Enhancing Cancer Care Quality through Identifying and Remedying Care Factors

2. Aim Identify remediable factors in the care received by patients Proposed by the JSC and JCCO as there was a belief that the standard of care was not uniform across the country

3. Expert group Medical/clinical and haemato-oncologists Palliative medicine physician Pharmacist Chemotherapy nurse Patient representative

4. Key areas defined The decision to treat Prescription and administration The safety of treatment End of life care Communication Clinical governance

5. Inclusion criteria Patients aged 16 years or over Solid tumours or haematological malignancies Received chemotherapy, monoclonal antibodies or immunotherapy during the study period Died within 30 days of receiving treatment

6. Data collection Questionnaire A Questionnaire B Casenotes Organisational questionnaire

7. Advisor groups All cases anonymised Clinical/medical/haemato-oncologists Palliative medicine physicians Pharmacists Chemotherapy nurse specialists Assessed all aspects of care

8. Overall assessment of care Good practice Room for improvement: clinical care Room for improvement: organisational care Room for improvement:clinical care & organisational care Less than satisfactory

9. Cases identified 47,050 treatment cases 55,710 deaths from any cause 1415 cases identified

10. Data returned

11. Recommendation Cancer services managers and clinical directors must ensure that time is made available in consultants’ job plans for clinical audit. They must also ensure that the time allocated is used for the defined purpose. (Cancer Services Managers and Clinical Directors)

12. Classification of hospitals

13. Hospital workload

14. Staffing

15. Emergency admissions facilities

16. General medical support

17. Other specialties onsite Critical care 204/291 Level 3 243/290 Level 2 Palliative care 81/156 consultant palliative care sessions Resuscitation teams 11 hospitals did not have one onsite

18. Recommendation Hospitals that treat patients with SACT but do not have the facilities to manage patients who are acutely unwell should have a formal agreement with another hospital for the admission or transfer of such patients as appropriate. (Medical directors)

19. Aim • Interpretation • Limitations • Results

20. Overall quality of care

21. Room for improvement • Decision to treat • Process of care • Prescribing, dispensing and administration of SACT • Communication • Patient information, medical records • SACT toxicity • Admission, assessment and treatment • Management of neutropenic sepsis • End of life decisions

22. Advisors opinion on the decision to treat

23. Decision to treat

24. Multi-disciplinary team meetings STANDARD The management of all cancer patients should be discussed at regular MDT meetings. Manual for Cancer Services: 2004

25. Tumour and patient characteristics • Tumour type • Tumour stage • Previous SACT • Medical complications of malignancy • Patient’s age • Patient’s performance status • Patient’s co-morbidities

26. Solid tumours

27. Haematological malignancies

28. SACT regimens • Carboplatin and Etoposide • Capecitabine • Gemcitabine and Carboplatin • Oxaliplatin • Carboplatin • R-CHOP and CHOP

29. Performance score

30. Clinical management plan

31. Decision to treat

32. Patient information 433/546 cases

33. Consent forms 310/546 cases STANDARD Written information should be provided on • treatment intention and expected response rates • acute and possible late side effects • mortality rates Obtaining Consent for Chemotherapy: British Committee for Standards in Haematology Guidelines

34. Recommendations NCEPOD supports the Manual for Cancer Services standard that initial clinical management plans for all cancer patients should be formulated within a MDT meeting. (Clinical directors)

35. Recommendations Giving palliative SACT to poor performance status patients grade 3 or 4 should be done so with caution and having been discussed at a MDT meeting. (Consultants)

36. Recommendations Consent must only be taken by a clinician sufficiently experienced to judge that the patient’s decision has been made after careful consideration of the potential risks and benefits of the treatment, and that treatment is in the patient’s best interest. (Clinical directors)

37. Recommendations All deaths within 30 days of SACT should be considered at a morbidity and mortality or a clinical governance meeting. (Clinical directors and consultants)

38. Process of care

39. Authorisation to prescribe SACT STANDARD Chemotherapy must be initiated and prescribed only by clinicians who are appropriately accredited and/or experienced Good Practice Guidance for Clinical Oncologists: RCR

40. SACT initiators

41. SACT prescribers

42. SACT prescribing accreditation • Independent prescribers n=32 • 6 at the consultant’s discretion • 23 post formal assessment and accreditation • 3 unknown

43. Initiator, prescriber, reviewer

44. Pre-treatment investigations

45. Pre-treatment assessments STANDARDS Toxicity should be recorded for each cycle using the Common Toxicity Criteria The outcomes of treatment should be monitored closely Appropriate action should be taken if - the side-effects are excessive - the cancer progresses. Chemotherapy Guidelines: COIN 2001

46. Documentation of toxicity and tumour response • Toxicity • Record of assessment – 64% • Toxicity checklist – 26/267 • Tumour response • Record of assessment – 54%

47. Prescriptions STANDARD All prescriptions of cytotoxic chemotherapy should be computer generated at least when using regimens from the agreed list. Manual for Cancer Services: 2004 n=426

48. Route of SACT administration

49. Recommendation All independent and supplementary prescribers (specialist chemotherapy nurses and cancer pharmacists) and junior medical staff should be locally trained/accredited before being authorised to prescribe SACT. (Cancer services managers and clinical directors)

50. Recommendation Junior medical staff at FY1, FY2, ST1 and ST2 grade should not be authorised to initiate SACT. (Clinical directors) Toxicity check lists should be developed to assist record keeping and aid the process of care in prescribing SACT. (Cancer services managers and clinical directors)