Chemotherapy Orders Research Articles

Successful use of problem-solving methodology to reduce pharmacy chemotherapy processing time

ObjectivesThe primary objectives of this study were to (1) reduce pharmacy turnaround time (TAT) without compromising safety and quality and (2) reduce compounding order overload during peak hours (8:00 AM-5:00 PM). The secondary objective was to decrease patient wait time pertinent to pharmacy services. SettingThe setting was a hospital-based pharmacy. Practice descriptionPharmacy dispensing more than 1800 doses daily, 30% of which goes to outpatient cancer treatment. Patients usually receive multiple compounded medications; thus, compounding numbers are several folds higher than patient number. High compounded chemotherapy order volume overloaded pharmacy staff during peak hours and was a major contributor to patient wait time. Practice innovationUsing Define Measure Analyze Improve Control Six Sigma and intelligent risk-taking strategies, a dedicated team identified root causes of problems and designed long-lasting solutions that would not compromise quality. EvaluationThe most effective initiative was the advanced preparation of chemotherapy for select patients (Concierge), which addressed pharmacy TAT, patient wait time, and chemotherapy order overload, all without affecting safety or quality of dispensed medications. ResultsPharmacy TAT decreased by 77% for Concierge patients and 31% for standard patients. Comparable decreases were observed for patient wait time: 67% for Concierge and 27% for standard patients. Safety and quality were maintained for all dispensations during and after implementation of Concierge. A concurrent 8% increase in patient number was observed despite no changes in physical capacity. ConclusionThe implementation of Concierge initiatives: markedly reduced pharmacy TAT without compromising safety checks performed by pharmacists; decreased chemotherapy order overload during peak hours; improved distribution of assignments for pharmacy staffand statistically significant decreased wait time for all patients, especially those selected for Concierge. Effective selection of Concierge patients minimized additional costs associated with wasted premixed chemotherapy. Improving workflow for a subset of patients affected a greater patient population, allowing additional patients to be treated daily.

Conversion from paper to electronic acute care chemotherapy orders.

UNC Medical Center converted to an electronic health record (EHR) in 2014. This conversion allowed for the transition of paper chemotherapy orders to be managed electronically. This article describes the process for converting inpatient paper chemotherapy orders into the new EHR in a safe and effective manner. A collaborative interdisciplinary approach to the EHR transition enabled our organization to move from using paper chemotherapy orders to fully electronic chemotherapy treatment plans in both ambulatory and acute care areas. Active chemotherapy orders for acute care inpatients were reviewed and transcribed by two oncology pharmacists in the cancer hospital prior to being signed by an attending physician. The newly input orders were independently verified by two pharmacists in the cancer hospital inpatient pharmacy. Nurse review of the signed and verified treatment plans, along with reconciliation of the medication administration record ensured a safe transition to the new EHR workflow. Providers benefit from the ability to review treatment plans remotely, track changes, and include supportive medications in one consolidated location. The coordinated team effort allowed for a smooth transition with minimal interruptions to patient care. The pharmacist-led, multidisciplinary conversion to electronic chemotherapy orders was safe, accurate, and occurred ahead of schedule for the EHR go-live. Advance communication and planning around scheduled inpatient admissions helped to minimize the impact of the transition from paper to electronic treatment plans. Both pharmacist and physician engagement were necessary to ensure a smooth transition for active inpatient treatment plans.

Enhancing the effectiveness of chemotherapy prescribing: A validation study of ChemoPalRx.

e19161 Background: ChemoPalRx is a free iOS mobile application developed for chemotherapy referencing and prescribing. Providers can readily download and use ChemoPalRx to generate and print chemotherapy formatted prescriptions. In the absence of a computerized chemotherapy order entry system, institutions may adopt ChemoPalRx for chemotherapy prescribing in place of traditional methods such as handwritten prescriptions. However, effectiveness of ChemoPalRx in the real-world practices has not been established. Methods: With our aim to determine the effectiveness of ChemoPalRx, we conducted a cross sectional study at an academic institution. Our study primary predictor was the method of generating a chemotherapy order, dichotomized as “handwritten” or “ChemoPalRx”. Primary outcome was corrected order, dichotomized as “corrected” or “satisfactory” order. Corrections were defined as any correction made to an order (e.g. illegible handwriting, modifications in drug dosing, missing chemotherapy or patient’s information). Covariates included fellowship training year (first, second, or third) and complexity of order (“simple” = 2 drugs or less; “complex” = 3 drugs or more). Correction rate (CR) was defined as the proportion of corrected orders. Chi Square test was used for statistical analysis. Results: From October 2019 to December 2019, 288 chemotherapy orders were examined, of which, 226 were handwritten (78.5%) and 62 were ChemoPalRx (21.5%). Of the 226 handwritten orders, 184 (81%) were satisfactory, 42 (19%) were corrected. Of the 62 ChemoPalRx orders, 57 (92%) were satisfactory, 5 (8%) were corrected. CR was significantly reduced by ChemoPalRx compared to handwritten (p = 0.034). Subgroup analysis found that first-year fellows tend to make more corrections on complex orders (CR: 19%) compared to second- and third-year fellows (CR: 6%) (p = 0.19), while second- and third- year fellows made more corrections on simple orders (CR: 22%) compared to first-year fellows (CR: 9%) (p = 0.013). Conclusions: ChemoPalRx significantly enhanced prescription accuracy compared to handwritten chemotherapy orders. Implementation of ChemoPalRx in real-world practices is validly feasible and effective. While ChemoPalRx may support less experienced providers on more complex orders, it may help to catch overlooked simple details for the experienced providers. In the evolving digital era in oncology, ChemoPalRx may be a promising alternative to handwritten prescriptions that can be readily available at one’s fingertips.

