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Laboratory medicine, along with the airline industry, has a long history of utilising quality management systems. It took until 1999 for The Joint Accreditation Committee of the International Society for Cellular Therapy (ISCT) and the European Group for Blood and Marrow Transplantation (EBMT), known as JACIE, to be established as an accreditation system in the field of haematopoietic stem cell transplantation (HSCT). The aim was to create a standardised system of accreditation to be officially recognised across Europe and was based on the accreditation standards established by the US-based Foundation for the Accreditation of Cellular Therapy (FACT).

Since the concept of JACIE was originally launched, many European centres have applied for initial accreditation with other centres gaining reaccreditation for the 2nd or 3rd time. Transplant units, outside of Europe, have accepted the importance of the JACIE Standards, with units in South Africa, Singapore and Saudi Arabia also gaining accreditation.

There is evidence that both donor and patient care have improved within the accredited centres (Passweg et al., Bone Marrow Transpl, 47:906–923, 2012; Demiriz IS, Tekgunduz E, Altuntas F (2012) What is the most appropriate source for hematopoietic stem cell transplantation? Peripheral Stem Cell/Bone Marrow/Cord Blood Bone Marrow Res. (2012):Article ID 834040 (online)). However, there is a lack of published evidence demonstrating that this improvement directly results from better nursing care. Therefore, the authors conducted a survey of nursing members of the European Blood and Marrow Transplantation Nurses Group (EBMT (NG)) to identify how nurses working in the area of HSCT felt that JACIE impacted in the care they delivered and the general implications of JACIE for nurses.

The HSCT (haematopoietic stem cell transplant) is a particular treatment for many haematological and non-haematological diseases. Broadly, there are three different categories of transplantation, autologous, allogeneic and syngeneic, which can be applied to most disease scenarios. Haematopoietic stem cells can be derived from the bone marrow, peripheral blood and umbilical cord blood. HSCT treatment can be divided into separate phases that start with the harvest of the stem cells and passing through the conditioning, aplasia and engraftment until the recovery of the haematopoietic functions. HSCT is indicated in many diseases, and these indications depend on numerous factors such as the disease type, stage and response to previous treatment. Among non-malignant diseases, aplastic anaemia, sickle cell disease and, more recently, autoimmune diseases can also be effectively treated with HSCT. One third of the transplants in children are performed for rare indications such as severe combined immunodeficiencies. Allogeneic HSCT can also cure a number of non-malignant diseases in children, such as Wiskott-Aldrich syndrome and chronic granulomatous disease (CGD). This chapter will include transplant in primary immunodeficiency in children as well as inherited bone marrow failure and inborn errors of metabolism.

Allogeneic haematopoietic stem cell transplant (HSCT) is the treatment of choice for a variety of malignant and non-malignant disorders. The aim of HSCT is to replace the patient’s haematopoiesis with that taken from a donor, and a prerequisite is the identification of a suitable donor. It is an intense and demanding process and puts considerable strain on both recipients and donors. The choice of donor has an impact on the transplantation process from scheduling to outcome. There are several common donor issues whether the donor is related or unrelated including eligibility, confidentiality, informed consent and right to refuse consent.

HSCT is a complex procedure, which involves a long and complicated pathway for the patient and the intervention of many health professionals. Within this multidisciplinary team, the transplant coordinator, usually a nurse, is the ‘essential marrow’, the heart and the vital backbone of this procedure; they are an essential transplant ingredient facilitating a fluidity of the pathway and a good transmission of information. Written information about the procedure is beneficial for patients either prior to clinic visit or during clinic to allow the patients and relatives to reflect on conversations. Transplantation carries a significant risk of morbidity and mortality, and these should be considered regarding the ‘need’ to transplant, based upon risk of disease, versus risk of the transplant. Pre-transplant assessments must also be undertaken, and the results of these along with suitable donor medical clearance and cell availability are essential to ascertain that transplant is a valid option and can proceed safely. Dealing with fertility preservation upon diagnosis of cancer is often challenging; this issue is even more complex for paediatric patients. PDWP recommends that counselling about fertility preservation opportunities should be offered to each patient receiving HSCT.

This chapter will also focus on vascular access for optimal treatment of haematology patients because stem cell treatment cannot be performed without it. Constant advances in haematology have raised challenging ethical dilemmas concerning end of life, palliative care, patient information, donor concerns and impartiality and issues related to the risk we run to our patients. Nurses provide a key role in patient education, providing pre- and post-transplant advocacy and counselling, plan hospitalisations and consultations. They also act as educators and role models to nursing students and share knowledge in accordance with local policies and JACIE guidelines.

