Unique Plan Description: ONC CAR-T (Immune Effector Cell Therapy)
Plan Selection Display: ONC CAR-T (Immune Effector Cell Therapy)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2023-10-17 14:55:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-04-05 10:34:36
Available at all facilities: Yes

Admission
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
Activity
	Activity-As Tolerated
		T;N, Ok to walk in halls with mask
Diet
	Regular Diet
		T;N
			Comment: Patient in protective environment
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	Magnesium Level
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	Phosphorus
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	LDH
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	Uric Acid
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	C Reactive Protein High Sensitivity
		T;N, Routine, spec type = Blood
	Ferritin Level Oncology
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	Partial Thromboplastin Time - MH/WH/JE
		T;N, Routine, spec type = Blood
	Prothrombin Time - MH/WH/JE
		T;N, Routine, spec type = Blood
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	ABORh Patient Type
		T;N, Routine, spec type = Blood
	Antibody Screen
		T;N, Routine, spec type = Blood
Diagnostic Tests
	EKG (ECG)
		Routine
Radiology
	Chest 1 View
		Routine
Medications

	dexAMETHasone
		10 mg, Tab, By Mouth, BID, duration: 3 Day(s)
			Comment: Day 0, Day 1, and Day 2
	levETIRAcetam
		500 mg, Tab, By Mouth, BID, duration: 30 Day(s)
			Comment: Indication: ProphylaxisDay 0 to 30
	ondansetron
		8 mg, Tablet-Disintegrating, By Mouth, Q8H, PRN nausea, T+1;N
			Comment: (1st line)
		8 mg, Injection, IV Push, Q8H, PRN nausea, T+1;N
			Comment: (1st line) Only if unable to take PO
	prochlorperazine
		10 mg, Tab, By Mouth, Q6H, PRN nausea
			Comment: For nausea refractory to ondansetron (2nd line)
	docusate sodium
		100 mg, Capsule, By Mouth, BID, PRN constipation
	polyethylene glycol 3350 oral powder for reconstitution
		8.5 gm, Packet, By Mouth, DAILY, PRN constipation
	Senna
		8.6 mg, Tab, By Mouth, BID, PRN constipation
	alteplase - CathFlo
		1 mg, Injection, Clotted Catheter, DAILY, PRN to maintain patency, duration: 2 Dose(s)/Time(s)
			Comment: Instill into occluded Central Venous Catheter and allow to sit for 30 minutes, then assess catheter function by aspirating.  If not restored, allow 90 additional minutes of dwell time and reassess.  If still unsuccessful then repeat dose one time only.
	metoclopramide
		10 mg, Tab, By Mouth, Q6H, PRN nausea
			Comment: For nausea refractory to prochlorperazine (3rd line)
	LORazepam
		1 mg, Tab, By Mouth, Q4H, PRN nausea
			Comment: For nausea associated with anxiety
	LORazepam Injectable
		0.5 mg, Injection, IV Push, Q4H, PRN nausea
			Comment: For nausea associated with anxiety, if unable to take PO form.
	enoxaparin
		40 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: start on day of admission. Hold when platelet less than 30,000
	acyclovir
		800 mg, Tab, By Mouth, BID, Indication: Prophylaxis
	fluconazole
		400 mg, Tab, By Mouth, DAILY, Indication: Prophylaxis
	magic mouthwash
		5 mL, Suspension, Mouthwash, QID
			Comment: Swish and Spit. Administer prior to chlorhexidine.
		5 mL, Suspension, Mouthwash, Q1H, PRN discomfort
			Comment: Swish and Spit
	chlorhexidine 0.12% oral rinse
		15 mL, Solution, Mouthwash, BIDPC
			Comment: Swish and gargle for 30 seconds then expectorate. Administer after magic mouthwash.
	melatonin
		3 mg, Tab, By Mouth, QHS, PRN insomnia
		Less than 65 years old(NOTE)*
	OLANZapine
		5 mg, Tab, By Mouth, QHS, duration: 4 Day(s)
			Comment: (Less than 65 years old )start day -1/day of admission; give on days -1, 0(infusion day), 1, and 2.
		65 years or greater(NOTE)*
		2.5 mg, Tab, By Mouth, QHS, duration: 4 Day(s)
			Comment: (65 years or greater) start day -1/day of admission; give on days -1, 0(Infusion day), 1, and 2.
Patient Care
	Resuscitation Status
		Full Code
		No Code
	VTE Advisor
		Medical
	Do not give medication
		T;N, enoxaparin if platelets less than 30,000.
	Isolation Precautions
		T;N, Protective, Reason for Isolation: Immune suppressed
	Weight
		T+1;0400, Q24H
			Comment: *STRICT* standing weight whether sleeping or not
	Incentive Spirometer
		Q2H
	Order Lab
		Blood Culture Set,  UA (culture if pos) and Chest 1  View if temp >/= 100.4 for greater than 1 hour or a single temperature of >/= 101.4 and notify attending hematologist/oncologist
	Notify MD of Lab results
		(Hospitalist) if magnesium <1.7, or > 2.6 mg/dl; if potassium <3.5 or >5.5 mmol/L; if phosphorus <2.5 or >4.5 mg/dL
	Notify MD
		Dr. Michalski cell phone: (402) 681-8221. Use this number for his IECT patients only.
	IV-Maintain
		
