropenia, as well as febrile neutropenia, and the
necessary assessment parameters, guidelines, interventions, and environmental modification that
must be implemented by University of Colorado Hospital health care providers in UCH clinical
settings when caring for neutropenic/immunocompromised Hematopoietic Stem Cell Transplant
Patients.

Accountability: All University of Colorado Hospital employees, physicians, volunteers,
students, temporary and contract employees are responsible for complying with the
precautions/measures described in this policy/procedure. Visitors and other non-hospital-
employee personnel will be informed of and asked to comply with the provisions of this policy
by the University of Colorado Hospital staff. Non-compliance will be dealt with on an
individual basis.

Definitions:
Neutrophils are the bodys first line of defense against microbial invasion. They constitute
Pamela Heinke 5/1/14 2:04 PM
Wenger, Barbara 4/30/14 1:02 PM
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approximately 40%-60% of the total white blood cell count that usually ranges from
4,000-10,000/mm
3
.
ANC = WBC count * ((PMNs/100) + (Bands/100))
ANC: absolute neutrophil count
WBC: white blood cell
PMN: polymorphonuclear cell
Neutropenia is defined as an absolute neutrophil count (ANC) less than 500/mm
3
.
1. The relative risk for infection increases as the ANC decreases. The ANC is categorized into
grades, which reflect the risk for infection.
a. Grade 1: ANC 1500-2000/mm
3
= No Significant Risk
b. Grade 2: ANC 1000-1500/mm
3
=Slight Increase in Risk
c. Grade 3: ANC 500-1000/mm
3
=Moderate Risk=Neutropenia
d. Grade 4: ANC less than 500/mm
3
=High Risk=Neutropenia

Signs and Symptoms of Infection
1. Localized symptoms of infection: pain at the site of infection that may or may not include
erythema or exudate.
2. Generalized symptoms of infection: chills, myalgias, arthralgias, cognitive or mental status
changes, anorexia, nausea/vomiting, fatigue, tachycardia, hypotension, tachypnea,
hypoxemia, oliguria, and fever.
3. Site-Specific symptomatology/exam findings: cough, dyspnea, abnormal breath sounds oral
pain, back pain, rigors, rectal discomfort with bowel elimination, pain at vascular access
device site, burning/urgency with urination.
Sources of Infection
1. The skin and mucous membranes are vulnerable sources of microbial invasion due to
IV/Central line access and mucositis. Additional risk factors include GVHD (Graft versus
Host Disease), and toxicities from conditioning regimens that cause prolonged neutropenia
(10-30 days).
2. Primary sites of infection in the neutropenic patient are the digestive tract (mouth, pharynx,
esophagus, large and small bowel, rectum), as well as the sinuses, lungs, and skin.
3. Hand hygiene is considered the most important procedure to prevent the spread of infections.
Refer UCH Policy and Procedure: Hand Hygiene-Outside The Surgical Setting.

Table of Contents:
I. Assessment Parameters
II. Nursing Intervention for Treatment of Febrile Neutropenia
III. Neutropenic Precautions Sign, Appendix A
IV. ED Approach to Patient with Possible Neutropenic Fever, Appendix B

Policy/Procedure:
Policy
The frequency and severity of infection are inversely proportional to the Absolute Neutrophil
Count; the risks of severe infection and bloodstream infection are greatest when the neutrophil
count is less than 100/mm
3
. For Patients undergoing HSCT, neutropenia can last from 10-30
days, which is consistent with the therapeutic goal of destroying malignant cells within the bone
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neutropenia lasting 7-10 days and are at much lower
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marrow; therefore, the intent of treatment is grade 4 neutropenia. After the neutrophil count
recovers, humoral and cellular immune dysfunction may persist, maintaining susceptibility to
infection for months. Approximately 48% to 60% of neutropenic patients who are febrile have
an established or occult infection. Approximately 10-20% of patients with a neutrophil count
less than 100/mm
3
will develop a bloodstream infection. Ineffective management of febrile
neutropenia can result in delayed treatment potentially resulting in sepsis, septic shock, and
poorer patient outcomes. Proactive management of neutropenia is critical to decreasing the
depth and duration of neutropenia following HSCT, limiting exposure to opportunistic and
nosocomial pathogens, and ensuring prompt intervention should febrile neutropenia or infection
develop.

