Development of Clinical
Pharmacy Standards in
Oncology
Joanne Robinson
Senior 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
Job title : Cancer Care
Pharmacist
Based within aseptic services
Based on ward/clinic
Clinical check of prescription
involves:
Clinical check of prescription
involves:
BSA & dose check
Check of diagnosis and staging
Appropriate administration
BSA & dose check
Appropriate supportive care
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
Forename
Patient number
General practitioner
Diagnosis:
Chemotherapy Regimen:
Community Pharmacist
RELEVANT MEDICAL HISTORY
Approx date Problem description
1
2
3
Known drug sensitivities:
Sex
Consultant
Approx Date
4
5
6
PREVIOUS TREATMENT FOR CANCER
Chemotherapy:
Date
No of cycles
1.
2
3
Radiotherapy:
Date
No Fractions
Ward
Problem description
Response / toxicities / cumulative doses
Response / toxicities
Other treatments (including surgery):
CONCURRENT MEDICATION: update on each cycle of treatment
DATES
start
stop
1
8
2
9
3
10
4
11
5
12
6
13
7
14
ADR's / OTC medications:
DATES
start stop
Initials / Dates of cycles
Height:
Weight
Surface Area ( m2)
Generic Care Issue
1
2
3
Action
Output (initial)
• Verified
• Modified
Chemotherapy Eligibility
(only complete on first
cycle)
Chemotherapy
Appropriateness
Refer to local protocol to verify treatment plan from diagnosis,
tumour type and performance status
• LP • OLP • CT
A: Drugs / doses
• • • • • • (Cross if verified
B: Administration
• • • • • • tick if adjusted)
(see monitoring plan for FBC/ CrCl/ LFT's)
Immunosuppressive
therapy
Patients taking concurrent immunosuppressive therapy in addition to
chemo
Comments/dose reductions:
• • • • • • (cross if verified, tick if adjusted)
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
Recurring care issues:
Action
Output
(Initial)
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
– Documentation
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
Available time per clinic
Minus efficiency factor
7.5
minutes
450
30
Total number of patients at clinic
Number of new patients
Number of return patients
Number of patients counselled
Number of patients counselled
Number of patients counselled
382.5
352.5
20
2
18
10
2
2
simple
intermediate
complex
Outpatients receiving Chemotherapy
New
Time taken per patient (mins)
Proportion of patients
Proportion of time
Time per group
Number of patients
Total number of outpatients able to be seen
in allocated clinic time by one pharmacist
Number of pharmacists required to cover clinic in
cover clinic in allocated time
Return
16
10%
9%
31
1.9
Education
12
90%
59%
207
17.2
6
50%
16%
57
9.58
Education Education
12
18
10%
10%
7%
10%
23
34
1.92
1.92
19.2
1.0
Total time required - per patient group
New
32
Return
216
Education - simple
60
Education - intermediate
24
Education - complex
36 plus liaison time
plus efficiency factor
Total
368
398.0 468.235294
Total 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
Available time per ward visit
Minus efficiency factor
Exclude liaison time
minutes
7.5
450
45
Total number of patients in the ward
Total new chemo admissions
Total return chemo admissions
Total non-chemo admissions
Total day 2 onwards
Number of discharges
Number of patients counselled -simple
Number of patients counselled - intermed
Number of patients counselled - complex
382.5
337.5
30
1
3
1
25
5
5
1
1
Inpatients
New chemo
Time taken per patient
Proportion of patients
Proportion of time
Time taken per group
Number of patients
Return chemo
20
3%
6%
20
1.0
15
10%
13%
45
3.0
no chemo 1st day
subsequent days
11
3%
3%
11
1.0
Total number of inpatients able to be seen in allocated ward
time by one pharmacist
Number of pharmacists required to cover ward in allocated time
Total time required - patient group
New
Return
no chemo 1st day
subsequent days
discharge planning
Education - simple
Education - intermediate
Education - complex
Total
Total number of hours of pharmacist time required
20
45
11
150
50
30 plus liaison time
plus efficiency factor
12
18
336
381.0
448.2352941
7.5
6
83%
45%
151
25.1
Discharge planning
10
17%
15%
50
5.0
Education
6
17%
9%
30
5.0
30.1
1.0
Education
12
3%
4%
12
1.0
Education
18
3%
5%
18
1.0
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 CPORT 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
Job title : Cancer Care
Pharmacist
Based within aseptic services
Based on ward/clinic
Clinical check of prescription
involves:
Clinical check of prescription
involves:
BOPA approved verification
steps
BOPA approved verification
steps
No Difference!
