CAR-T Assessment and Recognition through Informed Nursing Guidance

Year Submitted: 2025
Published Date: 02 January 2026

Tags: Inpatient Care, Quality Improvement, Change Management, Knowledge Management, Care Continuum, Care Process ＆ Redesign, Organisational Leadership

About this Content

Aims

This study aims to evaluate nurse-led model of care on:
1) Reducing delayed clinical evaluations and treatment for CAR-T therapy recipients experiencing CRS and ICANS.
2) Fostering a supportive culture: Encourage open communication and support among multidisciplinary teams to reduce hierarchical barriers.
3) Ensuring compliance: Achieve adherence to established assessment and escalation timelines.

Background

Chimeric Antigen Receptor T-cell (CAR-T) therapy has been associated with severe complications, particularly Cytokine Release Syndrome (CRS) and Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS). Timely recognition and management of these toxicities are critical. ICANS and CRS monitoring can be laborious, time- consuming and may be potentially delayed when physician led. Nurses, as front-line caregivers, are uniquely positioned to detect early changes in patient condition. A structured, nurse-led assessment and escalation process may help mitigate these delays and improve clinical outcomes.

Methods

This quality improvement project was initiated with a retrospective data review from 2023-2024 to evaluate baseline time to evaluation for CRS and ICANS, complemented by survey of nursing staff to identify potential implementation challenges.
A multidisciplinary team comprising physicians, nurse leaders, frontline nurses, and quality improvement specialists launched a quality improvement sprint. The team employed process mapping and root cause analysis to identify delays in the current assessment and escalation pathways. Based on these findings, targeted interventions were developed, including standardized assessment protocols, enhanced training on CRS and ICANS recognition, and streamlined communication channels for escalation. A pilot project was then implemented in a single ward, ensuring all team members were thoroughly trained and necessary resources were available. Key performance indicators, such as time to assessment and adherence to escalation protocols, were continuously monitored. Regular follow-up meetings were organized to track the implementation plan, address challenges, and make necessary adjustments. Comparative analysis between pre- and post-intervention data was conducted to assess the effectiveness of the nurse-led model in improving timely evaluation and treatment for CAR-T therapy recipients experiencing CRS and ICANS.

Results

Pre-implementation:
An analysis of 827 physician -led assessments done in year 2023-2024 revealed 37 missed and 234 delayed assessments, with a median delay of 90 minutes. The survey done showed 41.5% of nurses feel that they are not confident to do the assessment due to lack of clear formalized protocol, leading to confusion, delay in critical care and increased risk to patient safety.
Pilot implementation:
Out of 168 nurse-led assessments for 14 patients over a period of 6 months, there was 0 missed or delayed assessment. Nurse-reported confidence and protocol adherence rates improved significantly over the study period, reflecting enhanced clinical vigilance and communication. Qualitative feedback from the multidisciplinary team highlighted the positive impact of timely nursing assessments on clinical decision-making and patient safety.

Conclusion

Implementing a supportive escalation process enhances clinical responsiveness, promotes interdisciplinary collaboration, and reduces delays in critical interventions. By fostering a culture of psychological safety, continuous education, and clear communication, healthcare teams are better equipped to identify and manage complications promptly. This proactive and supportive approach not only improves patient outcomes but also empowers staff to act confidently and cohesively during high-acuity events.

Lessons Learnt

1. Standardisation reduces fear and variability
Clear workflows, assessment schedules, and documentation tools significantly reduce uncertainty and anxiety among nurses caring for high-risk CAR-T patients.
2. Training must be practical and role-specific
Structured, CAR-Tspecific training bundles improved nurses ability to recognise deterioration and act decisively, especially during early CRS and ICANS.
3. Clear escalation pathways are critical in rapidly deteriorating patients
Defined timelines and expectations for escalation empowered nurses to escalate promptly and reduced delays in medical intervention.
4. Multidisciplinary alignment strengthens outcomes
Standardised training and shared understanding between nurses and doctors improved communication, reduced confusion, and enhanced coordinated care.
5. Continuous monitoring sustains improvement
Ongoing audit, feedback, and leadership support were essential to sustaining zero missed or delayed assessments.

Keywords

Chimeric Antigen Receptor T-cell (CAR-T) therapy

Innovators' Details

Connect with this contributor!

Ngo Yu Ting - yu_ting_ngo@nuhs.edu.sg ↗ (opens in new tab)

Project Attachment