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Michelle Kenyon · Aleksandra Babic Editors
The European Blood and

Marrow Transplantation
Textbook for Nurses
Under the Auspices of EBMT

The European Blood and Marrow
Transplantation Textbook for Nurses
Michelle Kenyon • Aleksandra Babic
Editors
The European Blood

and Marrow
Transplantation
Textbook for Nurses
Under the Auspices of EBMT
Editors
Michelle Kenyon Aleksandra Babic
Department of Haematological Medicine Istituto Oncologico della
King’s College Hospital NHS Svizzera Italiana
Foundation Trust Bellinzona, Switzerland
London, UK
This book is open access.

ISBN 978-3-319-50025-6 ISBN 978-3-319-50026-3 (eBook)
https://doi.org/10.1007/978-3-319-50026-3
Library of Congress Control Number: 2018930542
© EBMT and the Author(s) 2018. This book is an open access publication.
Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons
license and indicate if changes were made.
The images or other third party material in this book are included in the book’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
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Printed on acid-free paper
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part of Springer Nature
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
Autologous and allogeneic haematopoietic stem cell transplantations (HSCT)

are curative procedures for patients with haematological diseases and immune
deficiencies.
This textbook is an easy-to-read primer for all those involved in the care of
HSCT patients. It offers a solid and comprehensive overview of different
nursing methods and requirements and their applications towards improving
HSCT patients’ outcome.
The book is divided into several chapters which allow reviewing the most
important components of nursing and caring after HSCT both in the adult and
paediatric patients. It also relies on real-life clinical situations to illustrate the
scientific principles and concepts.
Cutting-edge and updated nursing techniques are presented, but the basic
principles and general considerations are explained first.
This textbook developed under the auspices of the European Society for
Blood and Marrow Transplantation (EBMT) by highly skilled and experi-
enced colleagues in this field represents an invaluable resource that will be
highly useful to all professionals involved in the modern management of
HSCT patients.
EBMT is very proud of this unique achievement that has been long awaited
because nursing science must be continually improved in order to provide the
best patient care possible. It will contribute to better patient care and make it
visible not only for nurses but also for all other stakeholders. Far from being
all-inclusive, it will definitely serve as a catalyst for the interest of the
readership.
Mohamad Mohty
v
Preface
The EBMT Nurses Group: promoting excellence in patient care through

international collaboration, education, research and science
The EBMT Nurses Group (NG) plays an essential role in haematology
and haematological stem cell transplantation nursing. The group was created
33 years ago and now has over 750 members in more than 60 countries world-
wide with a principal nurse identified in almost each EBMT centre.
The EBMT NG’s mission is to enhance and value the nurses’ role all over
the world, supporting and sharing knowledge through communication, advo-
cacy, research, training and education. The group is dedicated to improving
the care of patients receiving SCT and works towards promoting excellence
in care through recognizing, building upon and providing evidence-based
practice.
Over the last two decades, BMT nursing has grown rapidly and has
acknowledged the need for care of the patients, their families and donors.
Advanced practice nurses have been taking a leading role in the care of
patients, providing in holistic care; BMT nurses are involved in the decision-
making process about treatment options for their patients, and they evidently
contribute to an enhancement in their patients’ quality of life. More and more,
EBMT NG is conducting a research on topics based within clinical practice
and is formulating their own research agenda.
The EBMT NG consists of a board and five committees (paediatric,
research, global educational, scientific and communication and networking)
and links with national groups/forums.
Recently, we enhanced our collaboration between EBMT and the
Haematology Society of Australia and New Zealand (HSANZ) Nurses
Group.
http://www.ebmt.org/Contents/Nursing/WhoWeAre/TheBoard/Pages/
TheBoard.aspx
Bellinzona, Switzerland Aleksandra Babic
vii
Contents
1 JACIE and Quality Management in HSCT:

Implications for Nursing �� 1
Carole Charley, Aleksandra Babic, Iris Bargalló Arraut,
and Ivana Ferrero
2 HSCT: How Does It Work?�� 23
Letizia Galgano and Daphna Hutt
3 Donor Selection�� 37
Mairéad Níchonghaile
4 Transplant Preparation �� 45
Caroline Bompoint, Alberto Castagna, Daphna Hutt,
Angela Leather, Merja Stenvall, Teija Schröder,
Eugenia Trigoso Arjona, and Ton Van Boxtel
5 Cell Source and Apheresis�� 71
Aleksandra Babic and Eugenia Trigoso
6 Principles of Conditioning Therapy and Cell Infusion�� 89
Sara Zulu and Michelle Kenyon
7 BMT Settings, Infection and Infection Control�� 97
John Murray, Iris Agreiter, Laura Orlando, and Daphna Hutt
8 Transplantation Through the Generations�� 135
Alberto Castagna, Lisa Mcmonagle, Corien Eeltink,
and Sarah Liptrott
9 Early and Acute Complications and the Principles
of HSCT Nursing Care�� 163
Elisabeth Wallhult and Barry Quinn
10 Supportive Care �� 197
S. J. van der Linden, M. E. G. Harinck, H. T. Speksnijder,
Teija Schröder, Ien Schlösser, Vera Verkerk,
Micheala van Bohemen, A. M. Rusman-Vergunst,
J. C. Veldhuijzen, and W. J. A. Quak
11 Graft-Versus-Host Disease (GvHD)�� 221
John Murray, Jacqui Stringer, and Daphna Hutt
ix
x Contents
12 Graft Versus Tumour Effect�� 253

Mairéad NíChonghaile
13 Engraftment, Graft Failure, and Rejection �� 259
Daphna Hutt
14 Late Effects and Long-Term Follow-Up�� 271
Michelle Kenyon, John Murray, Barry Quinn,
Diana Greenfield, and Eugenia Trigoso
15 Nursing Research and Audit in the Transplant Setting�� 301
Corien Eeltink, Sarah Liptrott, and Jacqui Stringer
About the Author
Michelle Kenyon works as Consultant Nurse (BMT Care and Survivorship)

at King’s College Hospital, London. She has worked for more than 25 years
in the field of haemato-oncology and stem cell transplantation. Her interest in
improving the patient experience of haematopoietic stem cell transplantation
(HSCT) led her to write The Seven Steps, a patient information book (2002)
and subsequently the Next Steps (2012). Around 50,000 copies of these titles
have been distributed and are now used as the basis of informed consent for
transplant recipients throughout the UK.
She studied her BSc in Cancer Nursing and MSc in Advancing Cancer
Nursing Practice at King’s College London, and undertook an empirical
research study exploring the use of life-coaching in stem cell transplant sur-
vivors for her dissertation. She supports patients throughout their post-trans-
plant recovery and has a particular interest in survivorship issues and the
effects of treatment. She launched the HSCT long-term follow-up clinic at
King’s College Hospital in 2014 and has found the patient insights inspiring
and the overall experience highly rewarding. She is the nurse representative
on the BSBMT executive, Vice Chair EBMT (UK) NAP group and is
Secretary of the EBMT NG.
Aleksandra Babic is a Nurse Manager, affiliate to Oncology Institute of

Southern Switzerland (IOSI), in Bellinzona, as Transplant Unit Coordinator
and Quality Manager. She received her nurse diploma from the College
Center of Professional Formation in Dubrovnik, Croatia, in 1988, and was
xi
xii About the Author
awarded a Master’s degree in Nurse Management in 2006. Until 2016 she

worked as a nurse manager in apheresis unit at IEO, European Institute of
Oncology in Milan, and has published papers on peripheral blood stem cell
collection and mobilisation (i.e. R-ESHAP Plus Pegfilgrastim as an Effective
Peripheral Stem Cell Mobilization Regimen for Autologous Stem-Cell
Transplantation in Patients with Relapsed/Refractory Diffuse Large B-Cell
Lymphoma, Transfus Apher Sci. 2013; Successful Mobilisation of Peripheral
Blood Stem Cells in Children Using Plerixafor: A Case Report and Review
of the Literature, Blood Transfus. 2013; Who Should Be Really Considered
as a Poor Mobilizer in the Plerixafor Era? Transfus Apher Sci. 2012) and
photopheresis (i.e. Efficacy of Photopheresis Extracorporeal Procedure as
Single Treatment for Severe Chronic GVHD: A Case Report, Transfus Apher
Sci. 2013). In addition, Aleksandra has presented at a number of conferences
worldwide, most recently including the GIIMA 3rd National Conference,
GITMO and the EBMT 2015 conference: Validation of PBSC collection
within JACIE program – A multicenter evaluation. From 2016 she is also a
JACIE Quality Manager Inspector.
Aleksandra is the former EBMT NG President (European Blood and
Marrow Transplant Society) Nurses Group, which includes more than 800
nurses in 64 countries worldwide. She is a former President of GIIMA, the
Italian Nurses Group in Mobilisation and Aphaeresis, and the founder and a
board member of the not-for-profit association, Nurses No Frontiers.
Brief History of HSCT Nursing: HSCT
Nursing Through the Ages
and Its Evolution
Since the beginning and progress of stem cell transplantations in the late
1950s/early 1960s, it was clear that nurses play a crucial role within the mul-
tiprofessional team caring for patients and their families undergoing this
treatment. Nurses as core professionals along physicians and other healthcare
workers care for patients and their families around the clock. Continuity of
care is vital to patients’ satisfaction as well as trust. In the beginning, care was
considerably cumbersome with HSCT patients who needed to be treated in a
sterile environment such as germ-free tents or bubbles. Being one of the
nurses who still remembers how that had to be handled, it is clear that this
work was very time consuming and specific material was needed because
everything – from the linen and clothes of patients up to every single book,
toy or newspaper – is all needed to be wrapped up and sterilized before given
to the patient. Next to helping patients deal with the time in the germ-free
environment, talking to their beloved ones through a plastic curtain or wear-
ing a mask covering emotions on the face, nurses of course also needed to
take care for the physical and psychological challenges patients faced.
• Nurses Field of Competences
To be able to care for patients and families, nurses need to perform duties
and responsibilities that often comprise more tasks than the ones taught in
nursing schools. Experience and long-term commitment to the care of HSCT
patients can be a challenge but also very rewarding. Novices to the field will
need to be supervised and supported by expert nurses from the beginning to
be able to endure also burdensome situations in a very person-centred care.
–– Coordinator, Communicator and Translator
Nurses play an important role as coordinator of all issues including coor-

dinating procedures and care activities within the interprofessional context
before, during and after transplantation. This includes organizing all neces-
sary diagnostic tests and checkups prior to transplantation. Sometimes they
are responsible also for the donor and his/her health including questions con-
cerning the donation of stem cells and its consequences. The process of trans-
plantation involves many professionals and specialties – therefore, all results
need to come back to one single point of coordination. It is important to com-
municate all diagnostic tests, their results, and what they mean in the situation
xiii
xiv Brief History of HSCT Nursing: HSCT Nursing Through the Ages and Its Evolution
of the patient in a language that the patient understands. Often the medical
language is difficult to understand by lay people, and therefore nurses play an
important role in translating the meaning and consequences to patients and
their families.
–– Preparer and Educator of Patients for Transplantation and the Period

