Letting Kids Be Kids: A Quality Improvement Project to Deliver Supportive Care at Home After High-Dose Methotrexate in Pediatric Patients With Acute Lymphoblastic Leukemia

Lori Ranney, Mary C. Hooke, Kathryn Robbins

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


The Children’s Oncology Group recommends children with high-risk acute lymphoblastic leukemia (ALL) receive high-dose methotrexate (HD MTX) throughout treatment. Historically, patients have been hospitalized for at least 54 hours for HD MTX. Literature supports the safety and efficacy of the transition of supportive care interventions of intravenous (IV) fluids and leucovorin to ambulatory care. The goal of this quality improvement (QI) project was to implement a system to support the safe delivery of supportive care in the home after inpatient HD MTX in children with high-risk ALL. An interdisciplinary team implemented system changes including an ambulatory supportive care protocol, standard computerized order sets, family education, and education of staff in the inpatient, outpatient, and home care setting. Measurements included laboratory results of renal function and medication clearance, length of hospitalization, and family-reported quality of life. During project implementation, 10 patients completed a total of 38 cycles. The system safely and effectively supported transition to the outpatient setting for all patients. Average length of stay was decreased by 37.8 hours per HD MTX cycle. Families reported that quality of life improved in most domains with family time and sleep having largest improvement, while level of stress remained the same. Ambulatory monitoring post-HD MTX requires a multidisciplinary approach to meet individualized patient needs. Future QI efforts should consider outpatient administration of HD MTX in addition to supportive care as a means to improved quality of life.

Original languageEnglish (US)
Pages (from-to)212-220
Number of pages9
JournalJournal of Pediatric Oncology Nursing
Issue number3
StatePublished - May 1 2020

Bibliographical note

Funding Information:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Lori Ranney was supported by a Graduate Scholarship in Cancer Nursing Practice, GSCNP-17-124-01 from the American Cancer Society. Kathryn Robbins was supported by a Doctor of Nursing Practice scholarship at the University of Minnesota School of Nursing from the Bentson Foundation.

Publisher Copyright:
© 2020 by Association of Pediatric Hematology/Oncology Nurses.


  • acute lymphoblastic leukemia
  • ambulatory
  • methotrexate
  • quality improvement
  • quality of life
  • Humans
  • Child, Preschool
  • Male
  • Home Care Services/organization & administration
  • Methotrexate/administration & dosage
  • Quality Improvement
  • Adolescent
  • Quality of Life
  • Female
  • Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
  • Child

PubMed: MeSH publication types

  • Research Support, Non-U.S. Gov't
  • Journal Article


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