Physician burnout: An innovative way to find “sanity out of madness” in the infusion center of a cancer institute.

e19246 Background: Physician burnout is affecting over 50% of physicians in the US alone and is related to the high workload, loss of anonymity and a sense of powerlessness in the face of multiple bureaucratic hurdles. The result is physical exhaustion, moral distress, high turnover and increased rates of suicide. Methods: The faculty and staff at Washington Cancer Institute (WCI) were surveyed using AMA/ASCO burnout questionnaire to identify burnout rates. A brainstorming session with staff captured the perceived causes of burnout in a fishbone diagram, and the most prominent cause was noted to be pertaining to delays in the infusion center (IC) related to chemotherapy orders. We tracked causes of delay in starting chemotherapy from 7/23/19 to 8/7/19, and utilizing a Pareto Chart identified that over 80% of the delays were due to missing chemotherapy orders on the day of IC appointment. Process flow charts were developed for all provider teams at WCI noting variations that may be leading to delays. The aim was to decrease the number of missing chemotherapy orders for patients coming to the IC by 50%, decreasing the resultant stress on providers and IC nurses. Results: By retrospective chart review, 6/21/2019 to 8/30/ 2019, an average of 13.18% of patients scheduled to receive chemotherapy at WCI IC had missing orders on the day of the infusion, which resulted in up to a 111-minute delay in starting chemotherapy. This, in turn, resulted in stress/burnout among 42.1% of providers and 55.6% of supportive staff. To remedy the problem, we implemented 4 interventions over two plan-do-study-act (PDSA) cycles. In the first PDSA cycle the process was standardized to obtain necessary labs 48 hours prior to IC appointment and review and sign orders by 2 pm the day prior to IC appointment. Email notifications were also sent to all providers and nurse navigators regarding missing orders 48 hours prior to IC appointment. In the second PDSA cycle we continued with the previous interventions in addition to addressing pharmacy related delays in releasing premedication if dose adjustments of chemotherapy are needed. In the time period of 10/2/2019 to 11/11/2019, two PDSA cycles were implemented and resulted in a decrease in the average number of missing orders on the day of IC appointment to 7% achieving our aim. Conclusions: Using a systems approach to standardize the process promotes a more effective environment in the work place and decreases burnout on physicians and staff.

Assessment of the utilization pattern of chemotherapy agents in patients with head and neck cancer in an oncology hospital

The prevalence of head and neck cancers (HNC) is increasing in developing countries, and its pharmacotherapy has become complex. Evaluation of drug utilization patterns (DUPs) of chemotherapy agents is needed to ascertain the rational use of medications in HNC. The aim was to evaluate the DUPs of chemotherapy agents in patients with HNC in an oncology unit. This prospective observational study was designed to review chemotherapy orders for patients with HNC and assess DUPs over a period of 2 years. Cancer patients aged > 18 years who were receiving chemotherapy together with supportive care medications were enrolled. A total of 208 patients met inclusion criteria and were enrolled in the study. The majority of patients were aged 45–75 years (64.4%), were male (81.3%), and used tobacco (54.9%). The most common sites of HNC were pyriform fossa (18.3%), tongue (17.8%), buccal mucosa (13.9%), and tonsils (10.6%). The majority of patients had head and neck squamous cell carcinoma (HNSCC) [93.3%] and were in stage III (32.2%) or stage IV (48.5%). Neoadjuvant chemotherapy (51%) followed by adjuvant chemotherapy (41.4%) were frequently prescribed. Chemotherapy agents prescribed in > 25% of patients included cisplatin (68.8%), paclitaxel (43.8%), and carboplatin (29.8%); supportive care drugs prescribed in > 25% of patients included dexamethasone (51%), metoclopramide (44.2%), chloramphenicol (39.4%), and pantoprazole (27.9%). Platinum analogs and taxanes were highly prescribed chemotherapy agents as they are highly effective in HNSCC. To prevent chemotherapy-induced cytotoxicity, supportive care agents, such as anti-emetics, proton pump inhibitors, anti-infective agents, and colony-stimulating factors, were used along with miscellaneous supplements.