After HSCT
Over the years, every centre developed modules, booklets or information

brochures for patients which always supported the educational activities to
prepare patients prior transplantation, help them through the phases of
transplantation and make them ready for discharge and the time at home
when no professional is around, and they have to make important decisions
and cope with the situation in their own home environment. Specific atten-
tion has developed towards educating the long-term survivors and their next
of kin in which nurses can play a prominent role because medical treatment
activities are more in the background and day-to-day questions have to be
dealt with. Some centres developed classes in which patients and families
get together, gain the needed information and share concerns and discuss
ways of coping. All this is often done under the auspice of nurses experi-
enced not only in transplant nursing but also in principles of patient
education.
–– Carer, Administrator and Technician
The administration of chemotherapeutic, immunosuppressive and

symptom-control drugs; blood products; and parenteral nutrition through a
central venous access device has developed over the years. The accurate han-
dling and care of the central venous catheter and infusion pump systems is
vital in the process because the catheter is related to the highest risk of infec-
tions. In addition, nurses often need to make important decision when no
physician is around to prescribe medication (such as during the night shift) to
ease suffering such as pain, mucositis, diarrhoea or nausea.
–– Social Supporter and Motivator
The distress during the time prior to undergoing HSCT, during isolation,
in the recovery phase and the time after (long-term recovery) is not to be
underestimated. Nurses play an important role as part of the interprofessional
team in communicating, motivating and supporting patients throughout the
entire process including the follow-up time. Connecting patients and family
members with other professionals such as social worker, psychologist or spir-
itual carer whenever emotional distress is overwhelming, other questions
arise and encouragement is needed is often considered very helpful.
Being culturally sensitive and meeting the spiritual needs of patients has
become a recognized challenge in our often multicultural societies. Because
of the 24/7 availability of nurses, they often detect these needs and are able to
call for the necessary support that patients and families need.
Brief History of HSCT Nursing: HSCT Nursing Through the Ages and Its Evolution xv
Although over the years there were tremendous improvements in out-

comes, namely, better survival rates, some patients and families need to face
limited life expectancy. In this phase, the early support of palliative care in
managing symptoms, helping patients in their often difficult and complex
decision-making and discussing who of the family can be involved to take
care and how to back up the family and look for additional offers to relieve
and unburden family members is vital. Advance care planning should be inte-
grated early into the care of stem cell recipients (Button et al. 2014), and
nurses can address the above-mentioned topics and help patients and families
to find a way in the often overwhelming and complex situation. An interpro-
fessional palliative care service, supposedly even offered pre-transplantation
(Loggers et al. 2016), could provide support in helping throughout often
complex and instable situations which could lead to a better understanding of
the situation, lessen distress and increase hope and quality of life (El-Jawahri
et al. 2016) in the unit of care.
• Extended Practice Roles
In the late 1990s during the EBMT conference in Aix-les-Bain (France),

nurses performing diagnostic and therapeutic interventions such as bone mar-
row or lumbar punctures – up to that time executed only by physicians – were
strongly discussed and also criticized by the nursing audience. That can prob-
ably be considered as the beginning of the development of extended roles that
nurses nowadays perform on a regular basis. Importantly, throughout the dis-
cussion, the core tasks of nurses remain in the hands of nurses and are not
delegated to other professions.
Probably a suitable mix of skills and grades of nurses is the foundation of
professional nursing within the interprofessional team. Nurses trained on an
academic level and performing tasks as a nurse practitioner or clinical nurse
specialist are considered as advanced practice nurses. Several role models
exist throughout the European countries. Learning from the highly qualified
nurses in the USA and their approach of nursing inspired many European
nurses to go beyond what was up to then traditional in their own country.
Being academically trained often enabled nurses to argue more based on
evidence-reflected practice and led to being accepted by other academic
professionals.
Being part of the interprofessional team with a strong shoulder-to-shoulder
workforce together with physicians, physiotherapist, dietitians, social work-
ers or chaplains, nurses found their unique role in being present with the
patients 24/7 during the treatment but also in the time before and after the
treatment. Nurses took over the responsibility to educate patients before the
treatment about any aspects that are important to successfully undergo the
procedure. Over the past decades, many nurses not only developed clinical
skills but are also excellent researchers looking deeper into the phenomena of
patients, family members and measuring outcomes based on a reflective way
of practising nursing. The field of nursing research in HSCT has evolved
from reflecting on symptom management and service development to quality
of life and long-term survival topics.
xvi Brief History of HSCT Nursing: HSCT Nursing Through the Ages and Its Evolution
Outcomes of research form the basis of standard operating procedures

(SOPs) developed to support clinical practice, guarantee a high level of prac-
tice, and audit and accredit the transplant centres on evidence-based practice
guidelines. The translation of evidence into clinical practice and taking into
consideration the local circumstances is challenging. Still there are varieties
among the nursing care in different transplant settings (Bevans et al. 2009).
Therefore, networks of nurses in the field in which nurses discuss patient-
centred outcomes are vital – not only to prevent the reinvention of the wheel
but mainly to establish high-quality standards and data that are comparable in
research. Nurses collaborate in local, national and international networks
such as the EBMT Nurses Group, the American Society for Blood and
Marrow Transplantation (ASBMT), the Special Interest Group of the
American Oncology Nursing Society or the Haematology Nurses and
Healthcare Allied Professionals Group (HNHCP). Also nurses reach out to
cancer nursing organizations such as the European Oncology Nursing Society
(EONS) because issues of haematological patients are not always specific to
the stem cell transplant patient population but knowledge from the care for
patients with other malignant diseases can be useful in the care.
The shift of the focus towards more educational tasks – especially since
the emergence of oral drugs developed to cure haematological malignancies
without the necessity of a stem cell transplantation such as tyrosine kinase
inhibitors – changed the work of nurses tremendously. Unexpectedly –
despite the anticipation that patients with cancer will always take their medi-
cation as prescribed by their physician – nurses needed to develop skills and
knowledge of adherence. By collaborating together with the industry and
patients, educational initiatives were developed to support patients in adher-
ing to the prescribed regimen often over a very long disease and therefore
symptom-free time.
• Importance of HSCT Nursing
The best compliment towards nursing was done by Prof. Edward Donnall
Thomas (1920–2012), founding medical director of the Fred Hutchinson
Cancer Research Center’s Transplant Program who shared the 1990 Noble
Prize in Physiology or Medicine with Dr. Joseph E. Murray: he stated that
nurses and nursing was his secret weapon without whom he could not have
achieved his goals. This acknowledges that nurses play a vital role as part of
the interprofessional team in caring for the transplant recipients and their
families. The statement of Prof. Thomas should be the basis on which nurses
should develop the skills, knowledge and expertise to enhance a reflected care
and be alert for any changes in treatments which might influence care. Picking
up changes and supporting the developments will become a challenge in the
often complex healthcare environment. Nurses will need to understand the
challenges and shape the future care for any person trusting in what the inter-
professional team has to offer – and maybe unravel the “secrets” of nursing
and make it more visible of what nursing has to offer.
Bern, Switzerland Monica C. Fliedner

Brief History of HSCT Nursing: HSCT Nursing Through the Ages and Its Evolution xvii
Literature
Bevans M, Tierney DK, Bruch C, Burgunder M, Castro K, Ford R, et al.

