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Healthcare in the Republic of Ireland experienced a shift in the delivery of services during the coronavirus disease 2019 (COVID-19) pandemic. In the authors’ hospital, patients receiving oral anticancer medicines had their care transferred from the hospital-based oncology day unit, initially to a hospital-based advanced nurse practitioner- (ANP-) led oncology service then to a community-based ANP-led oncology service. A retrospective audit of the assessment, monitoring, patient education and prescribing practices for adult patients attending the ANP-led hospital oncology service was undertaken in March 2021. A quality improvement plan was subsequently developed and implemented and the audit was repeated in February 2022 following transition to an ANP-led community-based oncology service. The re-audit showed a marked improvement in the standard of care delivered to adults receiving oral anti-cancer medicines from an ANP in the community.
Cancer Nursing Practice. doi: 10.7748/cnp.2023.e1833
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestThis work was supported by The Irish Cancer Society (grant number CNRA19RIC) in collaboration with the Health Research Board the National Cancer Control Programme and the Office of the Nursing and Midwifery Services Director. The authors wish to thank the Letterkenny University Hospital clinical audit department staff – Aine Slevin and AnnMarie Giles – for their assistance, technical support and input into the tool development. The funders had no role in research design, data collection and analysis, decision to publish or preparation of the manuscript
Richmond JP, Kelly MG, Murphy PJ et al (2023) Audit of advanced nurse practitioner-led care of the person prescribed oral anticancer medicines. Cancer Nursing Practice. doi: 10.7748/cnp.2023.e1833
Published online: 12 January 2023
Traditionally, systemic anticancer treatment (SACT) was administered in the acute hospital environment, preceded by patient assessment and safety checks linked to patient’s clinical status and laboratory results (Campbell 2014). The emergence and increased use of oral anticancer medicines has altered this process, with control of oral anticancer medicines administration shifting to the patient. However, while the actual medicines administration no longer involves specialist healthcare professionals, such as oncology and haematology nurses, there is still a requirement for ongoing assessment of patients’ fitness for treatment and the management of side-effects and toxicities. This is because oral anticancer medicines have the same benefits and toxicities as intravenous (IV) treatments (National Cancer Control Programme (NCCP) 2018). In particular, with oral anticancer medicines, there are safety concerns with regard to adherence or over-adherence (where patients keep taking a medicine even when they have significant side-effects because they perceive it to be treating their cancer) (Komatsu et al 2020). These are not issues connected with IV SACT, where the medicine is directly administered by the clinician.
Historically in the Republic of Ireland ongoing assessments of patients’ oral anticancer medicine regimens were undertaken by specialist healthcare professionals such as clinical nurse specialists, advanced nurse practitioners (ANPs) and medical staff in acute hospitals (Department of Health 2017, NCCP 2018). In practice, this required the patient to attend a hospital day unit and have a dedicated assessment with a review of their blood results. In effect, this was identical to the assessment for those receiving IV SACT. These assessments were time-consuming for patients and healthcare professionals and were criticised by an Irish medicines safety review, which identified a lack of standardisation in the hospital setting (Heckmann et al 2014). Beyond Ireland, evidence suggests that globally, hospital-based oral anticancer medicine monitoring does not ensure safe administration or patient adherence (Redelico et al 2018).
Recently, the model of care in the authors’ regional general hospital in Ireland underwent significant change. In March 2020, all post-cycle 2 oral anticancer medicine patients had their care transferred from the hospital day unit to a hospital ANP-led oncology service; in January 2022 this was further developed to an ANP-led oncology service in the community. A partial transfer of care had been planned as part of a research study, but when the coronavirus disease 2019 (COVID-19) pandemic started there was an urgent need to increase the hospital day unit’s capacity, so the entire caseload of post-cycle 2 oral anticancer medicine patients was transferred to reduce footfall through the hospital and a system of virtual assessment was commenced (Richmond et al 2022a).
The two audits outlined in this article aimed to assess the transfer of assessment and monitoring of patients receiving oral anticancer medicines from the hospital to the community in the authors’ locality (Richmond et al 2021).