	Order/Transfuse Blood Product
		T;N, Packed cells, 1 unit
			Comment: For hgb <7grams/dL.  Use irradiated and leukocyte reduced products. Enter order for: acetaminophen 650mg PO once prior to transfusion.
		T;N, Platelet, 1 unit
			Comment: For platelet count < or = 10,000. Use irradiated & leukocyte reduced product. Enter order for: acetaminophen 650mg PO once prior to transfusion
	Notify MD
		If >3 liquid stools in 24 hours, notify MD for diarrhea treatment
	Obtain Consent/Permit for:
		T;N, Chemotherapy/Biotherapy
	Complete ICE Assessment Tool
		To be completed at shift change. And PRN with RN change and/or mental status change., Q12H-Sch
	Complete CRS Grading
		Q12H-Sch
			Comment: 9am
	Cardiac Telemetry Monitoring
		Telemetry Indications: Other
Therapies
	Consult Physical Therapy, Evaluate and Treat
		Reason to See: Evaluate and Treat
			Comment: Order Dx: NonHodgkins Lymphoma Immune Effector Cell Therapy patient. See as needed throughout hospitalization
	Pulse Oximetry Spot Check RT
		BID
			Comment: Strict - whether sleeping or not
	Consult Occupational Therapy, Evaluate and Treat
		Reason to See: Evaluate and Treat
			Comment: Order Dx: Hodgkins NonHodgkins Lymphoma, Immune Effector Cell Therapy patient
	Therapeutic Recreation Eval and Follow
		Evaluate and followup
			Comment: Immune Effector Cell Therapy patient.  Lymphoma
	Consult Speech Language (MH), Evaluate and Treat
		T;N
			Comment: Immune Effector Cell Therapy patient Evaluate within 24 hrs, MBS if appropriate. Order diet as recommends Methodist Speech Therapy; call 402-354-4461 and leave message for consult.
Consults/Follow-up
	Consult Social Work
		Evaluation
	Consult Dietitian
		Regarding: Nutrition Assessment
			Comment: dietician to see frequently throughout hospitalization. Immune Effector Cell Therapy patient
	Consult Infectious Disease
		Reason for Referral: Immune Effector Cell patient | MPC Infectious Disease
	Consult Hospitalist
		Reason for Referral: Immune Effector Cell patient

Chemotherapy
IV Solutions
	Sodium Chloride 0.9%
		250 mL, IV, T;N+30, 25 ml/hr
			Comment: use as primary/flush with fludarabine
	Dextrose 5% in water Chemo flush
		250 mL, IV, Once, 25 ml/hr
			Comment: use as primary/flush with cyclophosphamide
Medications
Premeds
	fosaprepitant
		150 mg, INT, IVPB, Once, infuse over 30 min(s), T;N+300
			Comment: Give on Day -1 (day of admission), 30 min prior to melphalan
	palonosetron/dexamethasone/NS 50mL
		0.25 mg, IVPB, Once, infuse over 15 min(s), 200 ml/hr, T;N+90
			Comment: 30 min prior to chemotherapy
		12 mg, EVERY BAG
		50 mL, EVERY BAG
	ondansetron/dexamethasone/NS 50mL
		16 mg, IVPB, Once, infuse over 15 min(s), 200 ml/hr, T;N+90
			Comment: 30 min prior to chemotherapy
		20 mg, EVERY BAG
		50 mL, EVERY BAG
Chemotherapy Agent
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	cyclophosphamide/D5W 250mL
		500 mg/m2, IVPB, Once, T;N, Infuse Over 30 min(s)
		25 mL, EVERY BAG
		250 mL, EVERY BAG
	fludarabine/NS 100mL
		30 mg/m2, IVPB, Once, T;N, Infuse Over 30 min(s)
		10 mL, EVERY BAG
		100 mL, EVERY BAG
Patient Care

	Notify MD
		T;N, Contact Provider for further orders if allergic reaction protocol initiated

