Development of Clinical Pharmacy Standards in Oncology

1. Development of Clinical Pharmacy Standards in Oncology Joanne Robinson Senior Pharmacist – Oncology NHS Forth Valley Member of Scottish Oncology Pharmacy Practice Group

2. Spot the Difference Job title : Cancer Care Pharmacist Job title : Cancer Care Pharmacist

3. 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

4. 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

5. 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

6. 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 Elements of PCP

9. 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

10. 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 Care Planning in Practice

11. 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

12. Success! • > £1 million secured for pharmacy staff • > £1 million secured for pharmacy equipment

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

22. 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

24. Complex Inpatients • Timings • New admission • 25 minutes • Subsequent days • 15 minutes • Rest as per standard inpatients

25. 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

26. 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

27. 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

28. 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.

29. 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

30. Next Steps in Scotland • Standard pharmaceutical care plan will be updated

31. 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

32. 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

33. 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!