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Despite improvements in bone marrow biopsy, ‘much work to do’ to support APPs, patients
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Bone marrow biopsies are the gold standard for diagnosis, staging and monitoring of disease in hematology.
Although there are risks associated with the procedure, it generally has been viewed as very safe. Complications, most commonly pain and bleeding, are rarely or poorly documented.
Training and techniques for providers who perform bone marrow biopsies, often APPs, vary among institutions. For a procedure done with such frequency and that has significant impact on a patient’s diagnosis and treatment planning, a more standard approach to training providers and improving the patient experience is warranted.
Century of development
The first attempts at bone marrow aspirates occurred in the 1920s. Gloves and gowns were utilized for the procedure, which accessed marrow via tibia or sternum, but needle guards and anesthesia were not. In the 1950s, physicians began to recognize the pelvis as the greatest source of marrow, leading us to today’s standard site, the iliac crest, first utilized for bone marrow aspiration in 1952 by Howard R. Bierman, MD. Several different needles for biopsy and aspirate have been developed over time, including one by Khosrow Jamshidi, MD, in 1971. The Jamshidi remains a standard branded tool today. Electric “drills” were introduced to the market in the 1980s, but such devices, known as drivers, have not yet replaced a manual needle as the gold standard, perhaps mainly due to cost.
As more companies develop new needles and competition increases, quality of sampling is improving. Needles have sharper tips, better technology to core a biopsy sample, and scoring to help the provider assess size of the core. Attention on provider technique and patient experience, however, has had little focus.
Training and techniques
Data suggest the quality of aspirate and core sampling may relate to the provider’s level of expertise, yet techniques and training vary among providers and by institution and resources.
At large urban or academic centers, it is often APPs who perform these procedures as the nurse practitioner and physician assistant roles become more involved in invasive procedures. This is usually more cost-effective, and APP schedules are often more flexible to allow for these procedures.
Many centers have a protocol for the APP to be supervised and evaluated for a set number of procedures to obtain privileges to perform bone marrow biopsies independently. However, this usually is based on generic areas of evaluation, such as rationale for the procedure, judgment and technique, and overall quality, rather than step-by-step evidence-based standards. If no formal process is in place for privileges, some APPs may be forced into the more informal, outdated and unsafe training method of “see one, do one, teach one.”
Variations have been noted in training related to patient position (prone vs. lateral decubitus), amount and type of sedation or anesthesia, brand and type of needle (manual vs. electric), and order of aspirate and biopsy procurement.
Variations also exist in consideration of contraindications. Most providers feel there is almost no contraindication for a bone marrow biopsy, whereas others feel that some anticoagulants and severe levels of thrombocytopenia warrant correction or reversal prior to the procedure. Few institutions have standards for this outside of an intervention radiology department, which often has strict protocols.
A study published in Journal of the Advanced Practitioner in Oncology outlined a structured training and competency program for APPs, utilizing a written, verbal and video instruction method. APPs were given access to The New England Journal of Medicine’s “Bone Marrow Aspiration and Biopsy” online video, as well as a formal article on recommended preparation and technique. This was followed by 10 observations and 10 supervised procedures, utilizing both prone and lateral decubitus positions. The final piece of training was follow-up review of pathology reports to ensure adequate sampling was obtained for a pathologic assessment.
In general, the more training the APP has, the more accurate the landmarking and access to dense spicules and quality marrow sampling. Improper landmarking is a common finding in post-procedural adverse events. More institutions are moving toward a similar process of thorough and intentional training, as well as ongoing feedback between the provider and the pathologist, but we still have much work to do to support APPs performing these procedures, as well as for the patients experiencing them. Little data exist to correlate specific patient outcomes with provider training programs for this impactful procedure, leaving room for improvement in our evidence-based practices in hematology.
Patient experience
Not only are quality samples from a bone marrow biopsy essential for diagnosis and treatment planning, a successful procedure is vital to the patient experience, especially for those with leukemia or multiple myeloma, where multiple bone marrow biopsies are part of the disease trajectory.
Little has been done to study specific interventions to improve patient experience scores, but APPs are especially skilled at patient education and support, and often have more time in their schedules to allow 30 to 60 minutes for these procedures. Considerations should include premedication with an anxiolytic such as sublingual lorazepam for patients with significant anxiety. Workflow should allow for this to be discussed between the provider and the patient at the time that a bone marrow biopsy is ordered.
Providers should be trained in both prone and lateral decubitus patient positioning so that comfort can be provided if physical ailments or injuries prevent the patient from lying one way or the other. Time should be allowed for the local anesthetic to be effective. Four mg/kg of 1% lidocaine (not to exceed 300 mg) should be sufficient within 1 to 3 minutes, but providers often use much less and do not take time to pause for efficacy.
Equipment from multiple vendors should be evaluated to ensure an optimal and cost-effective needle is being utilized. Use of a lithium-powered driver has improved patient experience by reducing the amount of time it takes to advance the needle into the marrow cavity and decreasing attempts for patients with hard bones. The shortened time to complete the procedure with an electric driver decreases patient perception of pain by reducing length of the procedure itself. It also allows a provider more time to see additional patients or work in urgent marrows for acute leukemias. A small downside to an electric device is a drill-like sound, which can increase anxiety among patients whose baseline anxiety is already high. The patient should be walked through the steps of the procedure prior to initiation, and talked through each step as the procedure progresses.
Providing resources
Oncology providers should look more closely at this invasive and vital procedure. Although rates of complications are reportedly very low, pain, patient anxiety, and delays in diagnosis and treatment can ensue if not performed with care and a skilled technique.
APPs can be heavily involved in these procedures and provide compassionate and cost-effective care. Cancer centers should focus resources on optimizing the patient experience by ensuring providers have access to quality equipment, availability of sedation when appropriate, and thorough training, evaluation and support for APPs who perform this procedure.
References:
Bierman HR. Calif Med. 1952;77(2),138-139.
Jackson K, et al. J Adv Pract Oncol. 2012;3(4),260-265.
Parapia LA. Br J Haematol. 2007;doi:10.1111/j.1365-2141.2007.06749.x.
Paul JT, et al. Blood. 2011;118(21),4775.
Tanasale B, et al. Pain Manag Nurs. 2013:14(4),310-317.
Zehnder, JL. Bone marrow aspiration and biopsy: Indications and technique. UpToDate. Available at: www.uptodate.com/contents/bone-marrow-aspiration-and-biopsy-indications-and-technique#H1. Accessed on June 26, 2019.
For more information:
Christina Dunbar, MSN, RN, FNP-C, AOCNP, is chief advanced practice provider for the department of hematology at Levine Cancer Institute at Atrium Health. She can be reached at 1021 Morehead Medical Drive, Suite 60100, Charlotte, NC 28204; email: christina.dunbar@atriumhealth.org.
Disclosure: Dunbar reports no relevant financial disclosures.