teaser
David Robb
MRPharmS ADA DipPharmPract
Senior Clinical
Pharmacist
Neurosciences Critical Care and Oncology
Cambridge University Hospitals NHS Foundation Trust
UK
E:[email protected]
Addenbrooke’s Hospital in Cambridge is the heart of the Cambridge University Hospitals NHS Foundation Trust (see Box 1). Professor Sir Roy Calne performed the world’s first liver transplant here in 1968 and we remain at the forefront of many specialties.
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In the chemotherapy pharmacy (see Box 2) we have seen our compounding workload increase by around 10% per annum for the last 10 years. We forecast this rise will continue as clinical trials establish newer agents.(1) This is partly due to the inception of monoclonal antibodies into standard treatment and the establishment of ever more complex regimens using a multitude of agents. Improved detection strategies and a range of second- and third-line treatments will also mean that those diagnosed with cancer will begin treatment earlier and may continue treatment for longer. The service we provide therefore needs to evolve along with the treatments on offer.
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We also provide a service to rheumatology, renal services, urology and ophthalmology in addition to oncology and have approximately 90 clinical investigations solely in oncology at any one time. We have a recruitment rate of 18% of patients into active clinical trials. This is 8% higher than the Department of Health (DH) targets. On average we will prepare in the order of 2,000 items of chemotherapy per month. Our number of outpatients treated has doubled in the last nine years.
Our clinics provide a list of patients and the time they are booked to receive chemotherapy. However, this is fairly flexible and we must be ready to accept new prescriptions anytime from 9am to 4pm whilst maintaining a maximum turnaround time of two hours. This method of working enhances patient satisfaction by allowing the consultant assessment, the phlebotomist blood sampling (by our dedicated phlebotomy team) and the preparation and administration of chemotherapy to be undertaken on a single visit.
I spend half of my working week on the neurosciences critical care unit and the remainder as the system administrator for a number of software packages within preparative services and as a clinical oncology pharmacist.
Computerisation
Our main software package is called CliniChemo.(2) This software package allows the scheduling of whole treatment courses with minimal human input of data. We integrated the software into our practice within the last three years and have seen immediate benefits. It has considerably reduced the number of overtime hours claimed and errors produced. We can pre-empt clinic lists and, as delays inevitably occur, we can reschedule everything from single doses to whole regimens. It provides a patient record and a cost-analysis history for financial and audit purposes. This is not to say that this is a perfect computer package.
The NHS recently circulated plans for a single integrated system to report all data from medical records and scans to blood results and treatment scheduling on one system. This system, it is envisaged, will be similar to the system used by the Veterans Affairs hospitals in the USA. The data it holds would be available across all NHS sites that uptake the system, enabling seamless transition of care across shared care centres. Addenbrooke’s hospital, for instance, shares patients with five other local hospitals.
Also under discussion at a local level is a system of barcodes on prescription charts linked to a wireless tracker system so that staff and patients alike can monitor the progress of their treatment.
Standardisation
The Oncology Department maintains a rigid and robust quality assurance (QA) infrastructure. In a move away from handwritten chemotherapy prescriptions, we now maintain over 600 security-locked blank prescriptions on our intranet. These protocols are authored by senior consultants and checked by a senior pharmacist. Our QA team then creates an electronic format of this, which is rechecked. Once this is “published” on our intranet, I programme the regimen onto our system and have this checked by another pharmacist. As all prescriptions are coded, this code is all that needs be entered to schedule a patient for the entirety of the agreed treatment. This has significantly reduced errors and sped up the prescribing-to-administration time substantially. From 2005 figures, we now handwrite less than three prescriptions per quarter. If a consultant decides to diverge treatment from an established protocol, he or she must complete a nonconformance form (which must be countersigned by one of four senior consultants stating the reason for deviation). These are all logged, and if deemed a necessary addition to the array of treatments offered, a new standard protocol will be written to allow future prescriptions. This method guarantees rational and validated treatment plans for all of our patients. All prescriptions are reviewed annually and archived if no longer best practice.
Dose banding
An urban myth persists that we should not use more than two syringes to comprise any single dose. Our practices in dose banding have recently challenged this, and our nurses have welcomed our paradigm shift. Syringes of 50ml require more effort to administer. A larger number of smaller syringes may reduce the instance of repetitive strain injuries (RSIs). A larger number of doses can be prepared using fewer products, thereby reducing stock holding, expediting stock rotation and avoiding expiration.
A key factor in the promotion of dose banding is the recently adopted practice in the UK of pharmacists rounding doses within a limit of ±5% from the calculated dose.(3) A second key factor is the standardisation of products across regimens. For example, we altered all of our carboplatin protocols to be diluted in 500ml of glucose 5%. Again, this suddenly increased the number of prescriptions amenable to dose banding. Thirdly, our computer system allows us to review all previous regimens or particular cytotoxic agents. Monthly and annual trends can be reported and used to calculate which products to dose-band, at what strengths, and how many of each to order (see Box 3).
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Clinical trials
As previously mentioned, we have a large intake to clinical trials at Addenbrooke’s. The momentum of this is first because many of our consultants are or have been principal investigators in various large trials, and secondly because we share our location with a large research institution. The MRC (Medical Research Council) was pivotal in many groundbreaking medical developments, resulting in more than a handful of Nobel Prizes.(4)
In a pioneering bit of MRC research in 1975, Milstein and Köhler developed the first method of isolating and manufacturing monoclonal antibodies.(5) This sparked a wave of biotech industries in the Cambridge area, with whom the oncology department is closely involved. Therefore, we can be assured that the number of treatments in this area will increase in the next few years, and steps must be taken to account for this in workforce planning.
Oral chemotherapy
Recently, one of the changes with the biggest ramifications for practice has been the increase in oral agents. Capecitabine now has a licence in colorectal and breast cancers where once we may have used 5-fluorouracil (5-FU).
With oral vinorelbine now licensed in the UK for nonsmall-cell lung cancer and a licence in breast cancer looking imminent, a plethora of protein kinase inhibitors on the market (imatinib, erlotinib, etc) and increasing use of thalidomide, our next task is to evaluate the extra pressures now being taken by our traditional dispensaries.
References
- Summerhayes M. Risk management in oncology. Pharm J 2000;265:732-3.
- Systems Solutions Ltd homepage. Available from: http://www.syssol.ie
- Maclean F, et al. Dose banding of chemotherapy in the Edinburgh Cancer Centre. Pharm J 2003;270:691-3.
- Medical Research Council history. Available from: http://www.mrc.ac.uk/index/about/about-history/about-past_achievements.htm
- Medical Research Council publication. Monoclonal Antibodies. Available from: http://www.mrc.ac.uk/pdf_mon_antibodies.pdf
Resources
Cancer Research UK
W:www.cancerhelp.org.uk
American Cancer Society Homepage
W:www.cancer.org
National Institute for Clinical Excellence
W:www.nice.org.uk/
Events
ASCO (American Society of Clinical Oncology) 42nd Annual Meeting
2–6 June 2006
Atlanta, GA
USA
BOPA 8th Annual Symposium
14–16 October 2005
SECC, Glasgow, UK