Hematopoietic stem cell transplantation nursing: a practice variation study.
Oncol Nurs Forum. 2009; 36(6):E317–25. doi:10.1188/09.ONF.E317-E325.
Button EB, Gavin NC, Keogh SJ. Exploring palliative care provision for
recipients of allogeneic hematopoietic stem cell transplantation who relapsed.
Oncol Nurs Forum. 2014;41(4):370–81. doi:10.1188/14.ONF.370-381.
El-Jawahri A, LeBlanc T, VanDusen H, Traeger L, Greer JA, Pirl WF,
et al. Effect of inpatient palliative care on quality of life 2 weeks after hema-
topoietic stem cell transplantation: a randomized clinical trial. JAMA.
2016;316(20):2094–103. doi:10.1001/jama.2016.16786.
Loggers ET, LeBlanc TW, El-Jawahri A, Fihn J, Bumpus M, David J, et al.
Pretransplantation supportive and palliative care consultation for high-risk
hematopoietic cell transplantation patients. Biol Blood Marrow Transplant.
2016;22(7):1299–305. doi:10.1016/j.bbmt.2016.03.006.
JACIE and Quality Management
in HSCT: Implications for Nursing
1
Carole Charley, Aleksandra Babic,
Iris Bargalló Arraut, and Ivana Ferrero
Abstract
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?
C. Charley (*) • I.B. Arraut

JACIE Accreditation Office, Barcelona, Spain
e-mail: [email protected]
A. Babic
Istituto Oncologico della Svizzera Italiana,
Bellinzona, Switzerland
I. Ferrero
Stem Cell Transplantation and Cellular Therapy
Laboratory, City of Health and Science of Turin,
University of Turin, Italy/JACIE Accreditation Office,
Barcelona, Spain
© EBMT and the Author(s) 2018 1

M. Kenyon, A. Babic (eds.), The European Blood and Marrow Transplantation Textbook for Nurses,
https://doi.org/10.1007/978-3-319-50026-3_1
2 C. Charley et al.
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 mem-
bers 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 implica-
tions of JACIE for nurses.
Keywords
FACT-JACIE International Standards • Nurses implications • Quality
management • Standard operating procedures
1.1 Background to JACIE dards that gave rise to common difficulty experi-
enced by the transplant teams and to assess what
The 1990s saw an increase in the number of assistance, if any, would be required by the cen-
transplant teams performing haematopoietic stem tres for them to obtain accreditation. The results
cell transplantation (HSCT) (Passweg et al. of this pilot study underlined the need to imple-
2012). The procedure that was initially consid- ment national and international regulations
ered experimental during the 1960s/1970s was (Pamphilon et al. 2008) within each European
becoming an established treatment for many country. In January 2004, with the support from
blood cancers, solid tumours and acquired or the European Union under the Public Health
congenital disorders of the haematopoietic sys- Programme (2003–2008), the JACIE accredita-
tem within adult and paediatric populations. tion process was launched (Pamphilon et al.
Towards the end of the 1990s, the source of hae- 2008).
matopoietic stem cells was collectable from the To enable a set of international standards for the
marrow, peripheral blood and cord blood and provision of quality medical, nursing and laboratory
from autologous, sibling and unrelated donations practice in HSCT transplantation to be developed
(Demiriz et al. 2012). and recognised, JACIE collaborated with their
In 1998 two leading European scientific American counterparts, the Foundation for the
organisations, The International Society for Accreditation of Cellular Therapy (FACT) (JACIE).
Cellular Therapy (ISCT) Europe and the The “FACT-JACIE International Standards for
European Group for Blood and Marrow Hematopoietic Cellular Therapy Product Collection,
Transplantation (EBMT), formed a joint commit- Processing, and Administration” are revised on a
tee to be known as the Joint Accreditation regular basis.
Committee for ISCT and EBMT (JACIE) (JACIE JACIE remains a non-profit organisation with
n.d.; Cornish 2008). The purpose of this new all members being an expert within their spe-
committee was to establish a system to allow cialty: clinical, collection or processing
transplant teams to self-assess against a group of procedures of HSCT. Clinicians, nurses and qual-
standards (Cornish 2008), provide an inspection ity managers who are experts in their field can
process and recognise compliance with the stan- volunteer to become JACIE inspectors, if they
dards by awarding accreditation to those teams meet the criteria set. Potential inspectors must
who worked within the field of HSCT. A pilot attend a training programme, pass the inspector’s
study of the JACIE inspection and accreditation exam and act as an observer within the inspection
process was carried out in Spain 2000–2002. team as a trainee before their first official JACIE
This enabled JACIE to assess sections of the stan- inspection. As the JACIE accreditation process
1 JACIE and Quality Management in HSCT: Implications for Nursing 3
has evolved, the inspection team membership has Anthias et al. 2015, 2016). Nurses have suc-
extended to include apheresis nurses and more cessfully taking on the role of improving com-
recently experienced quality managers recognis- munications for donor mobilisation,
ing the multi-professional components of our collections and liaising with the staff of the
HSCT programmes. The accreditation process is processing facility.
continuous reflecting an established quality man- • Track and monitor collected cell products for
agement system (QMS); therefore accredited safety and viability from the time of donation
centres are required to apply for reaccreditation to the administration procedure. Patients’
every 4 years. In 2016, many transplant teams medical records must include not only the
were achieving reaccreditation for the 2nd or 3rd information of date and time of the collection
time, whilst other centres are applying for their but should include volume of collected prod-
initial application. At the beginning of December uct, type and volume of citrate and the product
2016, the JACIE website (www.jacie.org) (2016) identification. A transport log will be required
cited 334 successful initial accreditations; 197 to ensure traceability of all products from col-
successful reaccreditations from 26 countries had lection to processing and then to clinical for
been granted since 2000. Although the initial aim administration.
of the accreditation scheme was a voluntary pro- • Identify errors and incidents that can be
cess, in many countries, health-care systems/ reviewed and corrective actions be imple-
commissioners or health insurance providers and mented and allow a plan of action to be put
tissue banking authorities increasingly view into place to minimise the error reoccurring.
JACIE accreditation as important and demand • Formalise training and competencies.
accreditation to allow the procedure of HSCT to • Clearly identify the roles and responsibilities
be performed. of all staff working within the transplant team
Accreditation is the means by which a centre or with outside agencies (clinical, collection,
can demonstrate that it is performing to a required processing and support services; intensive
level of practice in accordance with agreed stan- care, radiotherapy, cleaning and transport ser-
dards of excellence. Essentially it allows a centre vices, laboratories and donor panels).
to certify that it operates an effective • Review documentation for evidence that stan-
QMS. Furthermore, due to the increased use of dards have achieved compliance on a regular
unrelated donors from different countries, inter- basis.
action and collaboration between units are key
elements for the success of stem cell transplanta-
tion. JACIE accreditation is a guarantee that the 1.2 reparing for JACIE
P
donor and the cellular product have been handled Accreditation
according to specific safety criteria.
A QMS is a mechanism to: 1.2.1 Considerations
• Ensure that procedures are being performed in In the early stages of preparing for accreditation,
line with agreed standards, with full participa- extra resources may be required: a dedicated
tion by all staff members. In a HSCT pro- quality manager, data collection manager and
gramme, this ensures that the clinical, support staff (pharmacist, dietician, social
collection and laboratory facilities are all worker) to fulfil the standards and prepare for the
working together to achieve excellent commu- inspection. Formalisation of the QMS and
nication, effective common work practices, accreditation will depend on structures already in
shared policies where appropriate and place.
increases guarantees for improved patient out- There will be many processing facilities that
comes and the use of international donor crite- are independent from the clinical transplant
ria for related donors (Gratwohl et al. 2014; teams and may also be responsible for c ollections
4 C. Charley et al.
of apheresis products. In this situation, the pro- administration, use of stem cell mobilisation
cessing facility and clinical facility have a choice agents and collection of cellular material.
of accreditation. They may decide to apply for The implementation of a QMS arises from
separate or combined accreditation. However, in the need to develop an appropriate system to
order to obtain JACIE accreditation, it is impor- optimise the quality of the service offered by a
tant that the QMS describes the communication stem cell transplantation unit, in a general con-
processes between all facilities involved and text of health-care quality improvement. A
provides the evidence that communications QMS is a tool that can be used to rapidly iden-
exist, e.g. minutes of weekly, monthly and tify errors or accidents and resolve them to min-
annual meetings must include the names of the imise the risk of repetition. A QMS assists in
attendees, sharing evidence of engraftment and training and clearly identifies the roles and
adverse events. It is important to remember a responsibilities of all staff (Cornish 2008;
clinical facility must use an apheresis and pro- Caunday et al. 2009).
cessing facility that are JACIE accredited. In 1966, Avedis Donabedian wrote a paper
Similarly, an apheresis facility must use a pro- entitled “Evaluating the Quality of Medical
cessing facility that is accredited before clinical Care”, where the concepts of structure, process
and apheresis facilities can be awarded JACIE and outcome in health care were introduced. The
accreditation. structure includes not only the physical aspects
in which care is given but also the resources and
tools available to the health-care team, the lead-
1.2.2 I mplementing a Quality ership and the staff. The process is how the
Management System health-care system and the patient interact. The
outcome includes the effect of care on diseases
HSCT is a procedure with a high technological and their prevention, such as the mortality rate,
content, which requires extensive attention the error rate and the quality of life (Samson
towards patients/donors who might introduce et al. 2007).
important problematic clinical factors and also During the 1950s, Edwards Deming intro-
towards sophisticated laboratory procedures duced the plan-do-check-act (PDCA) cycle, an
related to the collection, manipulation, cryo- iterative four-step management method used for
preservation and transplantation of haematopoi- the implementation and improvements of pro-
etic stem cells (HSCs). The continuous cesses and products, also known as plan-do-
improvement of stem cell technology requires study-act (PDSA). He also stressed the
that all procedures regarding HSCT be guaran- importance of viewing problems in the context of
teed through the definition of qualitative stan- a system and that most mistakes were not the
dards recognised by scientific associations and fault of the worker (Samson et al. 2007).
international organisations. For the collection, The major objective of the JACIE Standards is
processing and transplantation of HSCs, there are to promote quality medical and laboratory prac-
standardised procedures, which require specific tice in HSCT and other therapies using cellular
clinical, haematological and laboratory knowl- products; therefore dedicated quality manage-
edge and strict quality controls concerning all ment standards are found within the FACT-JACIE
processes from cellular collection and manipula- manual (clinical facility B04, marrow collection
tion to the administration of the collected prod- facility CM04, apheresis collection facility C04,
uct. Stem cell collection, processing, storage and processing facility D04).
transplantation must be carried out in a highly Quality management is the management of
regulated manner to guarantee both safety and activities involved in quality assessment, assur-
clinical efficacy. Therefore, quality assurance is a ance and control that try to improve the quality of
very important topic at all levels of HSCT, includ- patient care, products and services in cellular
ing robust nursing procedures, e.g. chemotherapy therapy activities.
A QMS could be implemented applying the In the 6th edition of the FACT-JACIE
PDCA cycle for the management and continuous Standards, more specific requirements for valida-
improvement of processes and products. tion and qualification studies have been delin-
eated, and the concept of risk assessment has
• PLAN means to establish the objectives and been implemented.
processes necessary to the centre. This means
define the scope of the QMS and identify which • Validation is documented evidence that the
processes within the scope are most important, performance of a specific process meets the
those staff who are involved in the important requirements for the intended application. For
processes and involve them in defining the tar- example, the procedure for thawing frozen
gets to be used to measure the quality of the cells should be evaluated, as there is a risk of
process. Ensure all staff knows how they can contamination and loss of cells during the
contribute to achieve the performance required. thawing process. A thawing control, on three
procedures, could be performed to assess
One important aspect to consider when imple- these criteria would validate the process.
menting a QMS is the organisation and interac- • Qualification is documented evidence that the
tion between the different facilities (clinical, equipment/facility/utility is meeting the user
collection and processing). The plan shall include requirement specification, working correctly
an organisational chart of functions, considering and leading to the expected results. For exam-
clinical, collection and processing staff, in par- ple, “the dry shipper used for the transporta-
ticular for those tasks that are critical to assuring tion of frozen haematopoietic stem cells
product or service quality. Training plans should should be validated for temperature control”.
be defined and put in place. Documentation may
be displayed in a variety of formats (job descrip- During the implementation phase, risk man-
tions, training records, qualifications certificates, agement should be an ongoing part of the quality
retraining). management process, to minimise hazards for
A document system should be implemented processes, patients and staff. There are several
serving multiple purposes for the QM pro- methods for the assessment of the risk, such as
gramme. They provide instructions on: Failure Mode and Effects Analysis (FMEA) or
Failure Modes, Effects and Criticality Analysis
• Activities, policies and processes controlling (FMECA), methods of assessing potential failure
various steps within the activities mechanisms and their impact on system, identi-
• Quality control and traceability of products, fying single failure points.
donor and patients
• DO means to implement the plan, execute the
The Quality Management Plan (QMP) (or process and carry on the activities. Once the
Quality Management Manual) should be one of programme has been established and staff
the first documents developed when preparing for trained, the activities and the quality plan
JACIE accreditation. The centre must have a should be maintained, through the document
standard operating procedure (SOP) outlining the system and the available resources. Policies
method by which to create, approve, implement and procedures could be revised, training pro-
and update SOPs (known as the “SOP for SOPs”). grammes implemented and the outcome
Clinical and collection protocols or laboratory analysis of cellular therapy product efficacy
methods must be translated into written proce- reviewed to verify that the processes in use
dures, in paper form or an electronic version, and provide a safe and effective product.
readily available to staff. The purpose of docu- • CHECK is to measure the results and compare
ment control is to ensure the correct approved them against the expected results or goals
documents are in use. defined by the plan. Audits represent one of
6 C. Charley et al.
the principal activities in this step and should as a self-evaluation tool. This document contains
be documented, independent inspection and all the JACIE Standards and will help the centre
retrospective review of activities to determine establish their level of compliance against each
if they are performed according to written pro- standard and identify further work required to
cedure and specified endpoints. They should achieve accreditation. Furthermore, the checklist
be conducted to ensure that the QMS is oper- is the pivotal tool used continually throughout the
ating effectively and to identify trends and JACIE accreditation process, until JACIE accredi-
recurring problems in all aspects of the pro- tation has been awarded.
gramme. Moreover, the transplant programme
should manage errors, accidents, deviations,
adverse reactions and complaints and monitor 1.3.2 pplication for JACIE
A
activities, processes and products using mea- Accreditation
surable indicators (Harolds 2015).
• Finally, ACT is to improve the QMS based on When the applicant has established a mature
the results of the previous steps. Investigation QMS, i.e. has been in place and operational for at
of errors and indicators and the implementa- least a year, a self-assessment of the standards
tion of corrective or improvement strategies has been performed and shows a high percentage
are undertaken and monitored with follow-up of compliance the centre can formally apply for
assessment to determine the effectiveness of JACIE accreditation. The completed application
the change. form and inspection checklist should be submit-
ted to the JACIE Office where the JACIE team
Data shown by Gratwohl and colleagues will review and approve the application form,
(Gratwohl et al. 2014) demonstrates the use of a finalising this part of the process by signing the
clinical quality management system is associated accreditation agreement with the centre.
with improved survival of patients undergoing Within 30 days of the application being
allogeneic HSCT. approved, the applicant will be required to pro-
vide the preaudit documentation to the JACIE
Office. The JACIE team and the inspectors will
1.3 he JACIE Accreditation
T determine that all required documentation has
Process been correctly submitted. The documents can be
provided in the language of the centre/applicant;
1.3.1 Start Working however in some exceptional cases, a translation
with the Standards in English of some key documents can be
requested. The preaudit documentation should be
The JACIE accreditation process begins when the submitted using the predefined folder structure
transplant centre, with the support of the hospital described on the JACIE website, which includes
management team (a key element in order to relevant documentation for all areas of the Stem
assure the required resources to successfully Cell Transplant Programme such as personnel
implement the JACIE accreditation process), documentation, donor consent information,
agrees to start working according to the JACIE labels and summary of QMS activities (Quality
Standards. Management Plan, audit report, policies).
It is important to gather all the necessary infor-
mation before commencing the JACIE accredita-
tion pathway. First read the JACIE Standards, 1.3.3 Arranging the Inspection Date
access the guides, manuals and supporting docu-
mentation from the JACIE website (www.jacie. The JACIE Office will begin the process to assign an
org). Then utilise the JACIE Inspection Checklist inspection date and the inspection team. However,
this part of the process can take approximately 6 • Closing meeting summarising the inspection
months from the approval of the application. The results with the transplant team
inspection team will consist of one inspector per
facility to be inspected. For example, if the applicant
has applied for adult clinical and bone marrow, 1.3.5 The Inspection Report
apheresis and processing accreditation, the inspec-
tion team will consist of the following: clinical, Following inspection, the inspectors submit their
apheresis and a processing inspector (The clinical completed written report and inspection checklist
inspector will be responsible for clinical and marrow to the JACIE Office. The inspection report is a
collection facilities). The inspectors are selected fundamental part of the accreditation process. The
according to their area of expertise: clinical, aphere- report will be prepared and presented to the JACIE
sis and processing. For instance, a clinician will Accreditation Committee by the JACIE Report
inspect the clinical facility. If a paediatric unit is part Assessors after their review and confirmation
of the inspection, a paediatrician will be assigned. with the inspectors over any issues, if necessary.
When there is more than one facility per area, for The Accreditation Committee is a group of
instance, two apheresis units, an extra collection experts from all areas of Stem Cell Transplantation
inspector will be included in the inspection team. (Clinical, Collection and Processing) that dis-
The applicant will be invited to view the list of cusses each individual report and determines cor-
JACIE inspectors, found on the JACIE website, rective actions the centre is required to implement
and inform the JACIE Office if there are any in order to achieve the JACIE accreditation.
inspectors that they prefer not to participate in Please bear in mind that although the inspectors
their inspection, due to conflict of interest. The identify areas of non-compliance, it is the JACIE
inspection will be performed in the language of Accreditation Committee who decide the correc-
the centre unless there are no JACIE inspectors tive actions, not the inspectors.
that speak the language of the applicant centre; in
these cases, the inspection will be performed in
English with language support. 1.3.6 orrections and Accreditation
C
Award
1.3.4 The Inspection A high percentage of all inspections reveal defi-