Peripheral blood stem cells have largely replaced harvested bone marrow stem cells both in the autologous and allogeneic settings. Advantages of peripherally harvested cells include higher stem cell dose, more rapid engraftment, reduced donor/patient discomfort, and better graft-versus-leukemia effect in the allogeneic setting. Within the apheresis machine, whole blood is separated into its components by centrifugation, and the red cell-depleted, stem cell-rich buffy coat is extracted for use as a stem cell product, simultaneously returning the other blood components back to the donor. Prediction of procedure length is based on the required cell dose target but still remains challenging. Moreover, the number of apheresis procedures needed should be as few as possible in order to reduce costs and patient/donor discomfort and to increase safety. The volume of blood which needs to be processed in order to collect an adequate number of stem cells depends on several factors such as method of stem cell mobilization, vascular access, and collection efficiency.

Another issue to take into consideration is cell storage: according to GITMO’s study (Perseghin et al. ) in most Italian centers, even up to 83.4% correspond to useless storage and only the remaining 16.6% to useful storage. Therefore, SIdEM and GITMO proposed a policy for autologous HPC disposal that fulfills clinical, ethical, and economic criteria.

JACIE standards on peripheral blood stem cell (PBSC) collection by apheresis require that collection, manipulation, and clinical use of peripheral blood stem cells must be validated and monitored rigorously. The validation procedure consists of systematic review of all apheresis procedures performed at the collection facility of a transplant program.

Prior to haematopoietic stem cell transplant (HSCT), conditioning therapy is used for disease eradication, creation of space for engraftment and immunosuppression. Conditioning therapy includes combinations of chemotherapy, radiotherapy and/or immunotherapy. Chemotherapy is delivered in different phases: induction, consolidation and maintenance. Total body irradiation (TBI) is widely used as part of conditioning regimens preceding allogeneic HSCT and is able to target sanctuary sites where some drugs cannot reach. Cancer immunotherapy treatment harnesses the body’s natural defences to fight the cancer, by involving components of the immune system. Conditioning therapy can have acute and chronic side effects due to the toxicity of the treatment. Nursing implications involve patient education and information, toxicity assessments, close monitoring and action plans. Stem cell infusion is usually a safe procedure but can cause adverse reactions ranging from flushing and nausea to life-threatening reactions. There should be written policies for the administration of cellular therapy products, and nurses must have training and competency in order to safely administer haematopoietic stem cells.

Despite improvements over the past several decades, infection remains a significant risk to all haematological patients receiving therapy. Those requiring allogeneic transplant and especially those that have HLA disparity or T-cell-depleted grafts have an even higher risk of infective complications due to delayed recovery of T- and B-cell function. Early identification with prompt effective treatment is paramount to improve all patients’ survival. Patient safety through robust adherence to hand hygiene and maintenance of the environment with cleaning and disinfection are the backbone of an effective preventative program. Basic nursing care and a sound knowledge base of the risks, presentation, diagnosis and treatment will improve patient care.

Haematopoietic stem cell transplantation (HSCT) generally includes preparative or conditioning regimes containing chemotherapy and/or radiotherapy in high doses. These regimens, as well as other treatments before and after HSCT such as immunosuppressive drugs to prevent graft versus host disease (GvHD) (see Chap. 11), may affect the patient’s organs and tissues and may cause both acute and long-term complications. In the evolving field of stem cell therapies, some complications that traditionally have been regarded as early complications are now, due to changes in preparative regimens and choice of stem cell source, sometimes seen later in the post-transplant out-patient setting. The complications covered in this chapter generally occur within 100 days post HSCT and are thus classified as early complications. Two of the most common early complications are oral complications/mucositis and sepsis. Some other relatively rare complications are also covered here: haemorrhagic cystitis (HC), endothelial damage (ED) syndromes including engraftment syndrome (ES), idiopathic pneumonia syndrome (IPS), diffuse alveolar haemorrhage (DAH), transplant-associated microangiopathy (TAM) and sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD). For all complications, recommendations for prevention and principles for nursing care are presented since careful nursing monitoring, prompt intervention and care may have an influence on patients’ morbidity and mortality.

Hematopoietic stem cell transplantation (HSCT) care is highly complex. This chapter focuses on the aspects of supportive care required following HSCT.

Assessment tools are key component of nursing practice and are necessary for planning and providing patient-centered care. HSCT care must be planned, implemented, and evaluated and is underpinned by collaboration with the entire multidisciplinary healthcare team.

With supportive care following HSCT, we ultimately aim to improve the quality of life of our patients in the posttransplant period.

Supportive care extends beyond symptom management and includes social, psychological, and spiritual care. The needs of the patient are multifactorial and can be complex, considering multiple issues at the e time and involving multiple disciplines.

Throughout supportive nursing care, our clinical competence is critical and is complemented by experience, knowledge, and awareness.