Achieving safety and quality in MCCN chemotherapy services

Quality  Purpose designed treatment facilities  Short waiting times  Short travelling times  Available (free) car parking  Excellent outcomes  Availability of clinical trials

Safety  Patient selection  Prescribing  Pharmacy prescription checking  Experienced nursing staff  Patient education  Effective toxicity management – triage

 Two reports concerning chemotherapy services published  NCEPOD  NCAG November 08

NCEPOD National Confidential Enquiry into PatientOutcomes and Death Establised 1982 maintain and improve the standards of medical and surgical care  reviewing patient management  undertaking confidential enquiries.

NCEPOD  Ist enquiry was into post-operative deaths

NCEPOD – 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 SACT Rationale A belief existed that the standard of care was not uniform across the country Aim Identify remedial factors in the care received by patients by patients

Inclusion criteria  Patients aged 16yrs +  Solid or haematological malignancies  Received SACT during the study period –June / July 07  Died within 30 days of treatment  Total numbers receiving SACT not recorded

CCO June/July 07  34 deaths within 30 days  4000 cycles of SACT delivered  1% pts

Overall quality of care

Room for improvement  Decision to treat  Consent and information  Prescribing and dispensing  Toxicity management

Advisors opinion on the decision to treat Advisors’ opinion 513/546 cases Appropriate Decision Appropriate Decision81% Inappropriate Decision Inappropriate Decision19% Reasons - Poor performance status - Poor performance status - Abnormal of investigations - Abnormal of investigations INCREASED TOXICITY - End stage disease - End stage disease - Lack of evidence of efficacy - Lack of evidence of efficacy DECREASED BENEFIT

Consent forms 310/546 cases STANDARD Written information should be provided on  treatment intention and expected response rates  acute and possible late side effects  mortality rates Most common side effects 75% Most serious side effects 52% Mortality risk 9% DOCUMENTATION ON CONSENT FORM

Recommendations of the report  Management plan formulated at MDT  Consent taken by an experienced clinician  Prescribing by experienced clinicians  Circumspection in treating poor PS pts  Experienced pharmacists check  Specialist advice available where patients are admitted with toxicity  Regular audit - neutropenic sepsis - deaths within 30 days - deaths within 30 days

Management of neutropenic sepsis: standards Intravenous antibiotics should be commenced within 30 minutes in 100% of patients who have received recent chemotherapy and who are shocked. Chemotherapy Guidelines: COIN 2001

NCAG Nov 08  Decision to start Ctx by consultant  Consent forms: common and serious toxicities and expected benefit  Dispensing and prescription verification by appropriately trained staff  Electronic prescribing  Access to 24hr helpline  Pro-active telephoning post Ctx  Improved communication: DGHs Cancer Centre  Acute oncology

MCCN –All Ctx is consultant prescribed –Proactive telephoning patients –Improve the triage service –Improved consent forms –Improved consent process –Purpose designed facilities across the network –Electronic prescribing  Facilitate audit –Develop acute oncology