Development of Clinical Pharmacy Standards in Oncology

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Development of Clinical Pharmacy Standards in
Oncology

• Joanne Robinson
• Senior Pharmacist Oncology
• NHS Forth Valley
• Member of Scottish Oncology Pharmacy Practice
  Group

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Spot the Difference
Job title Cancer Care Pharmacist
Job title Cancer Care Pharmacist
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Spot the Difference
Job title Cancer Care Pharmacist Based within
aseptic services Clinical check of prescription
involves BSA dose check Appropriate
administration Appropriate supportive care
Job title Cancer Care Pharmacist Based on
ward/clinic Clinical check of prescription
involves Check of diagnosis and staging BSA
dose check FBC, LFT UE check Appropriate
supportive care
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Content

• Development of Scottish SOP for pharmaceutical
  care planning
• Development of ASTCP capacity plan for cancer
• Update to clinical capacity plan
• Development of clinical quality standards in
  oncology

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Scottish Care Planning Standards

• Developed in 2001
• Aim to standardise clinical pharmacy practice in
  chemotherapy across Scotland
• GUIDELINES FOR THE COMPLETION OF PHARMACEUTICAL
  CARE PLAN FOR CANCER PATIENTS RECEIVING
  CHEMOTHERAPY
• STANDARDISED PHARMACEUTICAL CARE PLAN
  DOCUMENTATION

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Elements of PCP

• All patients receiving chemotherapy IV or oral
• PMH
• Previous treatment for cancer
• Current medication
• Height, Weight, BSA

• Chemotherapy eligibility
• Chemotherapy appropriateness
• Drugs/doses
• Administration
• Immunosuppressants
• Monitoring Issues
• Individual care issues

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Care Planning in Practice

• Care plan in original format used in majority of
  units/centres
• Some units/centres have kept same elements but
  adapted for local use

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Care Planning in Practice

• Advantages
• Standardises practice
• Allows us to define what is meant by clinical
  verification

• Disadvantages
• Documentation may duplicate effort
• Very few like the ticks and crosses

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Application of Capacity Plan

• Cancer in Scotland Action for Change published
  in 2001
• In excess of 50million investment promised
• ASTCP took unified approach to secure funding for
  pharmacy cancer services
• Scottish capacity plan for pharmacy services to
  cancer patients was developed
• Scotland-wide bid submitted for cancer pharmacy
  staffing

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Success!

• gt 1 million secured for pharmacy staff
• gt 1 million secured for pharmacy equipment

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What was this based on?

• Safe staffing levels
• Aseptic dispensing based on items
• Dispensing services based on items
• Clinical pharmacy services based on patient
  numbers
• 1 pharmacist 20 outpatients per day
• 1 pharmacist 30 inpatients per day
• Based on consensus of opinion which was
  benchmarked against current practice.

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Limitations of Model

• Model did not take into account complexity of
  workload
• Some patient groups require more intensive input
  eg BMT
• Some patients require more patient education eg
  Capecitabine

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Update to Capacity Plan - 2007

• Scottish Oncology Pharmacy Practice (SOPPG) and
  Scottish Aseptic Services Specialist Interest
  Group (ASSIG) tasked with updating capacity plan
• Aseptic capacity plan was updated taking into
  complexity of preparation and dispensing of dose
  banded products
• Approved by Directors of Pharmacy Group 2008

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Update to Clinical Capacity Plan

• Incorporate complexity of workload
• Inpatients v outpatients
• Oncology v haematology
• First step was to survey opinion of cancer
  pharmacists in 19 hospitals across all 3 cancer
  networks, cancer centres and cancer units

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Update to Clinical Capacity Plan

• Next step test assumptions
• Pharmacists asked to measure the actual time
  taken for outpatients and inpatients
• 9 centres participated
• New outpatients 58
• Return outpatients 241
• New inpatients 40
• Return inpatients 88
• Non-chemo inpatients 102

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New Model

• No difference between oncology and haematology in
  terms of timings
• Still needed different models for outpatients and
  inpatients
• Need to differentiate between routine and complex
  inpatients