Procedure
I. Assessment Parameters
A. Fever (single oral temperature greater than or equal to 38.3 degrees Celsius or
temperature greater than 38 degrees Celsius sustained for greater than one hour) is
usually the first and only sign of a potentially life-threatening infection. Localized
symptoms of infection such as redness, swelling, pain, and exudate may not be
present due to the inability of the patients body to create an inflammatory response
resulting from the absence or decreased number of neutrophils.
1. Although uncommon, a patient with neutropenia and signs or symptoms of
infection (i.e. abdominal pain, severe mucositis, perirectal pain) without fever,
should be considered to have an active infection.

B. Assessment Guidelines
1. Determine expected duration and severity of neutropenia
a. Consider the patients current and past treatment regimens including one or
more of the following: chemotherapy, radiation therapy, immunotherapy,
immunosuppressive therapy, HSCT.
b. Consider the patients comorbitities, medications, history of prior documented
infections, recent antibiotic therapy, exposure to infections from household
members, pets, travel (including Tuberculosis exposure), HIV status, and
recent blood product administration.
2. Assess for common sites of infection in patients with fever and neutropenia: the
alimentary tract, groin, skin, lungs, sinus, ears, perivagina, perirectum, and
vascular access device sites
3. Monitor vital signs (T,P,R,BP) Q4h or more often depending on clinical situation
(Provider decision)
4. Monitor Intake and Output Q4h
5. Obtain BID weights on all active HSCT patients and all HSCT that are readmitted
post transplant.
6. Monitor laboratory data:
a. CBC with differential, including WBC count. If ANC less than 1000, institute
neutropenic precautions. Refer to Neutropenic Precautions sign (Appendix
A).
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for all of these.
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b. Comprehensive Metabolic Panel, LDH, Uric Acid, Creatinine, BUN, LFTs,
Total Serum Bilirubin, and lactate as ordered by provider.
c. Blood and other Culture Reports-notify Provider if positive and institute
appropriate transmission based precautions if necessary. Refer to UCH Policy
and Procedure: Isolation/Transmission Based Precautions.
d. Consult Provider for potential chest x-ray, urinalysis, urine culture/sensitivity,
and pulse ox. Chest x-ray for all patients with respiratory symptoms.

