Transcript Slide 1

Aim
•
Identify remediable factors in the
care received by patients
•
Proposed by the JSC and JCCO
as there was a belief that the
standard of care was not uniform
across the country
Expert group
•
Medical/clinical and haemato-
oncologists
•
Palliative medicine physician
•
Pharmacist
•
Chemotherapy nurse
•
Patient representative
Key areas defined
•
The decision to treat
•
Prescription and administration
•
The safety of treatment
•
End of life care
•
Communication
•
Clinical governance
Inclusion criteria
•
•
•
•
Patients aged 16 years or over
Solid tumours or haematological
malignancies
Received chemotherapy,
monoclonal antibodies or
immunotherapy during the study
period
Died within 30 days of receiving
treatment
Data collection
•
Questionnaire A
•
Questionnaire B
•
Casenotes
•
Organisational questionnaire
Advisor groups
•
All cases anonymised
•
Clinical/medical/haematooncologists
•
Palliative medicine physicians
•
Pharmacists
•
Chemotherapy nurse specialists
•
Assessed all aspects of care
Overall assessment of care
•
•
•
•
•
Good practice
Room for improvement:
clinical care
Room for improvement:
organisational care
Room for improvement:
clinical care & organisational care
Less than satisfactory
Cases identified
•
47,050 treatment cases
•
55,710 deaths from any cause
•
1415 cases identified
Data returned
Recommendation
Cancer services managers and
clinical directors must ensure that
time is made available in consultants’
job plans for clinical audit. They must
also ensure that the time allocated is
used for the defined purpose.
(Cancer Services Managers and Clinical Directors)
Classification of hospitals
Hospital workload
Staffing
Emergency admissions facilities
General medical support
Other specialties onsite
•
•
Critical care
–
204/291 Level 3
–
243/290 Level 2
Palliative care
–
•
81/156 consultant palliative care sessions
Resuscitation teams
–
11 hospitals did not have one onsite
Recommendation
Hospitals that treat patients with
SACT but do not have the facilities to
manage patients who are acutely
unwell should have a formal
agreement with another hospital for
the admission or transfer of such
patients as appropriate.
(Medical directors)
•
Aim
•
Interpretation
•
Limitations
•
Results
Overall quality of care
Room for improvement
• Decision to treat
• Process of care
– Prescribing, dispensing and administration
of SACT
• Communication
– Patient information, medical records
• SACT toxicity
– Admission, assessment and treatment
– Management of neutropenic sepsis
• End of life decisions
Advisors opinion on the
decision to treat
Advisors’ opinion
513/546 cases
Appropriate Decision
81%
Inappropriate Decision
19%
Reasons
- Poor performance status
- Abnormal of investigations
INCREASED
TOXICITY
- End stage disease
- Lack of evidence of efficacy
DECREASED
BENEFIT
Decision to treat
PATIENT’S
DECISION
DISCUSSION OF
TREATMENT OPTIONS
ONCOLOGIST’S
ASSESSMENT
CLINICAL MANAGEMENT PLAN
MDT DISCUSSION
Multi-disciplinary team meetings
STANDARD
The management of all cancer patients should be
discussed at regular MDT meetings.
Manual for Cancer Services: 2004
MDT discussion
58%
CURATIVE treatment intent
PALLIATIVE treatment intent
88%
51%
FIRST LINE SACT
PREVIOUS SACT
43%
73%
Tumour and patient characteristics
•
•
•
•
Tumour type
Tumour stage
Previous SACT
Medical complications of malignancy
• Patient’s age
• Patient’s performance status
• Patient’s co-morbidities
Solid tumours
Haematological malignancies
SACT regimens
• Carboplatin and Etoposide
• Capecitabine
• Gemcitabine and Carboplatin
• Oxaliplatin
• Carboplatin
• R-CHOP and CHOP
Performance score
Clinical management plan
Decision to treat
DECISION TO TREAT
ADVISOR
APPROPRIATE
81%
ADVISOR
INAPPROPRIATE
19%
ONCOLOGIST
APPROPRIATE
82%
ONCOLOGIST
DIFFICULT DECISION
18%
DECISION
JUSTIFIED
5%
QUESTIONABLE
7%
PATIENTS CHOICE
INAPPROPRIATE
DECISION
6%
Patient information 433/546 cases
Verbal – doctor
Org Q
Cases
>95%
66%
Verbal – nurse
Chemotherapy leaflet
13%
>95%
Clinical trial information
27%
4%
BACUP booklet
>95%
10%
Audio-visual information
56%
<1%
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
Obtaining Consent for Chemotherapy:
British Committee for Standards in Haematology Guidelines
DOCUMENTATION ON CONSENT FORM
Most common side effects
75%
Most serious side effects
52%
Mortality risk
9%
Recommendations
NCEPOD supports the Manual for
Cancer Services standard that initial
clinical management plans for all
cancer patients should be
formulated within a MDT meeting.