ciencies and the degree of deficiency identified
The inspection will take place over a period of will vary in seriousness. In most cases, evidence of
1–2 days and is a thorough examination of all corrections can be submitted electronically.
aspects of the programme. The inspector will use However, if the deficiencies are considered a risk
the inspection checklist previously completed by for patients, donors or personnel, a focussed re-
the applicant to evaluate the centre’s compliance inspection will be required before JACIE accredi-
with the standards. tation can be finalised.
The inspection is usually divided in the fol- Centres are allowed a period between 6 and 9
lowing parts: months to implement and submit the corrections
to the JACIE Office. The same team of inspectors
• Introductory meeting by the programme direc- will review and assess the adequacy of the cor-
tor and the inspection team with all the pro- rections provided by the centre. Once the inspec-
gramme personnel tors are satisfied that all points have been resolved
• MEDA/B data audit and review of and with the approval of the JACIE Accreditation
documentation Committee, the applicant will be awarded the
• Interviews with personnel JACIE accreditation for a 4-year period, subject
• Closing meeting with programme director to an interim audit at the end of the second year.
8 C. Charley et al.
1.3.7 Post JACIE Accreditation 1.4 J ACIE Standards that Affect

Nursing: Clinical
The inspection is the most visible part of the and Collection
JACIE accreditation process. The most challeng-
ing part, once the JACIE accreditation has been The JACIE Standards are divided into sections:
awarded, is maintaining accreditation. At the sec- clinical and donor (B), collection of marrow
ond year of accreditation, the interim audit will be (CM), apheresis products(C) and laboratory (D).
due, and if the system has not been maintained, the Many of these standards are shared across each
hard work invested in achieving accreditation will facility as appropriate (Table 1.1).
become void and centres return to the beginning of It is not possible to describe, within this
the process when applying for reaccreditation. chapter, all the actions and evidence required to
The JACIE Committee warns against failing fulfil a full compliance for all the standards pub-
to uphold standards or maintain the QMS between lished in the latest edition of the JACIE
inspections. Those centres that fail to maintain Standards; therefore in Tables 1.2, 1.3 and 1.4,
their QMS due to lack of commitment or allow there are examples of appropriate standards,
their system to devolve may discover standards compliance and comments that have implica-
that were compliant at the initial inspection may tions for nurses.
become partially or noncompliant during the It is important that the nursing team takes
inspection required for reaccreditation. Inspectors ownership of the relevant standards and works
will identify failures to review documentation, towards achieving full compliance whilst being
perform audits and maintain competencies due to aware of the other standards that have implica-
the lack of available evidence during the accredi- tions on nurses or nursing (Table 1.5).
tation cycle.
Table 1.1 FACT-JACIE Hematopoietic Cellular Therapy Accreditation Standards (6th edition)
QUALITY MANAGEMENT
CLINICAL PROGRAM STANDARDS COLLECTION FACILITY STANDARDS PROCESSING FACILITY STANDARDS
PART B PART C PART D
B1 General C1 General D1 General