II. Nursing Intervention For Treatment of Febrile Neutropenia
A. Febrile Neutropenia in HSCT patients
a. Patients admitted for HSCT are treated with prophylactic antibiotics prior to
becoming neutropenic and throughout the expected neutropenic state during
hospitalization. Once patients receive their stem cells, they may begin G-CSF
(Dual cord SCT or Autologous SCT) therapy to assist in WBC recovery.
Refer to EHR for details.
b. When a patient becomes febrile (a single oral temperature greater than
or equal to 38.3 degrees Celsius or temperature greater than 38 degrees
Celsius sustained for greater than one hour), refer to EHR , which indicate
obtaining a chest x-ray, urinalysis, urine culture and sensitivity, and at least
two sets of blood cultures. At least one of the two sets of cultures is to be
obtained from the patients vascular access device if present.
1. Collaborate with the Provider regarding obtaining one of the two sets of
blood cultures peripherally.
c. According to the 2013 NCCN guidelines, if there is entry or exit site
inflammation around the vascular access device; 1) obtain a set of blood
cultures from each lumen 2) swab exit site drainage (if present) for culture
and 3)Vancomycin should be considered. If the vascular access device
cultures are positive for infection, collaborate with the Provider regarding
obtaining further blood cultures from each lumen, removal of vascular access
device, and additional antibiotic therapy. Notify provider immediately if port
pocket infection is suspected. Do not access the implanted port if infection
is suspected due to increased risk of further infection.
d. If patient symptomatology warrants, collaborate with the Provider regarding
obtaining site specific cultures including rectal, stool, skin, mouth, throat,
sputum, and nasopharynx.
e. If patient continues to be febrile, blood cultures, chest x-ray, urinalysis, urine
culture and sensitivity are to be done only once every 24 hours.
f. Refer to pre-printed orders for fever day antibiotic instructions. Once the
patient is febrile (a single oral temperature greater than or equal to 38.3
degrees Celsius or temperature greater than 38 degrees Celsius sustained for
greater than one hour ), antibiotics are to be given according to Fever Day 1
instructions. Initiate antibiotic therapy within the hour of the fever but not
before obtaining blood cultures. DO NOT HOLD ANTIBIOTICS FOR
RESULTS FROM CHEST X-RAY AND/OR URINE TESTS (refer to RRFP
in Appendix C). For each subsequent fever not within consecutive 24 hour
periods, collaborate with Provider regarding antibiotics to start/discontinue. If
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pre-printed orders pre-printed
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EPIC documentation.
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a patient continues to be febrile for consecutive 24 hour periods, continue to
follow the pre-printed orders indicating which antibiotics to administer.
g. S/P Hematopoietic Stem Cell Transplant Patients returning to the hospital for
complications related to their transplant, including infection, are to be
directly admitted to the Hematopoietic Stem Cell Transplant unit when
possible. When a bed is not available, they are to wait at home until a bed is
ready or if their condition warrants, they are to go to the Emergency
Department and be placed in a private room if possible.
1. If patient is febrile, ED Provider is to collaborate with Provider regarding
ED Approach to Patient with Possible Neutropenic Fever (Appendix B)
2. If patient is being admitted through the ED or Inpatient due to a fever
refer to the BMT/HEME ED/INPATIENT RAPID RESPONSE FEVER
PROTOCOL (RRFP) (Appendix C)
B. Environmental Modification
1. All neutropenic patients are placed in private rooms. Patients admitted for HSCT
are to be placed in positive pressure rooms with HEPA filtration.
2. Neutropenia precaution sign is to be placed beside the door to alert staff and
visitors of infection prevention protocol/measures. Refer to Neutropenic
Precautions sign (Appendix A).

