Multidisciplinary Optimization of Oral Chemotherapy Delivery at the University of Wisconsin Carbone Cancer Center

Abstract

PROBLEM FACED: Broad use of oral chemotherapy poses safety challenges that are not manageable by systems designed for intravenous chemotherapy. Our institution, the University of Wisconsin Carbone Cancer Center, was experiencing challenges in safety and uniformity of processes for delivering oral chemotherapy and associated care.WHAT WE DID: ASCO and the Oncology Nursing Society jointly published safety standards for administering chemotherapy that offered a framework for improving oral chemotherapy practice. We used these standards to define gaps in the safety and uniformity of our oral chemotherapy practice and to develop recommendations for improving processes. Areas for improvement were addressed by multidisciplinary workgroups that focused on education, workflows, and information technology. Key changes included defining chemotherapy, standardizing patient and caregiver education, mandating the use of comprehensive electronic order sets, routing all oral chemotherapy prescriptions for review by an independent pharmacy before dispensing, and standardizing documentation of dose modification. In addition, drug-specific materials were developed to create uniformity in adherence and toxicity monitoring. Collectively, these processes enabled significant safety mechanisms for oral chemotherapy analogous to those in place for intravenous chemotherapy. Revised processes were implemented over a 5-month period.WHAT WE FOUND: Defining oral chemotherapy allowed creation of a list of oral chemotherapies that could be recognized and grouped in our electronic health record (EHR), which enabled EHR-facilitated solutions,includingconsent verification, prospectiveorderreview,education, and monitoring.Thefollowing are key performance indicators: 92.5% of oral chemotherapy orders (n = 1,216) were initiated within comprehensive electronic order sets (N = 1,315), 89.2% compliance with informed consent was achieved, 14.7% of orders (n = 193) required an average of 4.4 minutes review time by the pharmacist, and 100% compliance with first-cycle adherence and toxicity monitoring was achieved. We defined elements needed for complete patient education and provided staff education on this effort but did not build any EHR-based forcing functions. Subsequent assessment showed poor performance in documenting all elements of oral chemotherapy education (36%), which demonstrated the need for continued improvement. CONFOUNDING FACTORS, DRAWBACKS:We achieved demonstrable success in improving oral chemotherapy practice. Our approach relied heavily on the ability to electronically recognize oral chemotherapy prescriptions and apply all of the safety systems designed for intravenous chemotherapy. Our institution uses a well-established EHR and can dispense many oral chemotherapies because we have a specialty pharmacy. Potential limitations of our approach include EHR specificity, as well as ongoing time commitments by pharmacists for prospective order review. The capacity to fill many prescriptions mitigates the risk of pharmacy-related errors an...

Education Milestones for Newly Diagnosed Pediatric, Adolescent, and Young Adult Cancer Patients: A Quality Improvement Initiative

“…The advance practice provider’s role within the multidisciplinary team is to enhance continuity of care and serve as a bridge between the medical and nursing disciplines. Agenda items include (a) who, how, when, and why to contact the medical team for assistance when at home; (b) how to care for a central line; and (c) a detailed and comprehensive review of medications to be taken at home (both scheduled and as needed; Landier et al, 2016; Mulkerin et al, 2016; Withycombe et al, 2016). For patients receiving chemotherapy, this milestone will occur just prior to (for patients receiving treatment in outpatient setting) or during (for patients receiving treatment inpatient) the first treatment.…”

<p>Phillygenin, a MELK Inhibitor, Inhibits Cell Survival and Epithelial–Mesenchymal Transition in Pancreatic Cancer Cells</p>

“…27,28 Over the years, the use of chemotherapeutic drugs, such as administration schedules and frequency of toxicity monitoring, has led to steady improvements in patient management. 29 However, there remains an urgent need to discover and develop novel, effective, and non-toxic agents for patient care. Although gemcitabine-based chemotherapy has improved survival in PC patients, the improvements are still limited.…”

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“…To date, the majority of published QI studies focusing on improving safety of oral chemotherapy delivery have been small, single-institution studies over short time horizons. [17][18][19][20] Our initiative exemplifies how a coordinated approach across many institutions can be successful in improving oral chemotherapy safety and the benefits and challenges associated with multi-institution QI initiatives. Factors that contributed to the success of the overall project included, but were not limited to, regional engagement to define the problem and identify the goal as a provincial priority, existing provincial QI infrastructure that includes substantial clinician leadership and engagement, defining what the responsibilities of the central decision maker versus the regional partners were, and alignment of the financial incentives.…”