Implementation of the ICE Scoring Tool for Inpatients after CAR-T Therapy

Immune effector cell-associated neurotoxicity syndrome (ICANS) is a complication of chimeric antigen receptor (CAR) T-cell therapy necessitating early identification. ASTCT recommends immune effector cell-associated encephalopathy (ICE) scoring to detect ICANS in patients aged ≥12 years. Our institution lacked a standardized process for nursing assessment of ICANS via ICE scoring. A collaboration of CAR-T physicians, research team members, and nursing leaders established a process and structure for daily inpatient nursing ICE assessments, allowing for early identification and management of neurologic changes. This abstract describes compliance and targeted areas to enhance uptake of ICE scoring. Nursing ICE scoring was implemented in June 2023 on a 50-bed inpatient oncology and bone marrow transplant unit in an urban, freestanding, quaternary pediatric institution. The sample included admissions from June 2023 to August 2024 for patients ≥12 years old within 28 days post-CAR-T infusion who were developmentally appropriate for ICE scoring and had an active nursing order. The CAR-T research team notified the Clinical Nurse Specialist (CNS) and inpatient provider of eligible admissions. The inpatient provider placed nursing orders for daily ICE scoring, and the CNS provided nurses with just-in-time training. Nurses documented ICE scores on paper initially and in the electronic health record (EHR) flowsheet once developed. Compliance was measured by comparing the number of days with documented ICE scores to the number of eligible patient days. Thirty-two admissions were evaluable. Three admissions had paper ICE score documentation and 29 had electronic documentation. Admissions ranged from 1 to 50 days, and 21% of admissions warranted transfers to the intensive care unit. ICE scoring compliance on the oncology unit was 84%, and overall documentation compliance was 78% for the duration of hospitalization. Care transitions were associated with decreased compliance. Altogether, 17% of patients experienced a decrease in ICE scores, emphasizing the importance of standardized neurologic assessments. ICE scoring was successfully implemented among nurses, allowing for timely ICANS detection and clinical trial data collection. Electronic documentation streamlined shared awareness of patients’ ICE scores. Future steps include improving EHR workflows and methods to identify patients requiring ICE scoring. Continued multidisciplinary collaboration will be key to refining these processes.