Network Audit on Virology Testing prior to R-Chemotherapy in patients with newly diagnosed DLBCL January to June 2016 Presented by Karan Wadhera

  Guideline a) All patients starting treatment with Rituximab should be screened for Hepatitis B virus infection, with testing for HBsAg and HBcAb a minimum, prior to commencing treatment- MHRA article Dec/2013  b) All patients starting treatment with R-CHOP chemotherapy should have Hepatitis B and C screening, prior to commencing treatment- SWSCN Protocol c) Routinely offer and recommend an HIV test to everyone attending their first appointment, for services providing treatment for Lymphoma- NICE guidance, Dec/2016

Aim To achieve a target of 100% compliance in screening for Hepatitis B and C infections prior to commencing Rituximab based treatment, with a minimum of HBsAg, HBcAb and Anti-HCV Ab tests being done, prior to treatment in patients with newly diagnosed Diffuse Large B Cell Lymphoma.

Patients All patients with a diagnosis of Diffuse Large B Cell Lymphoma, diagnosed between 01/January/2016 to 30/June/2016 and starting Rituximab based chemotherapy in the South West region, covering the following NHS Trusts: UH Bristol NHS Foundation Trust North Bristol NHS Trust Royal United Hospital Bath Gloucestershire Royal Hospitals NHS Trust Great Western Hospital, Swindon Musgrove Park Hospital, Taunton Weston General Hospital, Weston-Super-Mare

Method Individual Trusts involved in the audit, to complete an audit data collection sheet and to also include their local Trust policies and guidelines on virology testing. The completed proformas are then to be returned to Karan Wadehra at karan.wadehra@uhbristol.nhs.uk and helen.dunderdale@uhbristol.nhs.uk

Audit Data Collection Sheet

Results University Hospitals Bristol NHS Foundation Trust  a) Total number of patients: 20  b) Compliance with Hepatitis B and C screening: 9 (45%)

c) Non compliant cases HBcAb not checked ?wrong ICE request Oversight d) HIV testing compliance: 95%

North Bristol NHS Trust a) Total number of patients: 11 (one patient discounted in view of date of R-Chemotherapy not available) b) Compliance with Hepatitis B & C screening: 8 (75%)

c) Non compliant cases: 3 patients All three patients: Anti HCV not tested ?oversight ?requesting error d) HIV testing compliance: 100%

Royal United Hospital, Bath a) Total number of patients: 19 (one patient discounted in view of being private patient) b) Compliance with Hepatitis B & C screening: 0% c) Non compliant cases HBcAb testing not in Trust guidelines No Hepatitis test requested in others- OS, NA d) HIV testing compliance: 79%

Weston General Hospital a) Total number of patients: 8  b) Compliance with Hepatitis B & C screening: 100% c) HIV testing compliance: 100% WELL DONE!

Gloucestershire Royal Hospitals NHS Trust  a) Total number of patients: 20  b) Compliance with Hepatitis B & C screening: 17 (85%) c) Non compliant cases: 3 cases, Oversight (requested by clinician but not performed) d) HIV compliance: 30%: low rates of HIV testing

Musgrove Park Hospital, Taunton a) Total number of patients: 17 b) Compliance with Hepatitis B & C testing: 11 (65%) c) Non compliant cases: Oversight issue- 2 cases no HBcAb done, 1 case Hepatitis screening after R-Chemotherapy commenced d) HIV testing compliance: 80%

Great Western Hospital, Swindon NO DATA!

Conclusions 1. ‘Oversight’ issue 2. HBcAb testing not in RUH Bath Trust guidelines 3. ICE requesting issue in UH Bristol 4. Low rates of HIV testing in Gloucestershire Royal Hospital

Recommendations   1. Better education of junior medical staff- Induction, SpR training day etc.  2. MDT- Once R-Chemotherapy agreed in MDT, comment for clinicians to test for Hepatitis B & C. CNSs could request this after MDT 3. Lymphoma Nurse Specialists- can also request, while giving information to patients regarding R- Chemotherapy 4. Check box on electronic chemotherapy prescribing systems, for clinicians, who are prescribing first cycle of R-Chemotherapy 5. Pharmacy to flag up on chemotherapy chart- not issue chemotherapy until valid and appropriate Hepatitis testing done 6. Check box on chemotherapy chart for first cycle of R-Chemotherapy, for administering nursing staff to ensure that Hepatitis screening done 7. RUH Bath to incorporate HBcAb testing into Trust guidelines for patients commencing on R- 8. UH Bristol should incorporate a check box for Rituximab, while requesting Hepatitis B&C screening or introduce the mandatory tests under Haematology profiles 9. All Trusts to routinely offer HIV testing, to all patients with a Lymphoma diagnosis, as per current NICE guidelines.

Re-audit   Aim to re-audit in 6-12 months’ time, after above recommendations implemented at individual Trusts. Re-audit to be presented at SWAG SSG meeting 2018.

Contributors Sophie Otton, North Bristol NHS Trust Rebecca Hallam, Weston General Hospital David Dutton, Royal United Hospital, Bath Adam Bond, Gloucestershire Royal Hospitals NHS Trust Deepak Mannari, Musgrove Park Hospital, Taunton Helen Dunderdale, University Hospitals Bristol NHS Foundation Trust.