(Clinical directors)
Recommendations
Giving palliative SACT to poor
performance status patients grade
3 or 4 should be done so with
caution and having been
discussed at a MDT meeting.
(Consultants)
Recommendations
Consent must only be taken by a
clinician sufficiently experienced to
judge that the patient’s decision
has been made after careful
consideration of the potential risks
and benefits of the treatment, and
that treatment is in the patient’s
best interest.
(Clinical directors)
Recommendations
All deaths within 30 days of SACT
should be considered at a
morbidity and mortality or a clinical
governance meeting.
(Clinical directors and consultants)
Process of care
SACT
ADMINISTRATION
SACT PRESCRIPTIONS
PRE-TREATMENT ASSESSMENTS
STAFF - TRAINING AND ACCREDITATION
Authorisation to prescribe SACT
STANDARD
Chemotherapy must be initiated and prescribed only by clinicians
who are appropriately accredited and/or experienced
Good Practice Guidance for Clinical Oncologists: RCR
List maintained
Yes
Unknown
Initiator
Prescriber
77%
71%
24/285
28/285
SACT initiators
SACT prescribers
SACT prescribing accreditation
• Independent prescribers n=32
– 6 at the consultant’s discretion
– 23 post formal assessment and accreditation
– 3 unknown
Initiator, prescriber, reviewer
Pre-treatment investigations
Pre-treatment assessments
STANDARDS
Toxicity should be recorded
for each cycle using the
Common Toxicity Criteria
The outcomes of treatment
should be monitored
closely
Appropriate action should
be taken if
- the side-effects are excessive
- the cancer progresses.
Chemotherapy Guidelines: COIN 2001
Casenotes available
267/278
Documentation of toxicity
and tumour response
• Toxicity
– Record of assessment – 64%
– Toxicity checklist – 26/267
• Tumour response
– Record of assessment – 54%
Prescriptions
STANDARD
All prescriptions of cytotoxic chemotherapy should be computer
generated at least when using regimens from the agreed list.
Manual for Cancer Services: 2004
n=426
Route of SACT administration
Recommendation
All independent and supplementary
prescribers (specialist chemotherapy
nurses and cancer pharmacists) and
junior medical staff should be locally
trained/accredited before being
authorised to prescribe SACT.
(Cancer services managers and clinical directors)
Recommendation
Junior medical staff at FY1, FY2,
ST1 and ST2 grade should not be
authorised to initiate SACT.
(Clinical directors)
Toxicity check lists should be
developed to assist record keeping
and aid the process of care in
prescribing SACT.
(Cancer services managers and clinical directors)
Safety of SACT delivery
LIMIT SACT
TOXICITY
NURSE CHECKS
PHARMACY CHECKS
DOSE REDUCTIONS / TREATMENT DELAYS
Adjustments
to SACT regimen
Prescription safety checks
STANDARD
All cytotoxic chemotherapy prescriptions should be checked and
authorised by a pharmacist.
Manual for Cancer Services: 2004
Prescriptions checked
Yes
Unknown
Parenteral
Oral
97%
73%
21/295
30/295
Prescriptions reviewed
369
Evidence that the prescription had been
checked
53%
SACT administration safety checks
STANDARD
Doctors or specialist nurses who administer
chemotherapy must perform checks with a colleague to
confirm patient identity, drug regimen, dosage, route of
administration and frequency.
Good Practice for Clinical Oncologists: RCR 2003
POLICY – two nurses to
check SACT
89%
of organisations
EVIDENCE – two nurses
checked SACT
71%
cases
Recommendations
All SACT prescriptions should be
checked by a pharmacist who has
undergone specialist training,
demonstrated their competence and
are locally authorised/accredited for
the task. This applies to oral as well
as parenteral treatments.
(Clinical directors and pharmacists)
Recommendations
Pharmacists should sign the
SACT prescription to indicate that
it has been verified and validated
for the intended patient and that
all the safety checks have been
undertaken.
