1. Pharmacy Technician led chemotherapy education and toxicity assessment service: Oral Vinorelbine Sarah Goman Susan Edwards Carys Weale Bethan Tranter

2. Reason for New Service To provide evidence for the need to introduce a pharmacy service of which the primary aim will be to show an improvement in the safety of patient care. To show improvement in the patient experience with a positive impact on quality of life

3. Background Inconsistency in current vinorelbine pathways Inequalities with other oral SACT pathways

4. Aims To educate all patients in the Network receiving single agent vinorelbine To review those patients taking their day 8 dose of oral vinorelbine at home.

5. Study methods Questionnaires pre and post implementation To assess patient recall of oral chemotherapy information. To assess patient & staff satisfaction Time and motion study To assessing the time patients spend within hospital setting i.e. from appt time to leaving hospital To assess pharmacy dispensing times

6. Standards 100% of patients should be fully informed and receive verbal and up-to- date written information about their anti-cancer therapy and guidance on management of toxicities. 100% of patients should be satisfied with the Pharmacy technician led service Introduction of the pharmacy led service should reduce total time spent in hospital for patients

7. Patient Data and Demographics 53 patients 29 Breast 24 Lung Only a few patients have not been referred to the pharmacy service for clinical or other reasons

8. Recall of Information

9. Patient Satisfaction Q9 Were you satisfied that the Pharmacy Technician Day 8 assessment was thorough? FrequencyPercent Yes1995 No00 Not Documented15 Total20100 Q4a. Were you confident with the Pharmacy Technician who carried out the education (if given)? FrequencyPercent Yes1680 No00 Not Applicable420 Total20100

10. Medical Satisfaction Q1. I am confident that the Pharmacy Technicians will give a more complete level of education for patients receiving oral vinorelbine than we have time for in clinic FrequencyPercent Strongly Agree436 Agree764 Disagree00 Strongly Disagree00 Total11100

11. Medical Satisfaction (cont) Q3, I am confident that the Pharmacy Technicians will recover FBC results and give an equal level of toxicity assessment at the day 8 assessment call-back? FrequencyPercent Strongly Agree655 Agree545 Disagree00 Strongly Disagree00 Total11100

12. Time and Motion Study It was demonstrated that patients using the pharmacy led service received one less hospital visit of approx 3 hours plus any travel time every 3 weeks. It shows that if patients used the pharmacy led service, pharmacy could save approximately 44 minutes dispensing time per patient by dispensing Day 1 and day 8 drugs on day 1. Total pharmacy time Day 1 42 minutes Day 8 51 minutes Day 1 and Day 8 (pharmacy led education)39 minutes Overall Patient Journey Time Day 1 2 hrs 54 minutes Day 8 2 hrs 51 minutes Day 1 and Day 8 (pharmacy led education)2.51 hours

13. Day 8 Callback Data Total Number of Call Backs = 147 Date Range: 03/08/11 to 19/04/12 Disease Type per call back FrequencyPercent Breast7249 Lung7551 Total147100

14. Day 8 Doses given/not given BreastLungOverall Yes / given66 /72 (92%)62/75 (83%)128/147 (87%) Day 8 Neutropenia 000 (0%)

15. Reason doses not taken Borderline Temperature37.4 D/W Dr, in view of low grade temp and generally not feeling great to omit Pt not keen to take. D/W Dr, happy with pt decision. D/W Dr- not happy for pt to take. Dr Borely already told her not to take dose D/W Dr, in view of sickness, temp and high neutrophils, to omit dose. Return to clinic in 2 weeks as planned. Has been admitted to PMW with chest infection Has UTI temp 35.4, D/W Dr- do not take dose, Pancreatitis admitted to hospital Coughing up yellow phlegm and high neuts. D/W Dr – omit dose Omit - Fallen leg pain, swelling, knee down, pain in groin. Feeling generally unwell GP calling today. Cellulitis - pt on antibiotics D/W Dr - not for D8 Pt not proceeding with Vinorelbine D/W DR- not to take chemo ref pt to GP for review On antibiotics possible UTI. D/w Dr-omit dose Has a cold and on amoxicillin for sinusitis. D/W Dr - in view of upcoming holiday not to take dose pt admitted to POW not passing urine and very constipated spoke Contacted Dr as possible oral thrush advised to go to GP for antibiotics and omit dose Has cold and coughing up green phlegm & has headache. Pt is dry retching d/w on call registrar advised for pt not to take D8 On ASU very unwell

16. Toxicity Callback Data BREAST Grade 0 Grade 1Grade 2Grade 3Grade 4NDTotal Nausea41 (57%) 23 (32%) 2 (3%) 1 (1%) 05 (7%) 72 (100%) Vomiting54 (75%) 8 (11%)4 (6%) 1 (1%) 05 (7%) 72 (100%) Diarrhoea50 (70%) 16 (22%) 1 (1%) 005 (7%) 72 (100%) Stomatitis48 (67%) 17 (24%) 1 (1%) 006 (8%) 72 (100%) Constipation45 (63%) 20 (28%) 1 (1%) 1 (1%) 05 (7%) 72 (100%) Peripheral Neuropathy 56 (78%) 3 (5%)6 (8%) 1 (1%0 06 (8%) 72 (100%) Fatigue3 (4%) 52 (72%) 4 (6%) 0N/A13 (18%) 72 (100%)

17. Toxicity Callback Data LUNG Grade 0Grade 1Grade 2Grade 3Grade 4NDTotal Nausea48 (64%)20 (27%)3 (4%) 004 (5%)75 (100%) Vomiting60 (80%)5 (7%) 5 (7%) 1 (1%) 05 (7%)75 (100%) Diarrhoea54 (72%)12 (16%)3 (4%) 1 (1%) 05 (7%) 75 (100%) Stomatitis53 (71%)16 (21%)1 (1%) 005 (7%)75 (100%) Constipation29 (39%)28 (37%)10 (13%)2 (3%) 06 (8%) 75 (100%) Peripheral Neuropathy62 (83%)4 (5%) 3 (4%) 01 (1%) 5 (7%) 75 (100%) Fatigue7 (9%) 42 (56%)18 (24%)3 (3%) N/A6 (8%) 75 (100%)

18. Conclusions - advantages Releases capacity – Clinic appointments – Chair time – Pharmacy Improvement of patient knowledge and experience Patient and staff satisfaction Improves VCC clinical governance arrangements

19. Advantages cont’d Streamlined the service provided at VCC e.g All day 1 doses within a combination therapy given at chairside Pharmacy labelling of Vinorelbine improved

20. Disadvantages Workload is inconsistent (for pharmacy) Requires future funding stream Day 8 pathway to be refined/ re inforced Wastage of vinorelbine

21. Future Continue service at VCC Expand to other oral SACTS – toxicity monitoring – patient education Roll out to outreach All breast patients to take dose on same day Improvement of single agent prescription Toxicity sheet on Canisc

22. Pierre Fabre sponsored 15 hours per week for 1 year of pharmacy technician time to enable the pilot project to take place