Immune Effector Cell Infusion
Vital Signs
	Vital Signs
		T;N, Q15MIN
			Comment: Take vital signs prior to cell infusion, every 15 minutes during, and at completion of cell infusion.
IV Solutions
	Sodium Chloride 0.9%
		1,000 mL, IV, T+6;1200, 1 Dose(s)/Time(s), 100 ml/hr
			Comment: Run through central IV line during immune effector cell therapy. Discontinue when immune effector cell therapy done.
Medications
	diphenhydrAMINE
		25 mg, Injection, IV Push, Once
			Comment: Premedicate 30 minutes prior to Immune Effector Cells.
	acetaminophen
		650 mg, Tab, By Mouth, Once
			Comment: Premedicate 30 minutes prior to Immune Effector Cells.
		Tecartus(NOTE)*
	brexucabtagene autoleucel
		68 mL, Solution-Injection, IVPB, Once
		Yescarta(NOTE)*
	axicabtagene ciloleucel
		68 mL, Solution-Injection, IVPB, Once
Patient Care
	Obtain supplies/equipment
		T+6;0900, oxygen tubing, nasal cannula set up, 2 sets of secondary tubing, warm water bath
			Comment: Place at bedside on Immune Effector Cell Infusion day
	Notify MD
		T;N, For additional orders if patient experiences reaction to treatment.
		if urine output less than 60ml/hr, temp > or equal to 100.4, HR >120bpm or <60, or arrhythmia, SBP <90mmHg or >140mmHg, or SAO2 <92% on Room air, Respiratory rate > 25bprm or <12bpm, upward trends in creatinine and liver function tests
		If ICE score less than 10, tremors or jerking movements in extremities, change in mental status, such as: alertness, orientation, speech, ability to write a sentence
			Comment: Hold oral intake of food, fluids, and medicines until further direction from MD.
	Initiate MD Plan for:
		T;N, Allergy Reaction protocol if patient experiences reaction to treatment.
Therapies
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
			Comment: with immune cell infusion and PRN
Charges/Supplies
	0540T INF-Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous
		T;N

Allergy Reaction Protocol
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in trendelenberg
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, Routine, Bolus
		1,000 mL, IV, Routine, 30 ml/hr
Medications
	Benadryl
		50 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
		25 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
	Decadron (MH/WH)
		20 mg, Injection, IV PUSH, Once, PRN, allergic reaction
	SOLU-Medrol
		125 mg, Injection, IV Push, Once
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, Once
		0.5 mg, Injection, IM-Intramuscular, Once
		0.5 mg, Injection, SUBCUTANEOUS, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.5 mg, Injection, IM-Intramuscular, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 < 30kg(NOTE)*
		0.01 mg/kg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.01 mg/kg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 > or equal to 30kg(NOTE)*
		0.3 mg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.3 mg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
Patient Care
	Pharmacy Consult
		T;N, Allergy Reaction Protocol was entered on this patient, please verify allergy, and add allergen to patient allergies in medical record
	Discontinue Medication
		T;N, Discontinue IV medication or infusion and remove tubing
	Notify MD
		T;N, Contact PCP for additional orders

CHEMO Reaction Protocol
Vital Signs
	Vital Signs
		Assess vital signs every 2 to 5 minutes until the patient is stable. Place patient into a recumbent position with elevation of the lower extremities if hypotensive
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		Reassess vital signs every 15 minutes x 2, then q30min x 2, or more frequently as needed, I&O, etc until stable
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in Trendelenburg.
IV Solutions
	Sodium Chloride 0.9% IVPB
		500 mL, Solution-Injection, IVPB, DAILY, PRN see comment, 999 ml/hr
			Comment: for reaction to chemotherapy
		1,000 mL, Solution-Injection, IVPB, DAILY, PRN see comment, 999 ml/hr
			Comment: for reaction to chemotherapy
Medications
	Benadryl
		50 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy
		25 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy
	Decadron (MH/WH)
		20 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 1st choice steroid
	SOLU-Medrol
		125 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 2nd choice steroid
	Solu-CORTEF
		100 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 3rd choice steroid
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, DAILY, PRN see comment
			Comment: for hypersensitivity reaction not resolved by diphenhydramine and/or anaphylactic				reactions to chemotherapy, may repeat every 10 minutes for up to 3 doses
		0.5 mg, Injection, IM-Intramuscular, DAILY, PRN see comment
			Comment: for hypersensitivity reaction not resolved by diphenhydramine and/or anaphylactic				reactions to chemotherapy, may repeat every 10 minutes for up to 3 doses
Patient Care
	Notify MD
		T;N, Contact the oncologist if any of the reaction protocol medications are administered to the patient.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase