Developing a Chemotherapy Audit Toolkit for Victorian Health - - PowerPoint PPT Presentation

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Developing a Chemotherapy Audit Toolkit for Victorian Health - - PowerPoint PPT Presentation

Sep 02, 2023 384 likes •647 views

Developing a Chemotherapy Audit Toolkit for Victorian Health Services Shaun OConnor, VicTAG Adam Chapman, Cancer Strategy and Development, DHHS (Project funded by DHHS, Victoria) Background SOUTH AUSTRALIA August 2015 Underdosing of

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Developing a Chemotherapy Audit Toolkit for Victorian Health Services

Shaun O’Connor, VicTAG Adam Chapman, Cancer Strategy and Development, DHHS (Project funded by DHHS, Victoria)

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Background

SOUTH AUSTRALIA August 2015

  • Underdosing of cytarabine for 10 AML patients at Royal Adelaide and

Flinders Hospitals identified November 2015

  • Independent review – failures of governance and communication

NEW SOUTH WALES February 2016

  • Off protocol prescribing of carboplatin for a large cohort of head and

neck cancer patients at St Vincent’s Hospital Sydney identified August 2016

  • NSW Inquiry report - failures of governance and communication
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Background

Victorian response

  • February 2016 - Victoria’s Chief Cancer Advisor sought responses

from Victorian Integrated Cancer Services on chemotherapy safety processes across participating health services (survey 1)

  • August 2016 – Director Performance & System Design, and Ass. Dir

Private Hospitals sought further assurances from health services regarding chemotherapy safety processes (survey 2)

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Respondents

Survey 1 – February 2016 ICS (Integrated Cancer Services) identified and followed up local health services providing chemotherapy in their catchments

  • 27 health services provided responses

Survey 2 – August 2016 All HS identified as providing infusional chemotherapy were surveyed directly by DHHS and followed up to ensure completeness

  • 43 public health services
  • 26 private health services
  • 27% of services perform retrospective auditing of chemotherapy
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Survey findings

Highest use of

  • Standardised chemotherapy protocols
  • Protocols for nursing verification
  • Incident reporting

Medium use of

  • Protocols for pharmacy verification (poorer responses from privates)
  • Morbidity and Mortality meetings (poorer responses from privates)

Poorest use of

  • Regular auditing of compliance with chemotherapy protocols
  • Electronic prescribing/management systems
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How to respond?

Auditing…?

  • What to audit?

– Limitations » Ease of data access

  • Can you get what you want? How can you make it mean

something? » Human resources

  • Need for an efficient process
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How to respond?

Auditing…?

  • Why do we need to audit?!?

– Conflict between protocolisation and personalisation of healthcare » How to manage this to ensure that appropriate personalisation

  • ccurs whilst inappropriate is prevented
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Missing the point - the broader context

“'Preventability’ is not a useful concept because what is ‘preventable’ is subjective, changes over time, and depends

  • n the context of care” – Stephen Duckett

All complications should count. Using our data to make hospitals safer Grattan Institute 2018

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Development approach

  • Focus on Electronic Prescribing Systems for first six months

– Paper based systems to follow in next six months

  • Extensive consultation with sector to discover current approaches

implied by survey results

  • Extensive piloting phase to determine practicability in sector
  • Envisioned to fit in as part of wider quality framework
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Progress to date

  • Formed Steering Committee and Project Reference Group to guide

direction and governance

  • Analysed current sector approaches
  • Most established approach found with CHARM based on a variation

report – Obtained data from multiple sites and confirmed can be used at all sites – Following up with users of other EPS to investigate approaches that may mimic this approach » Other EPS currently implemented in Victoria: Cerner, EPIC, ARIA

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Oncology Electronic Prescribing Systems in Victoria

Current EPS None CHARM ARIA EPIC Cerner Ascribe Future EPS None CHARM ARIA EPIC Cerner MOSAIQ TrakCARE

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Audit Tool – Electronic Systems

  • CHARM

– Piloted at Barwon, LRH, PMCI, Icon Pharmacy (Slades)

  • Cerner Oncology

– Determining appropriate report

  • EPIC

– Determining appropriate report

  • ARIA

– In process of obtaining customised report

  • MOSAIQ

– Mature approach found in NSW

  • Other Electronic Prescribing Systems?
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Audit Tool – Demo

Variation Report – shows changes from protocolised changes Automatic filtering process Manual filtering process Discussion @ Tumour Stream Meeting/MDM (or equivalent)

TOOL

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Audit Tool – Demo

  • Key Features:

– Tool exists internal to each organisation » No variation data is reviewed externally (e.g @ DHHS) – Tool is unable to determine appropriateness of variations – Quality infrastructure surrounding Tool may vary depending on pre- existing setup

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Audit Tool – CHARM Variation Report

