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Efficiency in pharmacy services: facilitating advance preparation of chemotherapy

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With chemotherapy services under constant pressure to provide efficient and economic services, the Clatterbridge Centre for Oncology is looking to eHealth for the solution

Burhan Zavery
Principal Pharmacist

Helen Clark
MRPharm S
Chief Pharmacist

David Smith
Clinical Director
Clatterbridge Centre
for Oncology NHS
Foundation Trust
Bebington, Wirral, UK

Advances in chemotherapy treatment and cancer patient survival continue to place increased demands for chemotherapy services. Chemotherapy drugs are high-risk medicines as they are inherently hazardous, requiring careful and safe handling to prevent inadvertent exposure by healthcare professionals. Parenteral chemotherapy also has to be prepared in controlled conditions in pharmacy to ensure that doses are individualised to the patient and that the products are supplied to the patient in the correct presentation, correctly labelled, free of contamination risk and as prescribed. Delivering chemotherapy efficiently and economically to patients poses a huge challenge to chemotherapy preparation units all over the world.

This paper describes how the Clatterbridge Centre for Oncology (CCO) has modelled and designed its chemotherapy services to meet the needs of cancer patients in the North West of England.

In particular, the hospital has a unique model of preparing and delivering chemotherapy drugs in advance of patient appointments and arrival, allowing treatments to be delivered efficiently without delay and wait to patients. This process has enabled the hospital to maintain “zero” waiting time for chemotherapy services. This has posed considerable practical and pharmaceutical challenges to the traditional model of chemotherapy delivery, and the hospital has successfully adapted its working practices to meet these challenges.

The service
CCO is a specialist cancer centre providing nonsurgical oncology services for the population of Cheshire, Merseyside and the Isle of Man. The main treatment facility, which includes radiotherapy, chemotherapy and diagnostic imaging, is located at the Clatterbridge site in the Wirral, UK. The trust delivers specialist cancer services at different sites throughout Cheshire and Merseyside hospitals, providing visiting medical and nursing teams who deliver chemotherapy at the patients’ local hospital.

The centre treats around 5,000 patients per year, amounting to 25,000 chemotherapy treatment episodes. Pharmacy Preparative Services at CCO provides a centralised chemotherapy preparation service and prepares around 50,000 individualised chemotherapy doses for oncology patients per year.

Outpatient treatment of patients has been a primary goal of the service,[1-4] and the CCO has the most extensive devolved outpatient treatment model in the UK.

Advance preparation of chemotherapy
Advance preparation of chemotherapy has the advantage of providing chemotherapy to clinics in advance of the patient arrival. This has allowed CCO to develop an outpatient model of chemotherapy delivery whereby nursing and medical teams run chemotherapy clinics at local hospitals in the region.

From a pharmacy point of view, this model has allowed the pharmacy to develop a centralised model with economy of scale in terms of staff, facilities and drug utilisation. Generally in supply terms, pharmacy is sometimes seen as the cause of delays to patients simply because they are the last step in the chain. There are many reasons for treatment delay, such as chemotherapy not prescribed. At CCO, because chemotherapy is prescribed in advance, pharmacy are seen to expedite the process and not contribute to delays. In order to facilitate the advance preparation of chemotherapy, it is vital that the prescription or chemotherapy request is received in the pharmacy before the patient appointment.

At CCO, chemotherapy consultants prescribe the first chemotherapy treatment at the time of review and immediately book an appointment for the patient to receive the chemotherapy treatment. This has the advantage of easier scheduling of patients to appointments, and as the chemotherapy is prepared in advance and is ready for the clinics before the patients’ appointment, the chemotherapy clinics also run to time.

Once the treatment has been prescribed and the treatment appointment confirmed, the prescription is passed to pharmacy, where it is clinically checked by pharmacists to confirm the prescription and intended treatment. This allows prescriptions to be clinically verified beforehand, giving ample time for any problems or interventions to be managed.

Work and capacity can be planned and scheduled in a managed way, allowing a steadier pattern of chemotherapy production and an inbuilt business continuity plan of 48 hours.

The clinical check at this point involves confirming the treatment intent, adherence to the protocol, dose calculation, dose adjustments, supportive treatments, schedule check and legality of the prescription. The prescription is then filed and stored in pharmacy awaiting the planned treatment appointment. Subsequent cycles of chemotherapy, too, are prescribed in advance at the end of the chemotherapy appointment and sent to pharmacy in the same manner.

As the pharmacy clinically check the majority of solid tumour prescriptions for the whole cancer region (Merseyside and Cheshire) centrally, trends in prescribing errors can be picked up much more quickly. This has been especially true of oral  chemotherapy treatments which require careful monitoring as there could be several different regimes dependent on the actual protocol, such capecitabine and radiotherapy patients.

As described earlier, all chemotherapy is prepared in advance of the patient appointment. The clinic prescriptions are collated two days prior to the clinic date and chemotherapy worksheets prepared and dispensed. In order to maintain pharmacy capacity and protect the pharmacy workflow, no additional patients are accepted to the clinic, with the exception of urgent treatments.

This discipline is essential if the model is to be successful and therefore requires the support and commitment of medical and nursing staff. This truly multidisciplinary approach to managing capacity has the advantage of reducing pressure on chemotherapy services, whilst building flexibility for urgent patients to be treated.

Chemotherapy drugs are prepared, released and sent to clinic prior to the patient appointment. The pharmacist release involves confirming the product against the prescription but does not involve checking the patient bloods. This role is undertaken by chemotherapy nurses at the chemotherapy clinic.