C. Protective Measures for Neutropenic Patients
1. Handwashing is the single most important intervention to prevent infection.
a. All persons entering the room will soap and wash hands at time of entry and
time of exit with either alcohol based gel or with soap and water for 15
seconds.
2. Anyone with symptoms of illness is to avoid contact with neutropenic patients.
When contact is unavoidable, staff/visitors are to wear masks when entering the
patients room and adhere to proper hand hygiene.
3. Children under the age of 12 are not to enter the Hematopoietic Stem Cell
Transplant unit regardless of the presence of neutropenic patients.
4. Once neutropenic, ANC less than 1000, these patients are to be instructed to wear
this mask whenever they leave their room.
5. HSCT patients who are under contact isolation due to their being infected with a
highly transmissible infectious organism, such as VRE and MRSA, are to remain
in their room at all times, unless required to leave their room for testing. In this
case, the patient is to wear appropriate PPE, including yellow gown, and gloves.
If the patient is neutropenic and/or under airborne/droplet precautions a mask is to
be worn
6. Avoid rectal maneuvers (rectal temperatures, enemas, rectal medications, rectal
tubes, digital exams) and urinary catheterizations.
7. Avoid breakdown of skin and mucous membranes by limiting venipunctures or
other invasive procedures. Cleanse and protect wounds that break the skin as
directed by the Provider.
8. Refer to the Diet Restrictions and Recommendations for the Hematology and
Oncology Immunocompromised Patient
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Deleted: <#>Solid Tumor Febrile
Neutopenia patients not undergoing HSCT
<#>Notify Physician Provider to obtain order
to draw two sets of blood cultures. One set is
to be drawn from the vascular access device if
present, and one set is to be drawn
peripherally. Obtain an order for urine
culture/sensitivity and chest x-ray.
<#>According to the 2007 NCCN guidelines,
if there is entry or exit site inflammation
around the vascular access device, a set of
cultures is to be obtained from each lumen
and Vancomycin should be started or added
to the existing empiric therapy. If the
vascular access device cultures are positive
for infection, collaborate with Physician
regarding obtaining further blood cultures
from each lumen, removal of the vascular
access device, and additional antibiotic
therapy
<#>Obtain order to start antibiotics. Initiate
antibiotic therapy within the hour of the fever,
but not before obtaining blood cultures. If
patient symptomatology warrants,
collaborate with Physician regarding
obtaining site specific cultures including
rectal, stool, skin, mouth, throat, sputum, and
nasopharynx.
<#>Collaborate with Physician regarding
initiating G-CSF therapy.
<#>Febrile Neutropenic solid tumor oncology
patients in the Emergency Department are to
be triaged according to the ED Approach to
Patient with Possible Neutropenic Fever
(Appendix B)
Deleted: Allogeneic Hematopoietic Stem
Cell Transplant patients are to be fitted for a N-
95 mask upon admission.
Deleted: (N-95 for allogeneic transplant
patients at all times, standard mask for
autologous transplant patients, unless a N-95 is
required for airborne/droplet precautions).
Deleted: Place patient on neutropenic diet
and ensure that patient receives bottled water.
Patients undergoing HSCT are not to receive
food prepared outside of the hospital due to the
potential for infection.
Deleted: Refer to Neutropenic Precautions
sign (Appendix A)
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9. Change urinals and hats when visibly soiled. Change nasal canulas, O2 masks
weekly and when visibly soiled.
10. Encourage consistent patient personal hygiene
a. Daily shower or bath, including shampooing head/hair. Use CHG wipes as
directed for central line care.
b. Change linens daily and more frequently if visibly soiled.
c. Routine oral care. Refer to UCH Hospital Guidelines regarding oral care.
11. Live plant and flowers are not allowed in the rooms of neutropenic patients whose
immune compromise is such that infection can be acquired from soil/plant
organisms. Refer to UCH Policy and Procedure: Live Plant and Fresh Flower
Restrictions.
12. Animals are restricted from the HSCT unit due to the potential infection risk for
the immunocompromised patient population. Refer to UCH Policy and
Procedure: Animal Assisted Activities/Therapy Program.

References:
1. Dellinger R.P., Levy M.M., Rhodes A, et al. (2012) Surviving sepsis campaign:
international guidelines for management of severe sepsis and septic shock: 2012.
Critical Care Medicine. 41(2):580-637. (LOE 7)
2. Marrs, J. (2006). Care of Patients With Neutropenia. Clinical Journal of Oncology Nursing,
10(2), 164-166. (LOE 8)
3. NCCN. (2013). Fever and Neutropenia-v.1.2013. NCCN Clinical Practice Guidelines in
Oncology. (CD). Jenkintown, PA: NCCN. (LOE 7)
4. Nirenberg, A., Bush, A.P., Davis, A., Friese, C.R., Gillespie, T.W., Rice, R.D. (2006).
Neutropenia: State of the Knowledge Part I/Part II. Clinical Journal of Oncology Nursing,
33(6), 1193-1201, 1202-1208. (LOE 1)
5. Shelton, B.K. (2003). Evidence-Based Care for the Neutropenic Patient with Leukemia.
Seminars in Oncology Nursing, 19(2), 133-141. (LOE 7)
6. Zitella, L., Friese, C., Hauser, J., Holmes, B.G., Woolery, M.A., OLeary, C., Andrews, F.
(2006). Putting Evidence Into Practice: Preventions of Infection. Clinical Journal of
Oncology Nursing, 10(6), 739-750. (LOE 1)

Appendix A

NEUTROPENIC PRECAUTIONS

WASH HANDS BEFORE PATIENT CONTACT
Visitors with cold symptoms or contagious illness should not visit patient at this time.
Patient MUST wear a mask when leaving room.