B2 Clinical Unit C2 Apheresis Collection Facility D2 Processing Facility
B3 Personnel C3 Personnel D3 Personnel
B4 Quality Management C4 Quality Management D4 Quality Management
B5 Policies and Procedures C5 Policies and Procedures D5 Policies and Procedures

B6 Allogeneic and Autologous C6 Allogeneic and Autologous Donor D6 Equipment, Supplies, and Reagents
Donor Selection, Evaluation, and Evaluation and Management D7 Coding and Labeling of Cellular
Management C7 Coding and Labeling of Cellular Therapy Products
B7 Recipient Care Therapy Products D8 Process Controls
B8 Clinical Research C8 Process Controls D9 Cellular Therapy Product Storage
B9 Data Management C9 Cellular Therapy Product Storage D10 Cellular Therapy Product
B10 Records C10 Cellular Therapy Product Transportation and Shipping
Transportation and Shipping D11 Distribution and Receipt
C11 Records D12 Disposal
C12 Direct Distribution to Clinical D13 Records
Program
Table 1.2 Examples of “non compliant” clinical standards (FACT-JACIE Hematopoietic Cellular Therapy
Accreditation Standards: 6th edition)
B.03.07 NURSES
B.03.07.01 The Clinical Program shall have nurses Partially No evidence of formal
formally trained and experienced in the Compliant training in the transplant
management of patients receiving cellular setting
therapy.
B.03.07.02 Clinical Programs treating pediatric Partially Nurses are paediatric

patients shall have nurses formally trained Compliant qualified but lack
and experienced in the management of evidence of formal
pediatric patients receiving cellular training in the transplant
therapy. setting
B.03.07.03 Training and competency shall include:
B.03.07.03.03 Administration of blood products, growth Partially Hospital policy does not
factors, cellular therapy products, and other Compliant include the administration
supportive therapies. of cellular products;
therefore a policy for the
administration of cellular
products is required. This
policy can then be used
for training and
competency testing
B.03.07.03.06 Palliative and end of life care. Non Compliant No training
B.03.07.04 There shall be written policies for all

relevant nursing procedures, including, but
not limited to:
B.03.07.04.01 Care of immunocompromised patients. Partially Hospital policy used does

Compliant not include the severely
compromised transplant
patient, therefore a policy
or SOP required
B.03.07.04.03 Administration of cellular therapy Partially Policy/SOP does not

products. compliant include administration of
donor lymphocytes
B.03.07.06 There shall be a nurse/patient ratio Partially During the discussions

satisfactory to manage the severity of the compliant with nursing staff there
patients’ clinical status. appears to be an informal
policy in place to increase
the number of nursing
staff when required. A
formal policy should be
written
10 C. Charley et al.
Table 1.3 Examples of “non compliant” quality management standards for clinical and apheresis facilties (FACTJACIE
Hematopoietic Cellular Therapy Accreditation Standards: 6th edition)
B.04 QUALITY MANAGEMENT COMPLIANCE COMMENT
B.04.04 The Quality Management Plan shall include,

or summarize and reference, policies and
Standard Operating Procedures addressing
personnel requirements for each key position
in the Clinical Program. Personnel
requirements shall include at a minimum:
B.04.04.01 A current job description for all staff. Partially Job Description not
C.04.04.01 Compliant available for all nursing
grades/roles
B.04.04.02 A system to document the following for all

C.04.04.02 staff:
B.04.04.02.02 New employee orientation. Partially Orientation program in

C.04.04.02.02 Compliant place but no evidence
that nurse Smyth (only
worked on the ward for
3 months) has
participated in the
orientation program
B.04.04.02.03 Initial training and retraining when appropriate Partially No evidence of re-
C.04.04.02.03 for all procedures performed. compliant training for Nurse X
who has returned from
long-term absence.
B.04.04.02.05 Continued competency at least annually. Partially Not all nursing staff
C.04.04.02.05 compliant have evidence that
competencies are
performed annually
B.04.04.02.06 Continuing education. Partially Education program in

C.04.04.02.06 Compliant place but no attendance
list for each education
activity
B.04.08.03 Audits shall include, at a minimum:
B.04.08.03.03 Annual audit of verification of chemotherapy Non compliant Not performed

drug and dose against the prescription
ordering system and the protocol.
B.04.11 The Quality Management Plan shall include, Partially Policies and SOP are
C.04.11 or summarize and reference, policies and compliant included with the QMP.
procedures for cellular therapy product Staffs do not complete
tracking and tracing that allow tracking from the tracking forms.
the donor to the recipient or final disposition
and tracing from the recipient or final
disposition to the donor.
Table 1.4 Examples of “non compliant” policy and procedure standards for clincial and apheresis facilties (FACTJACIE
Hematopoietic Cellular Therapy Accreditation Standards: 6th edition)
B.05 POLICIES AND PROCEDURES COMPLIANCE COMMENT
B.05.01 The Clinical Program shall establish and

C.05.01 maintain policies and/or procedures addressing
critical aspects of operations and management in
addition to those required in B4. These
documents shall include all elements required
by these Standards and shall address at
a minimum:
B.05.01.08 Administration of HPC and other cellular Partially The policy has not been
therapy products, including products under Compliant updated to include Cord
exceptional release blood
C06.01.07 Labeling (including associated forms and Partially Labeling procedure

samples) Compliant should show more details
regarding roles of
physician and nurse
involved in labeling
operations
C.05.01.14 Equipment operation, maintenance, and Partially No evidence of

monitoring including corrective actions in the Compliant maintenance reports
event of failure.
B.07.04.04 Prior to administration of the preparative Non Compliant No evidence of two

regimen, one (1) qualified person using a persons verifying the
validated process or two (2) qualified people drug.
shall verify and document the drug and dose in
the bag or pill against the orders and the
protocol, and the identity of the patient to
receive the therapy.
B.07.06 There shall be a policy addressing safe Partially The policy has not been
administration of cellular therapy products. Compliant updated to include Cord
blood
B.07.06.04 Two (2) qualified persons shall verify the Non Compliant No evidence of two
identity of the recipient and the product and the person verify the drug
order for administration prior to the
administration of the cellular therapy product.
B.07.06.06 There shall be documentation in the recipient’s Partially No evidence of start and
medical record of the administered cellular compliant completion times of the
therapy product unique identifier, initiation and infused product written in
completion times of administration, and any the recipient’s medical
adverse events related to administration. notes
Table 1.5 Examples of “non compliant” process control standards for apheresis facilities (FACT-JACIE Hematopoietic
Cellular Therapy Accreditation Standards: 6th edition)
C.08 PROCESS CONTROLS COMPLIANCE COMMENT
C.08.10.01 Adequacy of central line placement shall be Partially No evidence that this
verified by the Apheresis Collection Facility Complaint standard is performed
prior to initiating the collection procedure.
C.08.11 Administration of mobilization agents shall be Partially The responsibilities of

under the supervision of a licensed health care Compliant administration of growth
professional experienced in their factors should be clearly
administration and management of defined in the
complications in persons receiving these appropriate policies
agents. especially for those
donors where shared care
is in place
C.08.12.01 Methods for collection shall include a process Partially Criteria for HPC-A
for controlling and monitoring the collection Compliant collection should be
of cellular therapy products to confirm defined together with
products meet predetermined release ranges of expected
specifications. results concerning HPC
product characteristics
1.4.1 taffing and Nursing