The primary aim was to audit the original hospital-based ANP-led oral anticancer medicine service against best practice standards to assess the safety and quality of the care delivered. The secondary aim was to identify practice gaps, develop and implement a quality improvement plan (QIP) and subsequently conduct a re-audit of the care of patients whose assessments were now being undertaken by the community-based ANP-led oncology service.
The audits detailed in this article comprised the following stages:
• A retrospective audit of the assessment, monitoring, patient education and prescribing practices for adult patients attending a hospital-based ANP-led oral anticancer medicine service, which took place in March 2021. The hospital-based practice was measured against evidence-based standards of care for patients receiving oral anticancer medicines (Richmond et al 2022b). A previous scoping review (Richmond et al 2021) had informed the development of these evidence-based standards (Richmond et al 2022b), which used the NCCP (2018) SACT model of care as a five-step framework (see Figure 1).
• The development of a QIP based on the findings of the March 2021 audit, which included four quality improvement measures.
• Following the QIP implementation and transfer of care of patients receiving oral anticancer medicines in the hospital to a community ANP-led service, a re-audit was undertaken in February 2022.
In conjunction with the hospital’s clinical audit department, an audit tool comprising two Microsoft Excel documents was developed to audit the care of patients taking oral anticancer medicines against the best practice standards (Richmond et al 2022b):
• Tool 1 – audited the ANP assessment and monitoring of the patient receiving oral anticancer medicines.
• Tool 2 – audited the oral anticancer medicine prescriptions written by the ANP. In Ireland, these are completed on the High Technology Medications Prescription Form (Irish Community Pharmacy Association 2018), which is a dedicated prescription sheet.
Minor refinements were made to these documents following a ‘fit-for-purpose’ pilot, using five patient case notes and oral anticancer medicine prescriptions.
A retrospective, randomly selected documentation audit of the assessment, monitoring, patient education and prescribing practices for adult patients attending the hospital-based ANP-led oncology service was undertaken in March 2021. To ensure adequate representation, the initial audit included 20 randomly selected patient records out of a caseload of 53 patients (38%). The patients gave consent for their details to be used. The results of this initial audit were analysed to identify practices that required quality improvement interventions. Following identification of these practices, a QIP was developed and subsequently implemented.
Following the QIP implementation and transition of care to the community-based ANP-led oncology service, a re-audit was performed in February 2022. For consistency, the second audit included 20 randomly selected patient records out of a caseload of 57 patients (35%). The same sampling framework, audit tools and data analyses were used in both audits to enable comparison and to evaluate the effects of the QIP.
• Control of oral anti-cancer medicines administration has shifted from specialist healthcare professionals to the patient, but patients still require assessment and monitoring by these professionals
• A hospital in Ireland transferred care of post-cycle 2 oral anti-cancer medicine patients from the day unit, first to a hospital based advanced nurse practitioner-led oncology service then to a community-based advanced nurse practitioner-led oncology service
• An initial audit to assess the transfer of assessment and monitoring of patients receiving oral anti-cancer medicines identified areas that required improvement
• A re-audit of the service showed a marked improvement in the standards of care delivered
The results of the initial audit in March 2021 and the re-audit in February 2022 against the five best practice standards are shown in Tables 1-5.
