1. Pilot project to introduce the delivery of high dose chemotherapy in the home setting using an ambulatory infusion device
Caroline Croezen
CNM II Haematology Day Ward
St James Hospital, Dublin

2. Background Historically high dose chemo given in the inpatient setting
Ambulatory care applies to patients who require close monitoring but are mobile and do not need to stay in hospital overnight
EPOCH is used to treat patients with diffuse large B cell lymphoma
Etoposide, prednisolone, vincristine, doxorubicin & cyclophosphamide
Using an ambulatory device regimes such as EPOCH can be safely delivered in the home setting

3. Background
A multi-disciplinary approach is key to making this model a success
Consultant
Medication Safety Officer
Liaison Nurse
Business Manager
CNMs from inpatient and outpatient ward
Pharmacy
Medical Physics
A Protocol was written

4. Method Met with reps from 2 different companies
1st pump CADD Legacy Pump-Smyth’s Healthcare
2nd Bodyguard Pump-Rockford Healthcare
Formal training from the company for staff of the inpatient and outpatient ward
Project lead ensured different staff set up the pump each day to ensure everyone had experience with pump set up and troubleshooting

5. Method
Complete first cycle given as inpatient to ensure no issues with alarms and charging
Subsequent cycles patient attends day ward daily for assessment and pump change
Staff on inpatient ward aware a patient at home on ambulatory pump
If any alarms patient would have to come in from home
Patients have 24 hour contact numbers and a spill kit

6. Method As day patient patient must start on a Monday
Day 1 Ritux is given on day ward
EPOCH pump attached and placed in backpack and patient goes home
Back the next day at the same time for pump disconnection and new EPOCH bag connection
Day 5 pump is removed and half hour cyclophosphamide infusion given
Bloods taken twice weekly in day ward

7. Agreed criteria for patient selection
Willingness and competence to undertake extra responsibilities such as charging of device every night
Good level of written and spoken English
Live within one hour of the hospital
Must have a central venous access device insitu

8. Case Study One 35 year old Polish National
Wife had just had a new baby
Able to continue work in IT while on ambulatory pump
Completed six cycles using the pump with no issues
Currently in remission

9. Case Study Two 21 year old fashion student
Suffered terribly with anticipatory nausea and vomiting
Lives in Drogheda
100% reduction in anticipatory nausea, quality of life greatly improved
Completed six cycles using the pump, currently in remission

10. Case Study Three 40 year old gentleman
Was up all night in hospital from high dose steroids
At home could watch TV until 5am without disturbing anyone
Was able to go out and about during the day and do his shopping
Currently in remission

11. Case Study four Surgical SPR within the hospital
Didn’t want to see colleagues on ward rounds
Wanted to be at home with his children
Massive increase in quality of life using ambulatory pump
Currently very well and in remission

12. Cost Savings 5 cycles treatment, 6 bed days per cycle
(A) Actual Current Costs
5 cycles treatment, 6 bed days per cycle
LOS per patient 5 x 6 = 30 days
10 patients per year: 30 x 10 = 300 days
Total current cost : 300 x (1000 EURO/night) = 300,000 EURO
(B) Proposed costs following business case implementation
One pump: euro
Giving set: 220 euro per 20
Rucksack: 175 euro
One box giving set per treatment course per patient=220
Total proposed cost: (Pump + giving set + rucksack) =2,345
C) Difference (Actual Current CostS (A)- Proposed costs (B)
300,000- 2,345=297,655 EURO

14. Conclusion
Using ambulatory infusion pumps regimes such as EPOCH can safely be delivered in the home setting
Greatly improves quality of life for patients
Quality initiative for hospitals as it reduces inpatient hospital stay by at least 6 days per cycle
Now standard of care-2 pumps purchased

15. References
Kliethermes M.A and Brown T.R. (2011) Building a Successful Ambulatory Care Practice: A Complete Guide for Pharmacists. American Society of Health System Pharmacists, Bethesda.
Newton, C. and Ingram, B. (2014) Ambulatory chemotherapy for teenagers and young adults. British Journal of Nursing 23 (4)

16. Thank You!!!!