S action to be taken for small teams, apheresis,
(Table 1.2) quality management and data collection teams, in
case of planned or unplanned long-term absence
Senior staff should be aware that the patient’s from work, therefore allowing the patient’s or
pathway, during the transplant process, can be donor’s pathway to continue without affecting
unpredictable. There are episodes when the the nursing or medical care given.
patient will experience complications of the treat- Not only should there be adequate nursing
ment required for HSCT that will require a higher staff, the nurses should be qualified, trained and
intensity of nursing care. During such episodes, competent in the roles they perform.
the nursing management should have an estab- JACIE can be a challenge and an opportunity
lished contingency plan to provide adequate for nurses in:
nursing care for these patients. Possible options
could be: • Reviewing existing procedures
–– Especially those that have been performed
• Nursing staff within the team allowed to work automatically in the same way despite
extra shifts being inefficient
• The employment of additional nursing staff • In adopting measures for clinical risk
with relevant experience from the hospital management
pool of nurses or from nursing agencies –– Paying more attention to long-term plan-
• Transfer of the patient to a high dependency or ning for continuing education of personnel,
intensive care setting procedures and tools for monitoring, veri-
fying and in achieving competence
Whatever the contingency plan, there should maintenance
be evidence in place, such as a written policy for • Development and implementation of internal
staffing. This policy should describe the plan of audits and quality indicators
Furthermore, JACIE is an opportunity for can be difficult to show (Table 1.3). Ongoing
nurse recognition within the organisation they training for clinical personnel should reflect:
work, in terms of contribution to the overall
results achieved. • Their experience
• Individual competencies and proficiencies
• Orientation for new staff
1.4.2 raining and Competencies
T • Preceptorship
(Tables 1.2 and 1.3)
Training needs to be flexible to reflect staff
All hospitals should have their own programme requirements and should be performed in a timely
for training, annual review/appraisal and compe- manner to demonstrate annual updating.
tencies. The structure already in place for record- When staff cannot attend a particular training
ing the individual staff members training can also session due to staffing issues, holidays or sick-
be used to record the JACIE Standards’ require- ness, a self-teaching system, e.g. an electronic
ments. A new system for training records for system that includes the presentation and self-
JACIE is not required if the following is assessment tool, may be an option to consider.
undertaken. For those centres that apply for a combined
adult and paediatric JACIE accreditation, it is
• Basic training: important that training sessions should include
–– A route that leads to the skills acquisition relevant age-specific issues for each topic, espe-
in order to obtain new or improved cially if the two age group populations are nursed
“performance” within the same ward environment. Where adult
• Educational training: and paediatric patients are nursed on separate
–– The set of activities, including basic train- wards, training sessions may be separate for cer-
ing, aimed to develop and enrich the staff tain topics, but it is also important to share ses-
on the technical, special, managerial and sions, where appropriate, to provide evidence
cultural side aspects of their role that both population groups are an integrated part
• Competence: of a combined transplant facility.
–– The proven ability to use knowledge and The FACT-JACIE International Standards
skills Accreditation requires that the clinical pro-
• Competency maintenance: gramme have access to personnel who are for-
–– The minimum activity that is required to be mally trained, experienced and competent in the
performed by each operator in order to management of patients receiving cellular ther-
retain the assessments defined in the spe- apy. Core competencies are specified within the
cific job description. standards, and evidence of training in these com-
• Competency matrix: petencies must be documented. This may be
–– The activities performed must be recorded achieved by evidence of in-service training,
in order to perform an annual assessment attendance at conferences, etc.
(quantitative and qualitative) for the activi- During September 2016, the EBMT (NG) in
ties that can be recognised. collaboration with JACIE and the EOC (Ente
Ospedaliero Cantonale - multicentre Swiss hos-
It is important that training and competency pital name, www.eoc.ch) launched the first video
programmes are structured and ongoing, with recorded course, aimed at physicians, nurses and
documented evidence of training topics and technicians working within JACIE-accredited
dates. Most importantly, an attendance register centres. The course focused on competency
for training and competency sessions is required. maintenance and could be accessed in person, on
Whilst initial supervised training is more easily the day, or through online conferencing and is
documented, annual competency maintenance now a source of video recorded e-sessions,
lectures and questionnaires, available online free mined period of time, it is necessary to reassess
of charge. Upon correct answering of question- the changes made to measure any improvements
naires on every topic, participants to the in-site or resulting from those changes. This is referred to
online conference are able to obtain a Certificate as “closing the audit loop”. A nursing audit sched-
of Competence that is validated by EBMT and ule works best when the nursing teams initiate the
JACIE that can be used as evidence towards the audit topics. It is important to include the audits
JACIE inspection. In addition, the activities were required by JACIE, e.g. (1) the verification of the
granted a CME certification by EBMT/EBAH chemotherapy drug and dose against the prescrip-
and Swiss CME credits (The course is available tion and the protocol and (2) the verification of the
at http://www.dsit.it/prj/ebmt2016/inex2.php). haematopoietic stem cell infusion.
This initiative was based on an online test system It is important that the audit is performed by
using a SharePoint internal hospital standard personnel that are not directly involved within the
operating procedures compliant with FACT- activity to be audited.
JACIE standards, developed by the Bellinzona
transplant centre (Babic et. al. 2015).
1.4.5 eporting Adverse Events
R
(Table 1.3)
1.4.3 enefits of Quality
B
Management (Table 1.3) To enable adverse events to be fully reported, it is
important that a culture of “no blame” is present.
The key aim of the JACIE process is to implement The hospital should have an established reporting
a QMS into clinical practice. Despite the difficul- system in place, and it is important that the
ties that maybe encountered, the process can be adverse events for transplantation and collection
useful for integration of staff from all disciplines of cellular products including apheresis and mar-
and professional collaboration. Staff education row can be coded separately to other departmen-
plays a key role in the implementation of the tal adverse events. This allows for clarity and a
whole system and in particular for the quality true record of the number of events recorded for
management system (Piras and Aresi 2015). The the transplant programme. Each episode is
majority of the quality standards are aimed at pro- reviewed and changes made if required. This is
viding evidence that there are systematic pro- then followed by an audit of the changes made to
cesses in place. Furthermore, several of the minimise a reoccurrence. Nurses working with
standards relate to having systems in place to patients and donors have a very important role in
record initial qualification, training and compe- reporting adverse events.
tencies and minimal qualifications for the trainer. It is important that all adverse events are
The hospital system can be utilised for these stan- recorded in the quality meeting minutes, quarterly
dards, and this evidence can be shown to the and annual reports and most importantly shared
inspectors. However, not all hospital record sys- with all the sections involved in delivery of the
tems register the training qualification required by transplant programme (clinical, collection and pro-
a member of staff who has a training role. cessing), as appropriate. For example, if a recipient
has a reaction to a stem cell infusion or there is a
deviation from the time specified for each infusion
1.4.4 Audits (Table 1.3) of thawed cells, these events should be reported
and shared with the processing facility.
Some nurses may be unfamiliar with this area. Where adverse events have been shared across
One approach is to view audits as assessing the departments, the inspector will require evidence
care you give, reviewing the evidence and making that the events were discussed, and if any changes
changes to improve the patient’s or donor’s expe- were made to practice that this was recorded, poli-
rience and/or nursing care given. After a predeter- cies were updated and the episode monitored.
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hair, stuff her fingers down his neck, pluck off ruthlessly the
finest blossoms from his favourite plants, throw his pet
books recklessly on the floor, thereby breaking their backs,
scribble over his carefully written Latin exercise, and yet he
could not find the heart to be angry with her.
"When could Father be home, if he comes?" asked Forbes,

after a few moments pause.
"He might be here by Christmas," answered Geoffrey. "Poor

Father! He must know by this time," he added, seating
himself again by the fire. "Mr. Hodson telegraphed to him
last night."
"Nurse says we needn't go back to school till after

Christmas," remarked Jack, "We shall have a jolly long
holiday."
"Jolly!" exclaimed Geoffrey, looking up in surprise,—then he

remembered that Jack was only seven years old.
CHAPTER II.
WHO BROKE THE DOLL?
Had the inhabitants of Hazelbury seen the Rev. Claude
Hodson on a certain winter's afternoon about a fortnight
after the events recorded in the last chapter took place,
crawling about the floor of his sitting room on all fours,
minus a coat, but with a rug thrown across his back, and
roaring in imitation of some wild beast, they would scarcely
have recognised him as their quiet and grave young curate.
With children, he felt thoroughly at ease, and specially with

his little friends the Fortescues. Nothing gave him greater
pleasure than to have all four of them to spend the
afternoon with him and to stay to tea.
Mrs. Fortescue had always been very kind to him, and he

had felt less shy with her than with most people.
Thinking that the young man must be lonely, she had

allowed the boys to run in and out of his rooms on their half
holidays, at his request, and thus a warm friendship was
formed between them.
The table was pushed to one side, its former contents cleared
quite away,
next Sunday's sermons among them.
During Mrs. Fortescue's last illness, no one could have been
more tender to and sympathizing with the children than he
was, and it was to him that Geoffrey had gone at once when
the end came. "Mr. Hodson," he had said, looking up at him
with tearless eyes, but with a pale face, "Mother has gone."
For the minute Claude was quite silent, and then he did,
what to him was the only possible thing he could do under
the circumstances.
"Let us pray, Geoff," he had said in a low voice, and though

no word was uttered aloud by either of them, they knelt
silently together, Claude's hand resting tenderly on the
boy's shoulder.
Geoff did not cry. His breath came quick and short for a few
minutes, and then he grew calm. From that day their
friendship was sealed.
On this particular afternoon of which I write, the Curate was

in his element. He had invited his little friends to tea and
had resolved to do what he could to cheer them up and to
make them happy, and he certainly had succeeded.
Game after game they had played, turning everything in his

room upside down.
The table was pushed to one side, its former contents

cleared quite away, next Sunday's sermons among them,
for the Vicar was away from home, and the preaching
therefore devolved on the Curate.
Dodie was sweeping about the room, with the table cloth
tied round her waist, forming a long train behind her, and
an antimacassar thrown over her head for a veil, and the
Curate himself amidst the shrieks of his little friends, was
prowling about the floor, supposed to be a wild beast, trying
to catch the children one by one.
Everything was in wild confusion, and Mrs. Green, the

landlady, hearing the merriment from her dull little parlour
at the back of the house, could not resist giving a peep into
her lodger's room, to see a bit of the fun.
At the sight of her at the door, Claude sprang up from his

humiliating position, and wiping the heat from his brow,
said:
"I'm afraid Mrs. Green that we are making an unearthly

noise, you've not a bad head to-day, I trust."
"Bless you, no Sir," said Mrs. Green, laughing, "It does one's
heart good to see them enjoying themselves, poor little
dears. I like a noise, it's cheery. 'Why Sally,' my husband
has said many a time to me, when I've complained of the
quiet of the country, 'I do believe,' says he, 'you'd like to
live in an Inn, where people are always going and coming.
One day, says he, when my ship comes in, I'll buy a Hotel
at Yarmouth or Margate or some such place, and then you'll
have as much noise as you like.'"
"You've had enough noise I expect for one day, any way,"
said Claude, suddenly becoming conscious that he was
standing talking to his landlady in his shirt sleeves, and
turning round to hunt for his coat among the confusion.
"Well as I tell you Sir, I like it, it's cheerful. Now that's what
I like to think about Heaven," continued Mrs. Green, who at
the slightest show of interest on the part of her listener, was
inclined to become garrulous. "We shan't have no dull back
parlours there I take it, not seeing a soul from one day to
another, all shut up by ourselves like. We shall always be
coming across new people there, and there'll be plenty to
see and to hear. Think of old Rachel, Sir, her as lives at the
bottom of the hill all by herself. She don't see a fresh face
from one week's end to another. What a nice change it'll be
for her now, that's to say if ever she gets there. I'm afraid
she ain't fit for Heaven yet from all I hear."
The children interrupted in their game stood staring at the

intruder, somewhat indignantly, while Dodie administered
sundry impatient thumps on Claude's back.
"I must say," added Mrs. Green, "that that daughter of hers
behaves shameful. Ever since she married the man Jones
she has quite neglected her poor old mother, and if ever she
gives her anything, you may be quite sure it ain't fit to eat,
something they can't eat themselves because it's turned."
"What!" cried Geoffrey. "Does she do that to her own