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Model for Outpatients

• Timings
• Chemotherapy care planning cycle 1
• 16 minutes
• Chemotherapy care planning cycle 2 onwards
• 12 minutes
• Patient education
• Simple 6 minutes
• Intermediate 12 minutes
• Complex 18 minutes

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Spreadsheets

• Devised to work out
• How many pharmacists required to care plan a
  certain number of patients in a certain time
  period
• or
• The total number of pharmacist hours required to
  care plan the total number of patients
• Takes into account a 15 efficiency factor to
  account for peaks in workload
• Allows for liaison time eg phoning, faxing,
  communication etc

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Model for Inpatients

• Timings
• New admission for chemotherapy cycle 1
• 20 minutes
• New admission for chemotherapy from cycle 2
• 15 minutes
• New admission no chemo
• 11 minutes
• Patients from day 2
• 6 minutes
• Discharge Planning
• 10 minutes
• Patient Education
• 6, 12, 18 minutes

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Complex Inpatients

• Timings
• New admission
• 25 minutes
• Subsequent days
• 15 minutes
• Rest as per standard inpatients

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Next steps

• Model was endorsed by the Scottish Directors of
  Pharmacy Group
• Timings to be incorporated into C-PORT pilot
  sites to further validate
• Agreement to share model UK wide and work
  collaboratively with BOPA to develop UK quality
  standards for cancer pharmacists

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Applicability to UK

• Cancer Action Team
• All chemotherapy prescriptions should be checked
  by an oncology pharmacist, who has undergone
  specialist training, demonstrated their
  appropriate competence and is locally authorised/
  accredited for the task.
• NCEPOD report (2008)
• Pharmacists should sign the SACT prescription to
  indicate that it has been verified and validated
  for the intended patient and that all the safety
  checks have been undertaken.
• What does this signature mean?
• May mean different things to different people

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Standardising Clinical Verification

• BOPA to consult on the minimum requirements for a
  pharmacist verification check
• Acknowledges there are differences in practice
  across the UK and therefore there needs to be
  flexibility in working practice
• Some elements may not require to be personally
  undertaken by the pharmacist as long as there is
  a documented system in place to ensure that these
  checks are undertaken

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Elements of Verification 1

• Check Patients details are correct on
  prescription
• Check prescribers details
• Check regimen protocol is appropriate for
  patients diagnosis, medical history and
  chemotherapy history
• Check regimen is the intended regimen
• Complete pharmaceutical care plans/ patient
  record
• Check there are no known drug interactions or
  conflicts with patient allergies
• Check body surface area (BSA) is correctly
  calculated, taking into account most recent
  weight.

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Elements of Verification 2

• Check dose calculations and dose units are
  appropriate according to BSA
• Check reason for any dose reduction(s)
• Check method of administration is appropriate
• Check laboratory values, FBC, UE and LFTs
• Check doses are appropriate with respect to renal
  and hepatic function and any experienced
  toxicities
• Check other essential laboratory tests have been
  undertaken
• Check supportive care prescribed is appropriate
  for the patient

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Next Steps in Scotland

• Standard pharmaceutical care plan will be updated

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Next Steps - BOPA

• Consultation on Verification standards
• Produce supporting toolkit/ guidance that gives
  details to inform SOPs
• Work with Scottish Cancer Pharmacy Group to
  further validate capacity plan
• Generic care plan made available for local use or
  adaptation

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Advantages

• Ensure safe provision of chemotherapy
• Standardisation of practice
• Tool for improving access to information for
  pharmacists
• Standards of practice allow capacity planning to
  be undertaken on larger scale
• More credibility due to national system
• Incorporate into future systems eg CPORT

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Spot the Difference
Job title Cancer Care Pharmacist Based within
aseptic services Clinical check of prescription
involves BOPA approved verification steps
Job title Cancer Care Pharmacist Based on
ward/clinic Clinical check of prescription
involves BOPA approved verification steps
No Difference!