NO FRESH FLOWERS OR PLANTS.
DIETARY RESTRICTIONS INCLUDE:

Fresh fruit and vegetables ONLY if washed under running water prior to peeling, cutting, or
eating (berries and sprouts excluded)
Wenger, Barbara 3/31/14 10:37 AM
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IV tubing every 2 days. Refer to UCH Policy and
procedure: Lines, Central Venous for instructions
regarding dressing changes.
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Comment: Find updated source
Deleted: <#>Centers for Disease Control and
Prevention. (2003). Guidelines for Environmental
Infection Control in Healthcare Facilities, 2003
[Data file]. Available from Centers for Disease
Control and Prevention web site, www.cdc.gov.
(LOE I)
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Comment: OLD
Deleted: <#>West, F., Mitchell, S. (2004).
Evidence-Based Guidelines for the Management of
Neutropenia Following Outpatient Hematopoietic
Stem Cell Transplantation. Clinical Journal of
Oncology Nursing, 8(6), 601-613. (LOE IV)
Comment: BOOKS: BMT ONS book, Chemo
guidelines.
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NO soft cheeses, unpasteurized foods/fluids, or pepper (from pepper shakers or pepper mills)
NO undercooked or raw meat, fish, eggs, or tofu.
Unroasted nuts or nuts in a shell
Teas will be prepared directly by staff for patient by request.

PLEASE SEE THE NURSE IF YOU HAVE ANY QUESTIONS REGARDING THESE
PRECAUTIONS

Appendix B

ED Approach to Patient with Possible Neutropenic Fever

ED GOAL:
PLEASE PAGE THE BMT/HEME TEAM IMMEDIATELY UPON PATIENT TRIAGE
Pager: 303-266-4162
! To administer antibiotics within 1 hour of ED presentation for patients with ANC (absolute
neutrophil count) less than 1000 mm
3

! To recognize which patients require in-patient management and which can be safely
managed as outpatients

(see Risk Stratification, p. 10)
! To facilitate outpatient AND inpatient work-up and continuity with patients oncology team.
INTAKE PROCEDURE:
! Identify high risk patient at Pivot
Patient with oncology information card
Patient s/p chemotherapy/radiation treatment within 14 days
Patient s/p hematopoietic stem cell transplant
Oncology patient with fever or other vague c/o
! Provide and instruct suspected neutropenic patient to wear a mask
! Obtain patients weight
! Document Neutropenic Patient in comments on tracking board
! Assign patient to an Intake room from pivot (single patient area) to be evaluated by an
attending physician. Intake attending may include neutropenic precautions if the patient has
known or suspected neutropenia. The patient may then be placed in an ED treatment room in
Main ED if recommended by provider.
! Notify Resource Nurse, who will notify attending or senior resident of patients arrival.
! Place Neutropenic packet of algorithms on patients chart and verify allergies once patient is
in the Main ED.

ED PROCEDURE:
INITIATE RAPID PRESPONSE FEVER PROTOCOL (RRFP) BASED ON ED OR
HEME/BMT PROVIDER.
! When patient is placed in exam room, immediately draw CBC with manual differential and
at least two sets of blood cultures.
! Draw second blood culture from a different site than that of the first set of blood cultures.
! Notify physician as soon as ANC results have returned (lab will call results to primary RN).
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! If ANC less than 1000, send all other labs as ordered on pre-printed order sheet. Other labs
may be clinically indicated even if ANC is greater than 1000.
! After receiving ANC results, the ED Attending or Senior Resident will contact the inpatient
BMT Nurse Practitioner/BMT Physician Assistant if the patient is s/p hematopoietic stem
cell transplant; otherwise the Oncology Fellow is to be notified.
! Physician will stratify patient to either IP or OP treatment (according to clinical criteria listed
in packet) and will order appropriate antibiotics if ANC less than 1000.
! If outpatient treatment is appropriate: the physician will call the patients primary
Oncologist/Nurse and will coordinate discharge with PO antibiotics.
! Antibiotics must be administered immediately upon receiving the order from the Senior
Resident or ED Attending.