Mother?"
"You may well cry out, Master Geoff, it's a wicked shame,
and I tell you Sir," she added, turning to Claude, "mark my
word, if that woman don't manage somehow to get the
Christmas Charities this year, even though her own old
Mother has to go without."
"Come, come, Mrs. Green," expostulated Claude, "She's not

quite so base as that, I hope. However I'll have an eye on
her at Christmas; and now," he added, as Dodie's thumps
became more violent, "do you think you could let us have
tea? It's early I'm afraid, but we're all hungry. Is it too
early?"
"Bless you no Sir,—not if you want it. I'm always willing to

do what I can to make you comfortable. 'Sally,' my husband
used to say to me when I had troublesome lodgers, 'don't
you mind being put about a bit, keep a cheerful
countenance my girl,' and so I've always tried to do Sir, and
though the kitchen fire is a bit low as I didn't know you'd be
wanting tea quite so early, I'll make it up at once Sir, and
tea will be ready in a few minutes."
And Mrs. Green hurried off with a good-natured smile on

her face, thinking to herself, "Who wouldn't be obliging to
such a nice young gentleman, I should like to know—such a
quiet lodger too—so different from my last party. I
sometimes wish he'd make a little more noise, that I do; it
'ud be more cheerful. But there now, it isn't his way. Bless
me! Flow those dear children are enjoying themselves," as a
fresh peal of laughter found its way down into the kitchen.
Nurse's hair would have stood up on end, if half an hour

afterwards she had looked in, and seen the zest with which
the three boys tucked in to the apricot jam and currant
cake, which their host brought out of his cupboard.
Geoffrey perhaps fared the worst of the three, for a great

deal of his time was spent in looking after Dodie, tying on
her bib, cutting her bread and butter into tempting little
shapes, so as to take off her attention from the currant
cake, which he knew she must not eat, giving her tiny little
portions of his own jam on her bread and butter to taste.
He would not let anyone do anything for her but himself,

and no mother could have been more careful of her.
"Mr. Hodson," said Forbes, when after tea they put on their
hats and jackets most unwillingly to go, "will you take us
one day into Ipswich to get our Christmas presents? It's
three weeks to Christmas now, and Nurse won't let us go
alone, though of course Geoff could take care of us. Mother
used always to let him go into the town alone."
"I want to get heaps of presents," said Jack, tugging away

at his boots breathlessly, "there's Nurse, and James, and
Ann, and Geoff of course, and the others, I don't think I can
buy mine all in a day."
"I wouldn't tell a lie if I were you," said Geoff, "it's very mean to
tell a lie."
"Well, you'll have to, that's all," said Forbes, "and we
mustn't forget Father's present, at least I suppose he'll be
with us then. We've had a telegram to say he is coming
soon, and he'll send another when it's quite decided. Do you
think you could take us, Mr. Hodson?"
Claude promised he would do what he could, and then

Dodie was put into her little mail cart, which of course Geoff
drew himself, and their friend saw them safely home.
Nurse met them at the door.
"It's wonderful kind of you Sir to have them," she said,

lifting Dodie out of the cart and giving her a hearty kiss, "I
hope they've all been good," then, as Claude made his
escape, after assuring her it had been quite as much
pleasure to him to have them, as it was for them to come,
Nurse made her way up into the nursery, seated herself in
her large chair by the fire, and began to take off Dodie's
gloves. But Dodie was tired, perhaps from over excitement,
and was not inclined to sit still, and finally ended in crying,
as the string of her little cape had got into a knot, and took
nurse some time to undo.
"Where's her doll?" said Nurse, "run and fetch it, there's a
good boy, it'll stop her crying."
Forbes went to the cupboard to look for it, but it was not
there. He hunted all over the nursery, but it was no where
to be found. After a long search, he went down into the
schoolroom, and to his astonishment found it hidden away
behind the curtain, with its face not only cracked, but
looking as if it had been melted in the fire. Forbes ran
upstairs two steps at a time, as he held out the doll for
Nurse to see; Jack, who was on the floor reading a book by
the light of the fire, looked up and turned very red, while
Dodie, catching sight of her disfigured doll, set up a lusty
scream, and was a long time before she would be
comforted, in fact not till Forbes had carried the doll out of
the room, having beckoned to Jack to follow him.
They met Geoffrey on the stairs.
"What's the matter with Dodie?" he asked.
Forbes explained the mysterious finding of the doll, and the

three went back into the schoolroom to see the exact spot.
"Who could have done it?" murmured Jack.
"That's just it," answered Forbes, "we must find that out of
course, it was hidden away on purpose."
"Could Dodie have broken it herself?" suggested Jack.
"Dodie! Of course not, why you saw yourself how scared

she was at the sight of it. I suppose Jack—" Forbes
hesitated and looked down at his little brother, who turned
again very red.
"Jack," said Geoffrey gravely, "you know something about

it, did you do it?"
"I? No! of course not, I don't know anything about it,"

stammered Jack.
"I wouldn't tell a lie if I were you," said Geoff, "it's very
mean to tell a lie."
"It isn't a lie," said Jack angrily, "I tell you I don't know who
did it."
"I do," retorted Forbes, "so there's an end of it," and he was
just about to leave the room when he felt a sharp kick on
his ancle, and turned round to see Jack's face crimson with
rage and his small hands clenched.
"Oh, that's it, is it?" said Forbes coolly, and being a much
stronger boy than Jack, had him down on the ground in a
moment of time, and held him there saying, "I shan't let
you go till you've confessed that you're a wicked little liar."
Geoffrey here interfered.
"Come Forbes, that isn't fair," he said, "he's a little chap,

and besides we have no right not to believe him. Let him
go, there's a good fellow."
But it was not till Forbes had administered a certain amount

of corporal punishment on the offender that he let him go,
and saw him make his way upstairs sobbing.
Jack did not however, for a wonder, go straight to Nurse,

but hid himself on the floor in a dark corner of the night
nursery.
There huddled poor little Jack, with a great burden on his

conscience. He had told a lie—a direct lie—and he had told
it twice, and yet he felt he could never confess that he was
the guilty one. They would never forgive him for spoiling
Dodie's doll, and they would always look down upon him for
telling a lie about it. Jack sat and cried all by himself in the
dark, and did not move from his corner till nurse herself
came up an hour afterwards with Dodie in her little
nightdress in her arms. It was only on putting the candle on
the chest of drawers that she discovered Jack.
"Why my beauty!" she cried, laying Dodie down and turning

towards Jack, "What's the matter, eh? Has anyone been
unkind to you?"
And taking him on her knee, she kissed him and smoothed
his hair, and rocked him in her kind old arms, in great
distress at finding him crying in the dark.
"He's thinking about his poor dear Mamma, I do believe,

bless him," she thought to herself, as Jack still sobbed,
giving no explanation of his tears; then aloud she said, "if
you're a good boy, you shall have a bit of cake for supper.
Leave off crying, there's a darling, while I tuck Dodie up,
and then I'll tell you a story by the nursery fire."
So Jack went down into the nursery, with the lie still on his
conscience, and looking very shamefaced. It was true he
was able to enjoy the large slice of currant cake which an
hour or two afterwards Nurse gave him, for Jack could
enjoy cake under almost any circumstances, but he did not
enjoy meeting Forbes' eyes fixed upon him, after taking an
unusually large mouthful.
Forbes and Geoff were eating the usual supper of bread and
butter by the table, and neither of them could quite make
out what Jack had done to deserve an extra treat in the way
of cake, and to be allowed to eat it by the fire,
notwithstanding the crumbs which fell on the carpet, and
against which Nurse as a rule waged war.
That look of Forbes, however, almost choked Jack. He was

eating the last mouthful, but I do not think he could have
eaten another, certainly not with Forbes' eyes upon him.
He was glad when it was time to go to bed. He went up to