DateModified MRNumber FamilyName FirstName Disease PathwayName PathwayHistoryNote 28-Jul-17 Breast - Adjuvant EPIrubicin 90mg/m^2 IV D1; CYCLOPHOSPHa mide [Added DRUG] Pegfilgrastim to Cycle 2 Day 1 25-Aug-17 Breast - Adjuvant DOXOrubicin 60mg/m^2 IV D1; Cycle 1 to 4; CYCLOPHOSPHa mide [Added DRUG] Aprepitant to Cycle 2 Day 1 05-Jul-17 Breast - Neo-Adjuvant DOXOrubicin IVINF 60mg/m^2 ONCE Day 1 (Cycle 1to4); [Updated DRUG] Pegfilgrastim Applied to Cycle 5 and all future cycles; [Deleted] Note: Neulasta to be 3-weekly as per DC 01-Dec-17 Breast - Metastatic NAB-paclitaxel 100mg/m^2 IV D1 and 8 and 15 [Updated DOSES] : Changed percentage to 80% for Nab-paclitaxel (rounding may occur) ; Applied from C4 D1 and all future cycles.; Remarks: 29-Dec-17 Breast - Neo-Adjuvant EPIrubicin IVINF 90mg/m^2 ONCE Day 1 Cycle 1 to4; CYCLOPHOSPHa [Updated DRUG] EPIrubicin Applied to Cycle 1 and all future cycles; Dose changed on C1 D1 Original Dose was 185mg. Reason:capped - weight per KW

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Audit Tool – CHARM Variation Report

DateModified Disease PathwayName PathwayHistoryNote 29-Dec-17 Breast - Neo-Adjuvant EPIrubicin IVINF 90mg/m^2 ONCE Day 1 Cycle 1 to4; CYCLOPHOSPHa [Updated DRUG] EPIrubicin Applied to Cycle 1 and all future cycles; Dose changed on C1 D1 Original Dose was 185mg. Reason:capped - weight per KW

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Audit Tool – CHARM Variation Report

DateModified Disease PathwayName PathwayHistoryNote 29-Dec-17 Breast - Neo-Adjuvant EPIrubicin IVINF 90mg/m^2 ONCE Day 1 Cycle 1 to4; CYCLOPHOSPHa [Updated DRUG] EPIrubicin Applied to Cycle 1 and all future cycles; Dose changed on C1 D1 Original Dose was 185mg. Reason:capped - weight per KW

Note: Not always Curative/Palliative Filter for Cycle 1 Filter for Supportive Care Medications

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Audit Tool – CHARM Variation Tool Function

80% Automatic Exclusion from Variation Report

DateModified MRNumber FamilyName FirstName Disease PathwayName PathwayHistoryNote 28-Jul-17 Breast - Adjuvant EPIrubicin 90mg/m^2 IV D1; CYCLOPHOSPHa mide [Added DRUG] Pegfilgrastim to Cycle 2 Day 1 25-Aug-17 Breast - Adjuvant DOXOrubicin 60mg/m^2 IV D1; Cycle 1 to 4; CYCLOPHOSPHa mide [Added DRUG] Aprepitant to Cycle 2 Day 1 05-Jul-17 Breast - Neo-Adjuvant DOXOrubicin IVINF 60mg/m^2 ONCE Day 1 (Cycle 1to4); [Updated DRUG] Pegfilgrastim Applied to Cycle 5 and all future cycles; [Deleted] Note: Neulasta to be 3-weekly as per DC 01-Dec-17 Breast - Metastatic NAB-paclitaxel 100mg/m^2 IV D1 and 8 and 15 [Updated DOSES] : Changed percentage to 80% for Nab-paclitaxel (rounding may occur) ; Applied from C4 D1 and all future cycles.; Remarks: 29-Dec-17 Breast - Neo-Adjuvant EPIrubicin IVINF 90mg/m^2 ONCE Day 1 Cycle 1 to4; CYCLOPHOSPHa [Updated DRUG] EPIrubicin Applied to Cycle 1 and all future cycles; Dose changed on C1 D1 Original Dose was 185mg. Reason:capped - weight per KW

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Audit Tool – Manual Exclusion

  • Rounding <10% (larger rounding as acceptable within institutional

guidelines)

  • Evidence based dose reductions for toxicity (local protocols or if no

local protocol, EviQ)

  • Alterations due to organ dysfunction
  • Variations to Supportive Care (e.g. anti-emetics, steroids if used for

nausea)

  • Temporary timing changes caused by patient condition/CDU availability
  • Dose capping as per documented institutional policy or evidence based

guidelines (e.g. obesity, carboplatin dosing based on institutionally agreed Cockroft-Gault equation)

  • Clinical trials
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Audit Tool – Presentation to Tumour Stream Group

  • Discussion by tumour stream group
  • Report to Head of Unit and Quality Department (?)
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Audit Tool - Paper

  • Paper based systems

– Starting to approach health services in Victoria – Aware of multiple issues » Time required » Sampling – how?

  • Random?
  • Prospective/Retrospective?
  • Focussed on tumour streams?
  • Capture x amount per prescriber?
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Best Practice Quality Framework

  • Audit tool will be part of Best Practice Quality Framework

– Covering spectrum of evidence to patient » Recommendations on processes for:

  • Transforming evidence to institutional protocol
  • Managing variation to protocol within an institution
  • Establishing appropriate review pathways for tool
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Challenges

  • Benchmarking
  • Prescriber – may not always be authorising consultant in EPS
  • Adaptability to each health service

– Specifics around programming of EPS, Quality framework

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Questions

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For more information

Contact

  • projectmanager@victag.org.au