Achieving safety and quality inAchieving safety and quality in

MCCN chemotherapy services MCCN chemotherapy services

QualityQuality

Purpose designed treatment facilitiesPurpose designed treatment facilities Short waiting timesShort waiting times Short travelling timesShort travelling times Available (free) car parkingAvailable (free) car parking Excellent outcomesExcellent outcomes Availability of clinical trialsAvailability of clinical trials

SafetySafety

Patient selectionPatient selection PrescribingPrescribing Pharmacy prescription checkingPharmacy prescription checking Experienced nursing staffExperienced nursing staff Patient educationPatient education Effective toxicity management – triageEffective toxicity management – triage

Two reports concerning chemotherapy Two reports concerning chemotherapy services publishedservices published

NCEPODNCEPOD NCAGNCAG

November 08November 08

NCEPODNCEPOD

NNational ational CConfidential onfidential EEnquiry into nquiry into

PPatientatientOOutcomes and utcomes and DDeatheath

Establised 1982 Establised 1982

maintain and improve the standards ofmaintain and improve the standards of

medical and surgical care medical and surgical care reviewing patient management reviewing patient management undertaking confidential enquiries.undertaking confidential enquiries.

NCEPODNCEPOD

Ist enquiry was into post-operative deathsIst enquiry was into post-operative deaths

NCEPOD – Nov 08NCEPOD – Nov 08

Deaths within 30 days of Systemic Deaths within 30 days of Systemic

Anti-Cancer Treatment (SACT)Anti-Cancer Treatment (SACT)

Deaths within 30 days of SACTDeaths within 30 days of SACT

RationaleRationale

A belief existed that the standard of care A belief existed that the standard of care

was not uniform across the countrywas not uniform across the country

AimAim

Identify remedial factors in the care receivedIdentify remedial factors in the care received

by patientsby patients

Inclusion criteriaInclusion criteria

Patients aged 16yrs +Patients aged 16yrs + Solid or haematological malignanciesSolid or haematological malignancies Received SACT during the study periodReceived SACT during the study period

– June / July 07June / July 07

Died within 30 days of treatmentDied within 30 days of treatment Total numbers receiving SACT not recordedTotal numbers receiving SACT not recorded

CCO June/July 07CCO June/July 07

34 deaths within 30 days34 deaths within 30 days 4000 cycles of SACT delivered4000 cycles of SACT delivered 1% pts 1% pts

Overall quality of careOverall quality of care

Room for improvementRoom for improvement

Decision to treatDecision to treat Consent and information Consent and information Prescribing and dispensingPrescribing and dispensing Toxicity managementToxicity management

Advisors opinion on the Advisors opinion on the decision to treatdecision to treat

Advisors’ opinionAdvisors’ opinion 513/546 cases 513/546 cases

Appropriate Decision Appropriate Decision 81%81%

Inappropriate Decision Inappropriate Decision 19%19%

Reasons Reasons

- Poor performance status - Poor performance status

- Abnormal of investigations- Abnormal of investigations

INCREASED INCREASED TOXICITYTOXICITY

- End stage disease - End stage disease

- Lack of evidence of efficacy- Lack of evidence of efficacy

DECREASED DECREASED BENEFITBENEFIT

Consent forms 310/546 casesConsent forms 310/546 cases

STANDARDSTANDARD

Written information should be provided onWritten information should be provided on treatment intention and expected response ratestreatment intention and expected response rates acute and possible late side effectsacute and possible late side effects mortality rates mortality rates

Most common side effects Most common side effects 75%75%

Most serious side effects Most serious side effects 52%52%

Mortality risk Mortality risk 9%9%

DOCUMENTATION ON CONSENT FORMDOCUMENTATION ON CONSENT FORM

Recommendations of the reportRecommendations of the report

Management plan formulated at MDTManagement plan formulated at MDT Consent taken by an experienced clinicianConsent taken by an experienced clinician Prescribing by experienced cliniciansPrescribing by experienced clinicians Circumspection in treating poor PS ptsCircumspection in treating poor PS pts Experienced pharmacists check Experienced pharmacists check Specialist advice available where patients are Specialist advice available where patients are

admitted with toxicityadmitted with toxicity Regular audit - neutropenic sepsisRegular audit - neutropenic sepsis - deaths within 30 days- deaths within 30 days

Management of neutropenic sepsis: Management of neutropenic sepsis: standardsstandards

Intravenous antibiotics should be Intravenous antibiotics should be commenced within 30 minutes in commenced within 30 minutes in 100% of patients who have 100% of patients who have received recent chemotherapy and received recent chemotherapy and who are shocked.who are shocked.

Chemotherapy Guidelines: COIN 2001Chemotherapy Guidelines: COIN 2001

NCAG Nov 08NCAG Nov 08

Decision to start Ctx by consultantDecision to start Ctx by consultant Consent forms: common and serious toxicities and Consent forms: common and serious toxicities and

expected benefitexpected benefit Dispensing and prescription verification by Dispensing and prescription verification by

appropriately trained staffappropriately trained staff Electronic prescribingElectronic prescribing Access to 24hr helplineAccess to 24hr helpline Pro-active telephoning post CtxPro-active telephoning post Ctx Improved communication: DGHs Cancer CentreImproved communication: DGHs Cancer Centre Acute oncologyAcute oncology

MCCNMCCN

– All Ctx is consultant prescribedAll Ctx is consultant prescribed– Proactive telephoning patients Proactive telephoning patients – Improve the triage serviceImprove the triage service– Improved consent formsImproved consent forms– Improved consent processImproved consent process– Purpose designed facilities across the networkPurpose designed facilities across the network– Electronic prescribingElectronic prescribing

Facilitate auditFacilitate audit

– Develop acute oncologyDevelop acute oncology