Geoffrey who kissed him as usual, but Forbes waved him
away, and Jack stumbled out of the nursery with his eyes
full of tears, and feeling himself to be the meanest little
wretch alive.
Jack slept in a bed in the night nursery, in the opposite
corner to Dodie's crib, which was close beside Nurse's big
bed, and as a rule, he fell asleep the moment his head
touched the pillow, but tonight he could not sleep. He lay
awake, longing to hear Nurse's step on the stair outside, he
longed for the comfort of her motherly presence. When,
however, she came up at last, Jack, afraid lest she should
ask him questions, feigned to be asleep at first, and then
when she had smoothed his pillow and tucked him up for
the night, he opened his eyes, and amused himself by
watching her shadow on the ceiling as she moved about the
room. But this amusement soon came to an end, before
long he saw her blow out the candle, and heard her get into
bed, and all was still.
Then Jack's burden, in the silence and dark, grew so heavy

and large that he could bear it no longer, and sitting up in
bed, he cried out "Nurse! Nurse!"
In a moment the candle was lit again, and Nurse by his

side.
"What is it, dearie?" she asked, putting her arms round him.
"Have you had a bad dream, dear heart?"
"I've told a lie," sobbed Jack. "It was me that spoilt Dodie's
doll, I was pretending to ha-ha-hang her for fun, and she
dropped and br-br-broke her face, and I tried to mend it, so
that no nobody should know. I broke it, and I thought the
fire would make the cr-cr-crack all right again, but it did-
did-didn't, it made it worse. So I hid it away in the sch-sch-
schoolroom, and I have told two lies to Geoff and Forbes,
and I don't think God will ever forgive me, and Forbes will
ha-ha hate me."
"You're a good boy to tell me," said nurse, "and don't you
cry no more, there's a darling. You just tell God about it.
You may get out if you like, and kneel down now and pray,
and I'm certain sure that if you are really sorry, the good
God will forgive you," and kind old Nurse wiped away a tear
or two herself, and after tucking him up in bed again, and
kissing him, she knelt down by her own bedside to pray for
her boy.
Jack confessed to Forbes next morning, and the latter gave

him a slap on the back, saying:
"That's right old boy, stick to the truth though another time,
that's all."
CHAPTER III.
PREPARING FOR CHRISTMAS.
According to his promise Mr. Hodson arranged an afternoon

on which to take the three boys into Ipswich.
They started early in the afternoon in high spirits. The sky

was a clear blue with white billowy clouds sailing slowly
across it, and the air was cold and crisp. The river which
they passed on their way to the town had caught the colour
of the sky, and one or two little white sailed boats were
reflected on its waters, while in the distance a large ship
with red sails was slowly making its way against wind and
tide.
Geoffrey was the only one of the three boys whose thoughts
were full of anything except the shops which they were
nearing, and the presents they were about to buy. He could
not but remember that the chief excitement in past years of
buying Christmas presents was over, that the best present
of all would not be wanted. How gladly would he have
parted with all his little savings if only he could buy his
Mother a present once again. He felt he would willingly give
her all he possessed.
Afraid as he was of giving people trouble himself, he was quite
aghast
at the way the boys insisted upon having the counter strewn
with various articles.
He had noticed the thought of his Mother cross Forbes' mind
that morning too. Just before they had started the latter
had been counting out his money, and arranging how much
he could spend on each person, when suddenly he came to
a full stop, and looking up at Geoffrey in whose eyes the
one word "Mother" seemed to Forbes to be so evidently
written, he had flushed crimson, and had to bite his lips to
prevent tears coming.
That Forbes was constantly thinking of his Mother, Geoffrey

was sure, but it surprised him to find how seldom the
thought of her seemed to cross Jack's mind. Nurse
apparently filled her place to him completely, and Geoffrey
recognised none of the "Mother hunger" in his little brother,
from which he suffered so much himself.
Even Dodie seemed to remember her more than Jack, for

often in her sleep, when she stirred she would murmur
"Mammie." It always gave Geoff a strange sensation when
he heard this, and he liked to fancy that in some way or
other, his Mother watched over his little sister and talked to
her in her dreams.
Geoffrey was the only one of the three boys who was silent,
as he walked by the side of Mr. Hodson to the town, his
hands deep in his pockets, but his silence was more than
made up for by the lively chatter of his two brothers.
The shops looked very tempting, decorated as they were for

Christmas, and the town was full of people. Claude Hodson
found he had given himself a task when he had promised to
take his little friends shopping. It was the first experience of
shopping with children, and before the afternoon was over,
he fervently hoped it would be the last.
Afraid as he was of giving people trouble himself, he was
quite aghast at the way the boys insisted upon having the
counter strewn with various articles for them to look at,
often without deciding to buy any of them. It never struck
them that they were giving trouble, or that they were
making their kind friend feel supremely uncomfortable. Jack
was the most undecided of the three as to what to buy. He
would change his mind a dozen times before he settled
upon anything. Every fresh thing he saw he wanted, and
liked better than the last.
Forbes, on the other hand, was the most unprincipled in the

matter of giving trouble, and his remarks about the
different articles covered Claude Hodson with confusion
more than once. "Why that isn't worth a shilling," he would
say, "it's nothing of a knife, only two blades! I got a much
better one last year for sixpence!" or "Haven't you any
better sticks than this? These are no good at all, I want a
regular wopper you know, one that I could knock a fellow
down with if he attacked us."
"I say, Forbes," said Jack, as they neared home, "I'll show you
your present,
if you'll show me mine?"
But if Jack was the most undecided, and Forbes the most
inconsiderate of people's feelings, Geoffrey was certainly
the hardest to please, as he made up his mind beforehand
exactly what he wanted, and would scarcely be satisfied
with anything short of it. Among the many things he wanted
was a doll for Dodie, as like as possible to the one his
Mother gave her, which Jack had spoilt. This doll must, he
explained, have light hair and blue eyes, and its head must
be turned a little to the right. Mr. Hodson's spirits sank
when he heard the minute description Geoffrey gave of the
doll, and knew that when he had once set his heart on a
thing, he would hunt till he found it, if he could.
"I promised Dodie I'd get her one as like the other as
possible," he explained to Mr. Hodson, who mildly hinted
that he must be quick, as it was getting late, "and of
course, I mustn't break my promise. I'm sure I've seen a
doll very like it, somewhere. You don't mind me trying a
little longer do you?"
At last Claude had to remonstrate, and Geoff had to give up

the idea of finding a doll with a turned head,—he found one,
however, with blue eyes and golden hair, and hoped that
Dodie would be satisfied with it. He had anyhow kept his
promise, and tried hard to find one like her broken
favourite.
So at last, with their pockets stuffed out and their arms full,
they turned homewards to Mr. Hodson's great relief, and
soon they left the lights of Ipswich behind them, and were
plodding quickly towards Hazelbury, through the dusk.
"I say Forbes," said Jack, as they neared home, "I'll show
you your present, if you'll show me mine."
Jack was tired, and they had both lagged behind the others.

Textbook The European Blood and Marrow Transplantation Textbook For Nurses Michelle Kenyon Ebook All Chapter PDF

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The European Blood and Marrow

Transplantation Textbook for Nurses

Providing HIV Care: Lessons from the Field for Nurses

Tumors and cancers : endocrine glands - blood - marrow

Oxford textbook of advanced heart failure and cardiac

Kidney Transplantation Bioengineering and Regeneration

Congenital and Acquired Bone Marrow Failure Mahmoud

Anesthesia and Perioperative Care for Organ

Davis’s Drug Guide for Nurses April Hazard Vallerand

Pharmacology for nurses Second Edition. Edition Diane

The European Blood and

Under the Auspices of EBMT

The European Blood

This book is open access.

Library of Congress Control Number: 2018930542

Printed on acid-free paper

Autologous and allogeneic haematopoietic stem cell transplantations (HSCT)

The EBMT Nurses Group: promoting excellence in patient care through

Bellinzona, Switzerland Aleksandra Babic

1 JACIE and Quality Management in HSCT:

12 Graft Versus Tumour Effect������������������������������������������������������������ 253

Michelle Kenyon works as Consultant Nurse (BMT Care and Survivorship)

Aleksandra Babic is a Nurse Manager, affiliate to Oncology Institute of

awarded a Master’s degree in Nurse Management in 2006. Until 2016 she

• Nurses Field of Competences

–– Coordinator, Communicator and Translator

Nurses play an important role as coordinator of all issues including coor-

–– Preparer and Educator of Patients for Transplantation and the Period

Over the years, every centre developed modules, booklets or information

–– Carer, Administrator and Technician

The administration of chemotherapeutic, immunosuppressive and

–– Social Supporter and Motivator

Although over the years there were tremendous improvements in out-

• Extended Practice Roles

In the late 1990s during the EBMT conference in Aix-les-Bain (France),

Outcomes of research form the basis of standard operating procedures

• Importance of HSCT Nursing

Bern, Switzerland  Monica C. Fliedner

Bevans M, Tierney DK, Bruch C, Burgunder M, Castro K, Ford R, et al.

C. Charley (*) • I.B. Arraut

© EBMT and the Author(s) 2018 1

Peripheral Stem Cell/Bone Marrow/Cord Blood Bone Marrow Res.

1.3.4 The Inspection A high percentage of all inspections reveal defi-

1.3.7 Post JACIE Accreditation 1.4 J ACIE Standards that Affect

B1 General C1 General D1 General

B4 Quality Management C4 Quality Management D4 Quality Management

B5 Policies and Procedures C5 Policies and Procedures D5 Policies and Procedures

B.03.07.02 Clinical Programs treating pediatric Partially Nurses are paediatric

B.03.07.03 Training and competency shall include:

B.03.07.03.06 Palliative and end of life care. Non Compliant No training

B.03.07.04 There shall be written policies for all

B.03.07.04.01 Care of immunocompromised patients. Partially Hospital policy used does

B.03.07.04.03 Administration of cellular therapy Partially Policy/SOP does not

B.03.07.06 There shall be a nurse/patient ratio Partially During the discussions

B.04 QUALITY MANAGEMENT COMPLIANCE COMMENT

B.04.04 The Quality Management Plan shall include,

B.04.04.02 A system to document the following for all

B.04.04.02.02 New employee orientation. Partially Orientation program in

B.04.04.02.06 Continuing education. Partially Education program in

Bellinzona, Switzerland Aleksandra Babic

1 JACIE and Quality Management in HSCT:

12 Graft Versus Tumour Effect�� 253

Bern, Switzerland Monica C. Fliedner

1.3.4 The Inspection A high percentage of all inspections reveal defi-

1.3.7 Post JACIE Accreditation 1.4 J ACIE Standards that Affect

1.4.1 taffing and Nursing