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Pharmacy support


therapy is at a later stage of the disease pathway and so the first consideration is whether the new treatment represents an extra line of treatment and/or replaces a therapy already available in the clinics. Either way it is important to understand the likely workload impact of the new therapy, number of patients etc, to understand whether the current service has sufficient capacity to deliver the new therapy. Consideration should be given to the wider chemotherapy service and whether efficiencies can be made elsewhere in order to release capacity. For example: ● Oral chemotherapy ● Subcutaneous antibodies ● Dose-banding3 ● Vial sharing ● Outsourced services (ready to use chemotherapy, homecare service)


● Care closer to home. Staff training


A number of staff groups within the chemotherapy service require different training to support the delivery of a new therapy, including: ● Prescriber – dosing, side effect management, patient population in studies


● Pharmacist – shelf life, side effects and their management, dosing


● Pharmacy technicians – aseptic manipulation


● Chemotherapy nurses – administration, toxicity management


● In-patient nurses – toxicity management


Pharmaceutical company sales representatives play an important role in delivering this training and providing materials. Networking with colleagues in neighbouring Trusts, especially those involved in Phase II/III clinical trials, provides additional expertise on the real world delivery of the therapy.


Dispensing


In order to dispense the therapy, the Pharmacy team must first have access to the medicine. In many cases in the UK, in order to gain funding approval, a patient access scheme is agreed between the Department of Health and Pharma. Previous analysis of such schemes showed a low uptake4


and so alters the value


proposition of the therapy and causes a wider opportunity cost. Trust Pharmacy teams need to identify the patient access scheme, where appropriate, sign any contractual obligations, and understand the


details of the scheme in order to work with the wider local team to ensure that the scheme is managed for all patients treated.


Protocol


To support a consistent approach to chemotherapy prescribing and administration, a local protocol is developed to outline5


:


● Cancer type ● Name of regimen and the therapeutic drugs used


● Therapeutic intent: palliative, adjuvant, neo-adjuvant, radical, as applicable


● Doses of therapeutic drugs ● Routes of administration ● Number of cycles or whether this is indeterminate


● Length of cycle and number and timing of administrations within a cycle


● Tests required before starting a course and prior to an individual cycle


● Supportive drugs with each cycle ● Therapeutic drug dose modifications and their indications.


This document provides a concise synopsis to support patients receiving chemotherapy and also provides an excellent resource for education and training. The use of local protocols also allows standardisation of supportive therapies, such as hydration and anti- emetics, across a service.


E-prescribing


Pre-defined prescriptions should be produced to facilitate prescribing and include all components of the chemotherapy regimen. While uptake remains variable, all chemotherapy should be prescribed on an electronic system, ideally linked to the wider hospital to provide clarity should a patient attend unwell after receiving chemotherapy. As with all systems and regimens built into an electronic prescribing system, it requires careful validation before it is used in the clinic to assure its accuracy, dose calculations are correct, etc.


Risk management


In spite of all of the steps outlined above, any process is liable to occasional near-misses and errors. The aim should always be to identify potential risks and develop processes to mitigate these. This includes consideration of the potential for never-events, such as wrong route chemotherapy,6


which has been a


particular challenge as therapies are licensed for additional routes of


administration such as bortezomib (intravenous or subcutaneous using different licenced concentrations), rituximab and trastuzumab (different formulations for intravenous infusion and subcutaneous injection). Pharmacy teams have an impact in risk management issues such as these through review of labelling, prescription descriptions, dispensing, and broader education. As always, a managed introduction of a new route of administration following communication to the wider clinical team and patients is key to reducing risks.


Patient information Patients and their carers require information to support informed decision-making as to whether to embark upon a proposed treatment option. Within the UK, there is excellent information provision by the third sector, such as Macmillan and Myeloma UK. Equally, pharmaceutical companies provide materials that may supplement this information. To reduce the burden of information provision, many Trusts now utilise these information sources and so should play a role in reviewing and updating their content.


Information and audit Following the generation of a prescription, data is required for a number of functions, including: (1) Coding of clinical activity to trigger remuneration. a Within the UK there is a national chemotherapy regimen list,7


the


purpose of which is to support the consistent coding of chemotherapy activity to support payment; this task is undertaken by clinical coders with the support of clinicians. The Trust pharmacy team produces an annual update of regimens used routinely locally and maps the relevant regimen name and delivery HRG to support this coding. As local prescribing in Derby moves onto a new electronic prescribing and medicines administration (EPMA) platform, work has commenced with informatics colleagues to automate the coding of activity


(2) Provision of systemic anticancer therapy (SACT) data8 a Across England there is a mandatory dataset (SACT) for which 43 data items are required. The data collection covers patients receiving cancer chemotherapy in


www.hospitalpharmacyeurope.com


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