As pharmacists do not wait to release chemotherapy based on blood results, this has reduced delay and interruptions in pharmacy. The medical and nursing staff assess the patients prior to receiving chemotherapy, confirming patient bloods and previous treatment toxicity to assess patients for fitness to receive chemotherapy.

At CCO, patients only visit the hospital on the day of their chemotherapy appointment. They are assessed and bloods taken on the day of appointment, reducing the travel and journey times for patients attending treatments. This has greatly improved the patients’ treatment experience. Also worth noting is that a very efficient phlebotomy and laboratory service supports the chemotherapy clinics.

Advance prescribing in this manner does carry the risk that the patient may not tolerate the prescribed treatment, requiring modification of the treatment on the subsequent cycle. In this instance the prescribed chemotherapy, prepared in advance, would not be suitable for the patient and a dose modification would be necessary. Because the pharmacy prepared chemotherapy in advance, a fluid capacity plan has evolved and the workload capacity within the pharmacy is able to accommodate urgent treatment requests. Workflow and workplace pressure are protected as the pharmacy is always working in advance.

Managing risks and facilitating advance preparation of chemotherapy
The main risk to chemotherapy services is the risk of unused chemotherapy as a result of nontreatment. Nontreatments can be as a result of patients not arriving for treatment and dose delay or modification due to toxicities. This poses a financial risk to the hospital and chemotherapy services.
This has been minimised by:

  • Controlling the storage and distribution of the chemotherapy.
  • Assigning longer prepared expiry to chemotherapy under the Specials Manufacturing Licence held by the pharmacy.
  • Standardising doses and dose banding.

Managing the storage and distribution chain of chemotherapy is essential if the prepared chemotherapy drugs are to be stored and retained in controlled conditions for use at a later date. Chemotherapy is transported in insulated transport boxes. Pharmaceutical refrigerators are used at chemotherapy clinics for storage of chemotherapy requiring refrigeration. Both room and refrigerator temperatures are monitored to ensure control of the storage environment.

The pharmacy also holds a Specials Manufacturing License issued by the Medicines and Healthcare products Regulatory Agency (MHRA.) The MHRA requires that chemotherapy preparation units observe good manufacturing practice and allows the department to prepare batches of chemotherapy doses assigning longer expiry to the aseptically prepared products.

Longer expiry to prepared chemotherapy has allowed the pharmacy to prepare batches of chemotherapy in advance as well as retain doses for patients who are unable to receive treatment and have treatments delayed. As the chemotherapy drugs are prepared in controlled environments under strict aseptic conditions, a maximal expiry based on physicochemical stability of the prepared drug is assigned to the products. This has been further facilitated by choice of chemotherapy drug and brand: for example, etoposide phosphate is used instead of etoposide at CCO. Etoposide phosphate has the advantage of having a better stability and physicochemical stability profile than etoposide.

The dose banding[5] and dose standardisation protocol has been successfully implemented at CCO with multidisciplinary support from both doctors and nurses. Pharmacists manage the dose-banding protocol and adjust the prescribed doses to the agreed dose bands. Standardisation and dose banding have been successfully implemented for drugs such as docetaxel, gemcitabine, oxaliplatin, irinotecan, epirubicin, paclitaxel, carboplatin and vinorelbine. The dose-banding and dose standardisation schedules adopted at CCO have been agreed with chemotherapy consultants, and the maximal accepted inter-band variability between doses is up to 10%. The dose bands were worked out to ensure that the bands had minimal variability of up to 5% between each dose band. The dose bands were also agreed taking into consideration toxicity profiles of the drugs and common doses prescribed.

This system has several benefits to the chemotherapy
service:

  • Improved the efficiency of the service by increasing the re-use of returned doses from patients.
  • Standardisation of doses enabling batch manufacture and outsourcing of prepared chemotherapy.
  • Standardisation of doses allowing for urgent patients to be treated at short notice by making available ready-prepared and returned standard doses.
  • Reduction in the potential for medication errors and protocol miscalculations.
  • Reduction in drug wastage from discarded drugs from partly used vials.
  • Reduction in drug wastage from deferred doses. At a regional level, the model also facilitates:
  • Economy of scale in terms of managing agreed chemotherapy protocols.
  • Standardisation of labelling for solid tumour patients.
  • Standardised training package for pharmacist screening assessment.
  • Monitoring of prescribing errors and near-miss dispensing errors through a regional centralised database.
  • Central access to prescribers and Tumour Specialist Groups (TSGs).
  • Access to prescribers and Tumour Specialist Groups (TSGs).

Future plans
Future plans for the chemotherapy service include making available access to the e-prescribing system at the network hospitals. This will enable the hospital to have a paperless prescribing and medicines management system, which should increase safety and transfer of prescriptions through the network.

Also, the Integration of Acute Oncology Services[6] in Merseyside & Cheshire is ongoing and will be rolled out by 2012. This will further bridge specialist chemotherapy services provided by CCO closer to cancer patients’ homes in the North West.

References
1. Department of Health. A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. Calman – Hine Report 2005.
2. NHS North West. A Cancer Plan for the North West of England to 2012. February 2008.
3. Department of Health. The NHS Cancer Plan. September 2000.
4. Department of Health. Cancer Reform Strategy. December 2007.
5. Plumridge R, Sewell G. Dose banding of cytotoxic drugs: a new concept in cancer chemotherapy. Am J Health Syst Pharm 2001; 58: 1760-4.
6. Chemotherapy Services in England: Ensuring quality and safety. A report from the National Chemotherapy Advisory Group. Draft for consultation: November 2008.



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