Patients arrive early and undergo a number of tests particularly relating to pathology. After 1-2 hours the results are available and the chemotherapy prescription is, or in some cases is not, confirmed. The patients, and their carers, must then wait whilst the chemotherapy is prepared in the pharmacy department. Pharmacy receives the majority of its chemotherapy orders within a small time frame with little or no indication of priority and is under pressure to complete the workload as quickly as possible.
Patients and ward staff become frustrated with delays to Chemotherapy and this is reflected in communications between teams. To help manage the expected pressure the pharmacy prepares as much chemotherapy as possible in advance of prescriptions being confirmed, however where chemotherapy doesn’t go ahead these drugs are wasted. Waiting patients occupy clinical space for longer than is necessary and this creates capacity pressures.
A project was commenced to address the multiple system deficiencies. It began in a small way and the approach was organic and progressed at a rate relative to the capacity for change among the affected staff and services. At all stages the project was informed by, and kept informed, all staff involved in the preparation and administration of chemotherapy. Although patients were not directly involved in the project they were the primary concern of the project board and nothing was implemented which would have a negative impact on patients or their experience of care.
A small multi-disciplinary team of enthusiastic and motivated staff were brought together headed by a senior nurse whose role enabled activities which were focused on service redesign.
The following key changes were implemented by the team:
• A designated staff-link between ward and pharmacy aseptic services was created.
• Specific software was introduced which integrated with existing chemotherapy prescribing software.
• Awareness of the process of chemotherapy aseptic preparation and the extent and value of unused chemotherapy was increased amongst ward staff and prescribers.
• Relationships between ward staff and pharmacy staff improved.
• Use of dose-banding, agreed between clinical pharmacists and prescribers, was optimised.
• Prescribing practice was changed so that all chemotherapy prescriptions were required to be confirmed with the pharmacy department at least 24 hours in advance of the scheduled delivery slot. • Prescribers were asked to account for high-value unused chemotherapy items and these were reported at multidisciplinary meetings.
• An agreed list of aseptically prepared chemotherapy drugs was created to indicate items which would not be prepared until final approval had been made on the day of administration.
• Scheduled administration times were provided on electronic scheduling system which enabled accurate prioritisation of aseptic preparation and planning of vial-sharing opportunities.
• A four point colour-coded aseptic preparation tray system was introduced which provided an immediate visual cue to staff with respect to specific processes to be undertaken and their priority.
• Increased use of out-sourced chemotherapy, largely enabled via dose-banding, which reduced the volume of chemotherapy prepared in-house and reduced wastage.
• Reduced overall admission times and improved patient satisfaction due to tighter appointment scheduling.
• Better management of patient expectations through being informed of clinical and operational processes at the start of treatment courses.
• Patient education via pharmacist-led presentations about aseptic preparation of chemotherapy provided to groups of patients, a photo-montage poster was placed in a high-traffic location in the ward.
Please contact Wendy Anderson, Macmillan Nurse Consultant - [email protected]