Appendix C
BMT/ HEME ED/ INPATIENT RAPID RESPONSE
FEVER PROTOCOL (RRFP)
Patient Qualifies for
RAPID RESPONSE FEVER PROTOCOL
Hospital Admission
Please note: This pathway is NOT an order set. This is a guideline for MDs/RNs for the INITIAL (first hour)
management of Heme/BMT patients who present to the ED or Inpatient Unit with FEVER or other signs of
serious infection. This pathway will be accompanied by an order set.
PLEASE PAGE THE BMT/ HEME TEAM IMMEDIATELY UPON PATIENT TRIAGE
Pager: 303-266-4162

"
Vital Signs
Every 15min. X4, then every 30min. X2, then every 60min.
"
Labs
(CBC/diff, CMP, Mg, Phos, LDH, Uric acid, Lactate)
"
Blood cultures
(2 sets from Central Line and 1 simultaneous peripheral set)
If difficult peripheral stick, complete Central Line cultures only
OR
2 set peripherally if no Central Line
"
IV Fluid Bolus
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NS 1000cc wide open)
If patient unstable (SBP<90, HR>120, dizziness, altered mental status), start IV Fluid Bolus
immediately after Vital Signs and notify NP/MD immediately
"
ANTIBIOTICS
(Please use the RRFP FEVER order set)
cefepime 2gm IV Q8
+/-
Vancomycin (use ONLY if hemodynamic instability, suspected line or skin infection,
suspected MRSA, PNA, mucositis)
If severe allergy to PCN/cephalosporins, use alternative antibiotics per RRFP order set
Above interventions to be completed within 30 min. of patient
#########arrival to ED/Inpatient Unit if Direct Admit##########
"
Diagnostic Testing/Source ID
CXR, CT, UA C&S, etc.
Do NOT delay antibiotics waiting for CXR or UA!!
"
11
th
Floor Inpatient Management
OR
ICU Transfer for EGDT if Unstable

Risk Stratification in Febrile Neutropenia
Fever is defined as a single oral temperature greater than or equal to !38.3C (101F) or greater than or equal to
38.0C (100.4F) for greater than or equal to 1 hour. Neutropenia is defined as a neutrophil count less than 500
cells/mm
3
, or a count less than 1000 cells/mm
3
with a predicted decrease to less than 500 cells/mm
3
. (IDSA, 2002)
Group Description
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Low
Risk (I)

Must
meet all
criteria
$ No associated comorbid illnesses*
$ Alert and oriented times 3 / No mental status changes
$ Non transplant, solid tumor or hematologic malignancy with no previous fungal infection
$ Serum creatinine less than 2mg/dl
$ Liver function tests less than 3 times normal
$ Receiving oncology care in the UCH system.
$ Has resources and is able to fill oral antibiotic prescription within 12 hours (able to comply with and
consent to outpatient pathway)
$ !Contact Hematology-Oncology Fellow to initiate outpatient order set and consent form.

High
Risk (II)
$ Bone marrow transplant / hematologic malignancies or uncontrolled cancer
$ Age greater than 60
$ Altered mental status or confusion
$ Unable to take PO medication (nausea / vomiting or mucositis); dehydration
$ No telephone or transportation, no acute medical center within 1 hour from home
$ Serum creatinine greater than 2.0 mg/dl or renal failure requiring intervention
$ Liver function tests greater than 3 times normal
$ SBP less than 90 mmHg, HR (resting) greater than 100 bpm, RR greater than 20/min, O2 sat less
than 90%(room air/baseline O2)
$ Uncontrolled comorbid conditions*, significant burden of illness or poor performance status
$ Expected prolonged neutropenia (less than 100/cells/mm
3
for greater than or equal to 7 days) or
bleeding requiring transfusion
$ Obvious central line infection , pneumonia or other complex infection
$ ! Initiate inpatient febrile neutropenia order set for inpatient admission and contact Hematology-
Oncology Fellow.

Critical
(III)
Meets high risk criteria and appears very ill (i.e. hypotension, shock)
! Initiate inpatient febrile neutropenia order set for inpatient critical car admission and contact Hematology-
Oncology Fellow.
*Comorbid conditions can include diabetes, COPD, CHF (cardiac problems or EKG changes.) The use of these guidelines is
subject to the clinical judgment of the practitioner and the patients clinical presentation.
OTR02030 (11/04)

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c301911 Page 1 of 10

University of Colorado Hospital Clinical Nursing Guideline

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