(Pharmacists)
Overall opinion on
final cycle of SACT
•
Inappropriate in 154/435 (35%)
– Inappropriate decision to initiate
final COURSE of SACT
– Inappropriate timing or doses of
final CYCLE of SACT
– Progressive disease
•
•
•
•
Information for patients who
become unwell
Admission to hospital and
management of sepsis
Deaths after SACT and end of life
care
The need for regular audit
Information for unwell patients:
standards
There should be written information for patients
detailing how to seek advice if they become
unwell with complications of chemotherapy
Manual for Cancer Services: Department of Health
2004
Patients should have access to appropriate
advice and care at any time, day or night, should
they suffer unexpected consequences of
treatment
Good Practice Guide for Clinical Oncologists: Royal
College of Radiologists
Grade 3 and Grade 4 toxicity
220/514 (43%) cases
Information for unwell patients:
findings
•
96% of hospitals provided information to patients about
what to do if they become unwell
•
43% of patients who died within 30 days of SACT
suffered grade 3 or 4 treatment related toxicity
Patient delay in reporting
side effects
Examples of good practice in
patient education
• Nurse and/or pharmacist led
education clinics
• Follow up call from hospital to
patient
• Dedicated phone line for patients
to call
•
•
•
•
Information for patients who
become unwell
Admission to hospital and
management of sepsis
Deaths after SACT and end of life
care
The need for regular audit
Hospital admissions after SACT
If a patient becomes unwell after
receiving SACT due to side effects,
progression of disease, or
worsening co-morbidity they must
be able to get appropriate advice
and if necessary admission under
the care of an appropriate
specialist.
Emergency admission policies
Emergency admission policies
• 85% of patients admitted to
hospital within last 30 days of life
• Of those 18% (nearly 1 in 5) were
not admitted to the hospital in
which they received SACT
Specialty of first admission during
last 30 days of life
Time to review by oncologist
Appropriateness of specialty for
patient’s condition
• May depend on the reason patient
is unwell
• Time to specialist review - may
exclude telephone review
• Additional training?
• Shift in care of emergency
admissions?
Recommendation
In planning the provision of oncology
services outside of cancer centres,
commissioners should take into
account the need for specialist
advice to be readily available when
patients are admitted acutely.
(Cancer services managers)
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
Management of neutropenic sepsis:
standards
Every acute hospital should have written
guidelines on the diagnosis and
management of neutropenic sepsis. All
medical staff should be aware of their
existence and a copy should be readily
available in all relevant clinical areas
including Accident & Emergency.
Chemotherapy Guidelines: COIN 2001
Management of neutropenic sepsis:
standards
Networks should agree, document and
disseminate guidelines for both
prophylaxis and management of
neutropenic sepsis …… These patients
should be managed by a specialist
haemato-oncology MDT.
Improving outcomes in haematological cancer:
NICE 2003
Neutropenic sepsis policy
Recommendation
Emergency admissions services must have
the resources to manage SACT toxicity
These should include:–A clinical care pathway for suspected neutropenic sepsis
–A local policy for the management of neutropenic sepsis
–Appropriately trained staff familiar with the neutropenic
sepsis policy
–The policy should be easily accessible in all emergency
departments
–Availability of appropriate antibiotics within the
emergency department
(Cancer services managers and clinical directors)
•
•
•
•
Information for patients who
become unwell
Admission to hospital and
management of sepsis
Deaths after SACT and end of
life care
The need for regular audit
Where patients died
Effect of treatment on outcome
Why patients died
Deaths after SACT
and end of life care
“how we care for the dying is an
indicator of how we care for all sick
and vulnerable people”
(Ivan Lewis care service minister, Department
of Health 2008)
Do Not Attempt Resuscitation
(DNAR)
• Hospital trusts are required to
have resuscitation policies in
place to support people’s
choices about future care and
treatment
DNAR
End of life care pathways
• Developed for cancer patients
• Only found in notes of 57
patients
End of life care pathways
• Help those with advanced, progressive,
incurable illness to live as well as possible until
they die
• Enable the supportive and palliative care needs
of both patient and family to be identified and
met throughout the last phase of life and into
bereavement
• Includes management of pain and other
symptoms and provision of psychological, social,
spiritual and practical support
(National Council for Palliative Care 2006)
Recommendation
A pro-active rather than reactive approach
should be adopted to ensure that palliative
care treatments or referrals are initiated
early and appropriately: Oncologists should
enquire at an appropriate time, about any
advance decisions the patient might wish
to make should they lose the capacity to
make their own decisions in the future.
(Consultants)
•
•
•
•
Information for patients who
become unwell
Admission to hospital and
management of sepsis
Deaths after SACT and end of life
care
The need for regular audit
Audit
• Neutropenic sepsis in solid tumours
was audited in 45% (101/224)
hospitals
• Neutropenic sepsis in
haematological malignancies was
audited in 51% (100/196)
Audit
• Solid tumours: 24% of hospitals
• Haematological malignancies: 14%
of hospitals
• The deaths of only 16% of patients
in this study were discussed
Which cases were discussed
The need for regular audit
• Most hospitals held regular
audit/clinical governance meetings
• About half discussed adherence to
NICE guidelines but only a quarter
discussed chemotherapy toxicity
Recommendations
Regular clinical audit should be
undertaken on the management of
all cases of neutropenic sepsis
following the administration of
SACT.
(Clinical directors)
Recommendations
All deaths within 30 days of SACT
should be considered at a morbidity
and mortality or a clinical
governance meeting.
(Clinical directors and consultants)
Thank you
www.ncepod.org.uk