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AML Care at Home: An Evidence-Based Toolkit to Personalize the Care Setting for Recovery From Pediatric AML
Alix E Seif1,2, Sara L McDonough1, Emily M Becker-Haimes3
1Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
A new toolkit for pediatric acute myeloid leukemia (AML) patients allows safe early discharge after chemotherapy, reducing hospital stays. This approach to outpatient neutropenia management shows promising results for selected children with AML.
Area of Science:
- Pediatric Oncology
- Hematology
- Clinical Implementation Science
Background:
- Current guidelines mandate hospitalization for children with acute myeloid leukemia (AML) during severe neutropenia.
- Selected pediatric AML patients discharged before neutrophil recovery exhibit comparable bacteremia and mortality rates to hospitalized patients.
Purpose of the Study:
- To develop and pilot an "AML Care at Home" toolkit for outpatient management of pediatric AML patients post-chemotherapy.
- To assess the clinical and implementation outcomes of this novel toolkit.
Main Methods:
- The "AML Care at Home" toolkit, comprising a discharge eligibility tool and outpatient management guidelines, was implemented.
- Toolkit reach (proportion of postinduction 1 courses with toolkit use) and total inpatient days per course were primary outcomes.
- Data were collected via chart abstractions.
Main Results:
- The toolkit was utilized in 68.8% of 48 postinduction 1 chemotherapy courses across 22 patients.
- Early discharge was facilitated in 43.8% of courses through appropriate toolkit use.
- Median inpatient days were significantly reduced in toolkit-guided early discharge courses (8 days) compared to inpatient-only or non-toolkit-guided courses (26-31 days).
Conclusions:
- Pilot implementation of the "AML Care at Home" toolkit surpassed reach targets.
- The toolkit implementation resulted in fewer inpatient days per course than anticipated.
- The toolkit effectively identifies and supports suitable pediatric AML patients for early discharge and safe outpatient monitoring.
Purpose:
Current care guidelines for children with AML recommend hospitalization during severe neutropenia. However, selected patients discharged before neutrophil recovery have similar chemotherapy course-specific bacteremia and mortality rates to those who remain hospitalized. On the basis of published literature, we developed a toolkit to guide outpatient care after myelosuppressive AML chemotherapy and piloted its implementation at a single institution. We present the pilot clinical and implementation outcomes.
Methods:
The AML Care at Home toolkit includes a discharge eligibility assessment tool and outpatient management guidelines for pediatric patients with AML and was implemented on November 15, 2022. Toolkit reach, defined as the proportion of postinduction 1 courses with toolkit use (target: 60%), was the coprimary implementation outcome, and total inpatient days per course was the coprimary clinical outcome. Chart abstractions were used to ascertain total inpatient days per course and other clinical outcome designations.
Results:
During this pilot implementation program, 22 patients underwent 48 postinduction 1 chemotherapy courses. The toolkit was used in 33 (68.8%) courses. Appropriate toolkit use allowed for early discharge in 21 (43.8%) courses and directed inpatient recovery in 11 (22.9%). Median total inpatient days were markedly fewer for toolkit-guided early-discharge courses (8 days, IQR, 5.5-14.5) than toolkit-guided inpatient-only courses (26 days, IQR, 22-39) or when the toolkit was not used as intended (31 days, IQR, 25.3-34.8).
Conclusion:
Pilot implementation of the AML Care at Home toolkit exceeded our target reach goal and led to fewer inpatient days per course than expected on the basis of previous studies of outpatient neutropenia management. These data reflect the utility of a toolkit created on the basis of published data to identify and support appropriate patients for early hospital discharge and safe outpatient monitoring.
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