Standard 1.1: Before commencing an oral anti-cancer medicine all patients to be assessed to ensure they are suitable for oral anti-cancer medicine therapy | |||
Evidence | Audit, March 2021: adherence to standard (%) | Re-audit, February 2022: adherence to standard (%) | |
75% | 100% | ||
| Explanation and education concerning storage and handling (0%) | Explanation and education concerning storage and handling (0%) | |
Explanation and education concerning method of administration (5%) | Explanation and education concerning method of administration (90%) | ||
Explanation and education concerning possible interactions (5%) | Explanation and education concerning possible interactions (5%) | ||
Explanation and education concerning management of side-effects (40%) | Explanation and education concerning management of side-effects (90%) | ||
Standard 1.2: Patient consent must be acquired in writing before commencing oral anti-cancer medicine treatment | |||
Evidence | Audit, March 2021: adherence to standard (%) | Re-audit, February 2022: adherence to standard (%) | |
100% | 100% | ||
| 0% | 100% | |
100% | 100% | ||
n/a (regimen did not change) | n/a |
Standard 4.1: Standardised education to support safe oral anti-cancer medicine administration and management of side effects should be available for patients | ||
Evidence | Audit, March 2021: adherence to standard (%) | Re-audit, February 2022: adherence to standard (%) |
| 15% | 65% |
20% | 70% |
The results of the initial audit in March 2021 identified four key areas requiring quality improvement interventions and a QIP was formulated to address these before the re-audit took place:
1. Develop a guideline for oral anticancer medicine care locally to include use of the Multinational Association of Supportive Care in Cancer (MASCC) oral agent teaching tool (MOATT) (MASCC 2016), including best practice for consent, patient education, patient assessment and prescription writing.
2. Based on best practice requirements (Richmond et al 2022b), develop dedicated oral anticancer medicine assessment forms.
3. Instigate local and national discussions to ensure that an oncology pharmacist would verify all repeat oral anticancer medicine prescriptions, which was not available locally (at the time only initial prescriptions were verified).
4. Instigate discussion with the NCCP to review the use of the High Technology Medications Prescription Form to include prompts for safety elements.
The steps taken to implement the four stages of the QIP after the initial audit, are shown below:
• The guideline for oral anticancer medicine care (Richmond et al 2022b) was written by the authors with involvement from the wider multidisciplinary team and ratified by the dedicated hospital committee.
• Three dedicated oral anticancer medicine assessment templates were developed which included dedicated space and prompts for documenting all aspects of the assessment as follows:
• Initial assessment, physical review and check patient’s understanding of oral anticancer medicine therapy (to include MOATT assessment (MASCC 2016)).
• Assessment for repeated and/or ongoing physical review for patients receiving oral anticancer medicines.
• A similar but condensed version of the above assessments for virtual reviews.
• A local and national discussion concerning the need to have oral anticancer medicine prescriptions verified by an oncology pharmacist. This resulted in a national agreement that a dedicated pharmacist for oral anticancer medicine management would be established in each SACT treating unit in Ireland.
• A discussion ensued with the NCCP to review the use of the High Technology Medications Prescription Form because there was insufficient space for all the required elements and a notable absence of prompts for specific safety information. A proforma was developed and is now consulted each time an oral anticancer medicine prescription is written to ensure all the requirements are included (Box 1).
• Following implementation of this QIP, the second audit took place in February 2022 (results can be seen in Tables 1-5).
Any written oral anti-cancer medicine prescription must include the following patient details:
• Allergy assessment
• Hospital number
• Height, weight and body surface area (if required)
• National Cancer Control Programme oral anti-cancer medicine protocol code
• Frequency of patient review
• Oral anti-cancer medicine cycle number (to include number of days if applicable)
• Number of planned cycles of oral anti-cancer medicine – for curative intent, cycles may stop at cycles 6 or 8; for palliative patients, the cycles of treatment may continue until the cancer progresses
• Method of administration – for example, with or without food
• Limit medicines rules – for example, prescription should state ‘dispense X number of tablets or capsules only’
Completion of the audit cycle showed a marked improvement in the standards of care delivered to adults receiving oral anticancer medicines.
QIP initiatives that aimed to improve treatment decisions included adoption of the newly developed best practice guideline (Richmond et al 2022b), which included MOATT (MASCC 2016). MOATT is an easy-to-use, well researched and internationally available oral anticancer medicine educational tool (Rittenberg 2012) and has been endorsed for use by the NCCP, which means it is relevant to Irish clinicians. Use of this tool increased from 15% to 65% between the two audits (standard 4.1). It is important to note that the 35% of patient records where MOATT was not used in the February 2022 re-audit related to patients who had started their oral anticancer medicine treatment before the QIP was formulated. MOATT is now incorporated in the local dedicated ANP assessment form for initial oral anticancer medicine assessment.
