Oral chemotherapy practices at Ontario cancer centres.

PURPOSE: The use of oral chemotherapy agents in cancer treatment is increasing. To better understand issues affecting the optimal use of these agents, Cancer Care Ontario conducted an environmental scan of current practices in Ontario related to prescribing, dispensing, patient education, and supporting regimen adherence. METHODS: A series of semi-structured interviews were conducted either by phone (11 regions) or via email (two regions) with Ontario's Regional Cancer Centres over a 3-month period in 2012. A questionnaire was pre-circulated to the regions to guide the discussions. RESULTS: Responses were received from 13 of 14 regions. Considerable variation in practice was found. Of 13 responding regions, 12 (92%) lacked formal procedures or processes for the prescription of oral chemotherapy. Ten regions (77%) reported using either handwritten prescriptions or a mixture of methods with only three regions routinely using computerized order entry systems for oral chemotherapy prescribing. Oral chemotherapy was reported to be labeled as "chemotherapy" in 46% of the regions. Twenty-three percent indicated that they provide extensive patient education through a multi-disciplinary approach. A number of tools were used to encourage patient adherence in different regions. Patient education was identified as an area where more work could be done. CONCLUSION: Results indicate a lack of formal policies and variable practices across all aspects of oral chemotherapy in many regions. However, some regions have developed and implemented successful initiatives. The results from this review are informing provincial priorities and being shared between regions to support collaborative learning.

Determining resource intensity weights in ambulatory chemotherapy related to nursing workload.

Ontario cancer programs aim to deliver high-quality nursing care and treatment that is safe for patients and staff. The reality of health care is that financial constraints, inherent in the delivery of care, require that funding mechanisms count not only the cost of drugs, but factors such as pharmacy and nursing human resource costs. While some organizations have developed patient classification systems to measure nursing intensity and workload, these systems apply primarily to inpatient populations, and are fraught with numerous challenges, such as the need for nurses to document to justify the workload required for care. The purpose of this paper is to outline the methodology and engagement of nurses to develop regimen-based resource intensity weights that can be applied to ambulatory chemotherapy suites. The methodology included determination of workload related to nursing time to prepare, teach, counsel and assess patients, as well as time to gather supplies, access lines, monitor, manage adverse reactions, manage symptoms and document care. Resource intensity weights provide better measures of the complexity of care required by cancer patients in ambulatory settings.

Key components of intravenous chemotherapy labeling: a systematic review and practice guideline.

OBJECTIVE: To determine the necessary components and formatting of an intravenous chemotherapy label to maximize safe delivery and minimize errors. Date sources. The MEDLINE and EMBASE databases (up to April 2009) were searched for relevant evidence. Reference lists from retained studies were then searched for additional trials. An environmental scan was also conducted to locate other published and unpublished sources of information. Study selection. Relevant articles were selected and reviewed by one methodologist. Articles were selected for inclusion if they were published English language reports of Phases II or III randomized controlled trials, other comparative studies, single-arm studies, practice guidelines, or systematic reviews with or without meta-analyses, which related to the study question. MEDLINE and EMBASE searches yielded 685 potential studies of which 17 met the inclusion criteria. The environmental scan located one guideline. Three additional relevant studies were identified during the external review process. In total, 21 documents met the inclusion criteria. Data extraction. Data were extracted by one methodologist. Quality of systematic reviews was assessed using the AMSTAR tool. All other studies were evaluated based on study characteristics applicable to the particular study design. Data synthesis. The evidence collected and the consensus of expert opinion of Cancer Care Ontario's Chemotherapy Labeling Panel form the basis of a series of recommendations for the generation of intravenous chemotherapy labels including formatting, required information, and order of information. These guidelines inform the efficient, effective, and safe administration of intravenous chemotherapy. Illustrative examples are provided.

Using breakthrough series collaborative methodology to improve safe delivery of chemotherapy in Ontario.

PURPOSE: Chemotherapy delivery is complex, involving multiple providers across settings to deliver safe, effective care. Cancer Care Ontario initiated a provincial breakthrough series collaborative, based on methodology from the Institute for Healthcare Improvement (IHI), to improve the safe delivery of chemotherapy, from ordering through preparation and administration. METHODS: Over the 1-year period of the collaborative, three in-person sessions educated participants on improvement methodology. Twenty teams tested and implemented elements of a predefined change package in their local systems. Monthly teleconferences supplemented the education while encouraging a culture of knowledge sharing. Teams completed monthly self-assessment surveys that evaluated their progress using a 6-point scale, where 1 indicated no evidence of improvement and 5 indicated achievement of all goals and improvement objectives. RESULTS: Monthly self-assessment surveys revealed that over time, scores improved from 1 to 4, indicating significant progress. Moreover, 100% of participants reported in an exit survey that the collaborative had improved the culture of safety in their organizations. The gains of the collaborative have been sustained through development of a practice community and provision of ongoing coaching through the IHI Open School. CONCLUSION: Participation in the collaborative enabled local interdisciplinary teams to develop processes and structures to support ongoing quality improvement, including formation of a sustainable structure for knowledge translation and exchange. However, lack of a shared provincial target limited overall evaluation. Other lessons learned included providing adequate time for planning and clearly defining roles and responsibilities of involved teams and project sponsors.

Use of continuous infusion pumps during radiation treatment.

INTRODUCTION: Despite increasing chemoradiotherapy treatment, there is a paucity of information regarding the effects of radiation exposure on ambulatory infusion pumps used to deliver chemotherapy or other essential medications. The aim of this overview is to present the available evidence on this subject, heighten awareness within the clinical community, provide considerations for minimizing possible negative effects on patient care, and encourage the monitoring of infusion devices after exposure to radiation or electromagnetic interference. METHODS: Published literature was systematically searched using MEDLINE and EMBASE; gray literature was searched using Google and an environmental scan of relevant Web sites. A multidisciplinary working group reviewed the compiled evidence, and a draft of the document was sent to health professionals from various disciplines for an external review. RESULTS: Four reports and three manufacturer device alerts were identified that suggest a risk of pump malfunction as a result of radiation exposure. The estimated cumulative dose at which pump failure has been reported ranges from 28.5 to 42 Gy; however, additional clinical investigations should be undertaken. Pump relocation, pump shielding, and assessment of the pump after radiation exposure are most commonly suggested to minimize pump malfunction related to radiation exposure. A list of additional considerations is offered for those developing institution specific policies and procedures based on the available evidence and expert consensus. CONCLUSION: The varied and unpredictable results of radiation exposure on infusion devices suggest that additional testing should be carried out to determine the limits of dose exposure and to raise awareness around this patient safety issue.