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

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)

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

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)

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

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

How to respond? Auditing…? • What to audit? – Limitations » Ease of data access o Can you get what you want? How can you make it mean something? » Human resources o Need for an efficient process

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 occurs whilst inappropriate is prevented

Missing the point - the broader context “'Preventability’ is not a useful concept because what is ‘preventable’ is subjective, changes over time, and depends on the context of care” – Stephen Duckett All complications should count. Using our data to make hospitals safer Grattan Institute 2018

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

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

Oncology Electronic Prescribing Systems in Victoria Current EPS Future EPS None None CHARM CHARM ARIA ARIA EPIC EPIC Cerner Cerner MOSAIQ Ascribe TrakCARE

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?

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

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

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

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

Audit Tool – CHARM Variation Report Filter for Supportive Filter for Cycle 1 Care Medications DateModified Disease PathwayName PathwayHistoryNote EPIrubicin IVINF 90mg/m^2 [Updated DRUG] EPIrubicin Applied to Cycle 1 ONCE Day 1 and all future cycles; Dose changed on C1 D1 Cycle 1 to4;� Original Dose was 185mg. Reason:capped - 29-Dec-17 Breast - Neo-Adjuvant CYCLOPHOSPHa weight per KW Note: Not always Curative/Palliative

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

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

Audit Tool – Presentation to Tumour Stream Group • Discussion by tumour stream group • Report to Head of Unit and Quality Department (?)

Audit Tool - Paper • Paper based systems – Starting to approach health services in Victoria – Aware of multiple issues » Time required » Sampling – how? o Random? o Prospective/Retrospective? o Focussed on tumour streams? o Capture x amount per prescriber?

Best Practice Quality Framework • Audit tool will be part of Best Practice Quality Framework – Covering spectrum of evidence to patient » Recommendations on processes for: o Transforming evidence to institutional protocol o Managing variation to protocol within an institution o Establishing appropriate review pathways for tool

Challenges • Benchmarking • Prescriber – may not always be authorising consultant in EPS • Adaptability to each health service – Specifics around programming of EPS, Quality framework

Questions

For more information Contact • projectmanager@victag.org.au