Pre-treatment patient education on the storage and handling of medicines and possible interactions scored 0% and 5% respectively on the March 2021 initial audit and neither showed improvement on the re-audit (standard 1.1). Medicine and food interactions are known to be common in oral anticancer medicine administration and patient education is a critical aspect of care (Segal et al 2014). In the future, the onus will be on the ANP to urgently address this deficit.
Adherence to prescribing was greatly improved by the development of a proforma (Box 1). In the re-audit, 100% adherence was mostly achieved in the various sub-standard measurements. Only once did the re-audit adherence rate drop below 90% to 75%, where the planned treatment start date was missing in 25% of the prescriptions (standard 2.2). There was no dedicated oncology pharmacist employed specifically for oral anticancer medicines in the authors’ hospital at the time of the audits, and subsequently two of the authors were involved in discussions with the NCCP about rectifying this. In line with NCCP key safety objectives, pharmacists dedicated to oral anticancer medicine care will be established in each SACT treating unit in Ireland in the near future.
Standard 3 states that to ensure safety and to enable patient guidance, the first oral anticancer medicine cycle and/or any dose modification should be dispensed in a hospital setting (NCCP 2018).
Physical assessment of the patient by an oncology healthcare professional is required before the patient commences their first treatment with oral anticancer medicine. Adherence to this was 70% in the initial audit (standard 3.1). This low score was surprising. However, on further analysis it was found that four of the patients in this initial audit would have had their first oral anticancer medicine assessment as the COVID-19 pandemic was developing in 2020, when virtual care was more prevalent. In addition, for three others, the electronic hospital system identified that the patient attended for a physical assessment but that this was not documented. Similar to other aspects of care, this low score for physical assessment of the patient preceded the change to ANP care, and in the re-audit it had improved to 100%.
Adherence to specifying the limitation rules, such as identifying a limit on the number of oral anticancer medicine to be dispensed, also improved by the development of the proforma (Box 1). Adherence increased by 45%, from 55% to 100%, in the re-audit (standard 3.2). While responsibility for dispensing oral anticancer medicine lies exclusively with the community pharmacy, this evaluation did not audit the actual number of tablets or capsules dispensed because it was outside the authors’ remit. Use of the proforma, however, has helped to ensure that the oral anticancer medicine prescription identifies the exact numbers of days of medicines required (for example 14 days in a 28-day cycle), which should guide and lead to enhanced safe dispensing practices and adherence (Shields et al 2015).
Despite measurable improvements in this standard there was still room for improvement. One meta-analysis by Walsh et al (2019) concluded that medicines non-adherence may be significantly associated with all-cause hospitalisation and mortality in older people. However, patient education has been identified as an intervention that can improve medicines adherence (Anderson et al 2020). Therefore, further use of MOATT (MASCC 2016), which has been shown to increase patients’ self-efficacy in adhering to oral anticancer medicine regimens (Tokdemir and Kav 2017), may improve this standard in the future.
The documented evidence of medicines adherence detailed in standard 5:2 increased from 0% to 95% between the initial audit and re-audit. Estimates of medicines adherence in the literature range from 46% to 100% among patients taking anticancer medicines and there is a significant association between medicines nonadherence and suboptimal clinical outcomes (Greer et al 2016).
In standard 5:5, adherence to the sub-standard ‘Letter to GP sent if patient’s condition, medicines or dose changes, or at least every six months’ increased from 40% to 100% between the audits. This is an important finding, as effective communication between GPs and acute hospital teams is vital in coordinating care for patients (Druel et al 2020).
Overall, the introduction of dedicated oral anticancer medicine assessment templates was effective in improving adherence to standard 5.
Development of the evidence-based standards for the administration of oral anticancer medicines was a vital antecedent to these audits and enabled development of appropriate tools for auditing patient care. The audit and re-audit of ANP-led oral anticancer medicine practice in the hospital and then in the community demonstrated improvements in patient care following implementation of a QIP. However, the results of the re-audit demonstrate there is still scope to improve the care of patients receiving oral anticancer medicines and the authors aim to continue to address these gaps in care.
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