Development of Clinical Pharmacy Standards in

OncologyJoanne RobinsonSenior Pharmacist – Oncology

NHS Forth Valley

Member of Scottish Oncology Pharmacy Practice Group

Spot the Difference

Job title : Cancer Care Pharmacist

Job title : Cancer Care Pharmacist

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 & U&E check

Appropriate supportive care

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

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

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

GENERIC PHARMACEUTICAL CARE PLAN : CANCER CARE Surname

Date of birth / age Sex Consultant Ward

Forename

Patient number

General practitioner

Diagnosis:

Chemotherapy Regimen:

Community Pharmacist

RELEVANT MEDICAL HISTORY Approx date Problem description Approx Date Problem description

1 4 2 5 3 6

Known drug sensitivities: PREVIOUS TREATMENT FOR CANCER Chemotherapy: 1. 2 3

Date No of cycles Response / toxicities / cumulative doses

Radiotherapy:

Date No Fractions Response / toxicities

Other treatments (including surgery): CONCURRENT MEDICATION: update on each cycle of treatment

DATES DATES start stop start stop

1 8 2 9 3 10 4 11 5 12 6 13 7 14

ADR's / OTC medications:

Initials / Dates of cycles

Height:

Weight

Surface Area ( m2)

Generic Care Issue Action Output (initial) 1 Chemotherapy Eligibility

(only complete on first cycle)

Refer to local protocol to verify treatment plan from diagnosis, tumour type and performance status � LP � OLP � CT

� Verified � Modified

2 Chemotherapy Appropriateness

A: Drugs / doses � � � � � � (Cross if verified B: Administration � � � � � � tick if adjusted) (see monitoring plan for FBC/ CrCl/ LFT's)

3 Immunosuppressive therapy

Patients taking concurrent immunosuppressive therapy in addition to chemo � � � � � � (cross if verified, tick if adjusted)

Comments/dose reductions:

GENERIC PHARMACEUTICAL CARE PLAN : CANCER CARE Monitoring Issues:

Cross if no problem, tick if a problem and document in care issues section or annotate N/A if not assessed Nausea and vomiting � � � � � �

Mucositis/Mouthcare � � � � � �

Neurology � � � � � �

Bowel habit � � � � � �

Neutropenic Sepsis � � � � � �

Skin Toxicity � � � � � �

Pain control � � � � � �

Insomnia � � � � � �

Depression � � � � � �

Absorption / distribution � � � � � �

Counselling/Education � � � � � �

Discharge/ self med issues � � � � � �

FBC � � � � � �

LFT's / bilirubin � � � � � �

Renal function � � � � � �

Other: � � � � � �

INDIVIDUAL CARE ISSUES Date Care issue Action Output (Initial)

Recurring care issues:

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

Care Planning in Practice

• Advantages– Standardises

practice– Allows us to

define what is meant by clinical verification

• Disadvantages– Documentatio

n may duplicate effort

– Very few like the ticks and crosses

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

Success!

• > £1 million secured for pharmacy staff

• > £1 million secured for pharmacy equipment

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.

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

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

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

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

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

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

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

Clinical Pharmacy Capacity Planning Spreadsheet Outpatients

hours minutesAvailable time per clinic 7.5 450Minus efficiency factor 382.5

30 352.5

Total number of patients at clinic 20Number of new patients 2Number of return patients 18Number of patients counselled simple 10Number of patients counselled intermediate 2Number of patients counselled complex 2

Outpatients receiving Chemotherapy

New Return Education Education EducationTime taken per patient (mins) 16 12 6 12 18Proportion of patients 10% 90% 50% 10% 10%Proportion of time 9% 59% 16% 7% 10%Time per group 31 207 57 23 34Number of patients 1.9 17.2 9.58 1.92 1.92

Total number of outpatients able to be seen 19.2in allocated clinic time by one pharmacist

Number of pharmacists required to cover clinic in 1.0cover clinic in allocated time

Total time required - per patient groupNew 32Return 216Education - simple 60Education - intermediate 24Education - complex 36 plus liaison timeplus efficiency factor Total 368 398.0 468.235294Total number of hours of pharmacist time required 7.8

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

Clinical Pharmacy Capacity Planning Spreadsheet Inpatients

hours minutesAvailable time per ward visit 7.5 450Minus efficiency factor 382.5Exclude liaison time 45 337.5

Total number of patients in the ward 30Total new chemo admissions 1Total return chemo admissions 3Total non-chemo admissions 1Total day 2 onwards 25Number of discharges 5Number of patients counselled -simple 5Number of patients counselled - intermed 1Number of patients counselled - complex 1

Inpatients New chemo Return chemo no chemo 1st day subsequent days Discharge planning Education Education Education

Time taken per patient 20 15 11 6 10 6 12 18Proportion of patients 3% 10% 3% 83% 17% 17% 3% 3%Proportion of time 6% 13% 3% 45% 15% 9% 4% 5%Time taken per group 20 45 11 151 50 30 12 18Number of patients 1.0 3.0 1.0 25.1 5.0 5.0 1.0 1.0

Total number of inpatients able to be seen in allocated ward 30.1time by one pharmacist

Number of pharmacists required to cover ward in allocated time 1.0

Total time required - patient groupNew 20Return 45no chemo 1st day 11subsequent days 150discharge planning 50Education - simple 30 plus liaison timeplus efficiency factor Education - intermediate 12Education - complex 18Total 336 381.0 448.2352941Total number of hours of pharmacist time required 7.5

Complex Inpatients

• Timings– New admission

•25 minutes– Subsequent days

•15 minutes– Rest as per standard inpatients

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

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

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

Elements of Verification 1

• Check Patients details are correct on prescription

• Check prescribers details• Check regimen protocol is appropriate for

patient’s 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.

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, U&E 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

Next Steps in Scotland

• Standard pharmaceutical care plan will be updated

Next Steps - BOPA

• Consultation on Verification standards• Produce supporting toolkit/ guidance

that gives details to inform SOP’s • Work with Scottish Cancer Pharmacy

Group to further validate capacity plan • Generic care plan made available for

local use or adaptation

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

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!