Evaluation and optimization of a clinical pharmacist driven transitions of care model for malignant hematology.

To implement and optimize a pilot transitions of care model for scheduled chemotherapy admissions in patients with hematologic malignancies at our institution.Methodology: We utilized the plan-do-study-act (PDSA) quality improvement technique to prospectively measure success of interventions related to improving transitions of care processes that occurred in multiple stages including development of standardized operating procedures, electronic medical record documentation, and education to the malignant hematology multidisciplinary group. Chart review was performed retrospectively for at least nine patients per PDSA cycle. Areas of intervention addressed and measured regarding communication between the ambulatory care and acute care settings included: admission purpose, processes related to insurance benefits investigations for specialty medications required in the post-discharge setting, and plan for growth factors, prophylactic antimicrobials, and follow-up.Results and conclusions: We included 28 patients and performed a total of three PDSA cycles demonstrating specific improvements in: communication regarding status of benefits investigations performed for specialty medications prior to admission, resolution of these benefits investigations at various time points, improvement in efficient use of the electronic medical record for chemotherapy orders, and patient instructions for appropriate use of prophylactic antimicrobials. Although improvement was noted initially with prescribing of discharge antiemetics and antimicrobials, regression to baseline was noted with the third PDSA cycle.

Economic benefits of pharmacy technicians practicing at advanced scope: A systematic review.

To critically appraise the literature to determine the cost and time savings for institutions when pharmacy technicians practice in advanced scope roles. A systematic review was registered with Prospero and conducted in January 2019. Searches were conducted in Business Source Pro, CINAHL, EconLit, EMBASE, InformGlobal, Medline, ProQuest, PubMed, Scopus and Web of Science. Search terms included pharmacy technician/pharmacy assistant and cost or time or economic evaluation. After article selection in the web-based platform Covidence©, data was extracted, and a narrative review was performed. A total of 16 publications were eligible for inclusion in the review. Pharmacy technicians practicing at advanced scope led to both cost savings and time savings. Six studies reported a cost saving, six reported a time saving and four reported both time and cost savings. Annual savings ranged from AUD $4526 - $88,719.89, linked primarily to the difference in wages between pharmacists and pharmacy technicians. Studies that focused on time savings evaluated checking dispensed items, taking medication histories and entering chemotherapy orders; demonstrating savings of up to 5min per task completed. Appropriately trained pharmacy technicians practicing at advanced scope have the potential to save time and reduce hospital costs. Identifying the cost saving opportunities from technicians acting in advance scope roles will provide incentives for hospitals to expand their technician workforce.

Risk Factors for Increased Length of Stay (LOS) in Patients with Hematological Malignancies Electively Admitted for Chemotherapy

Introduction Despite more robust attempts to deliver chemotherapy in the outpatient setting, certain regimens for hematologic malignancies require inpatient hospitalization for treatment and monitoring clinical status. Increased length of stay (LOS) for planned chemotherapy admissions leads to increased healthcare utilization and decreased patient satisfaction. We sought to identify potentially modifiable risk factors for increased LOS. Methods Planned chemotherapy admissions to the inpatient hematology services at Mayo Clinic (Rochester, MN) from October 2018 through March 2019 were reviewed. We included patients who had treatment plans based on four pre-specified common regimens for acute myeloid leukemia, relapsed non-Hodgkins lymphoma and multiple myeloma. Patients who remained in the hospital for lack of caregiver support were excluded. Patient characteristics, including age, malignancy type, and chemotherapy regimen were recorded. Encounter characteristics included day of week of admission, time of admission, time chemotherapy plan initiated, and whether or not all necessary procedures (labs, vascular access, chemo orders) were completed prior to admission. Primary outcome was LOS. Secondary outcome was time to treatment initiation (TTI) after admission. Results There were 100 planned admissions for patients receiving four regimens: cytarabine consolidation, EPOCH, ICE, VDT-PACE, during the six month review period. Thirty-six admissions did not occur as planned (regimen changed, rescheduled, or disease progression). Of the remaining 66 admissions, 11 outliers were excluded from primary analysis. Baseline characteristics are summarized in Table 1. Univariate analysis with independent t-test found no difference in LOS for patients who had physician chemotherapy orders in place prior to admission. To the contrary, we detected a non-significant trend toward longer mean length of stay for patients that were not seen in clinic on day of admission (Table 2). On ANOVA, there was a statistically significant difference in LOS when comparing Monday admissions 3.93 days (95% CI 3.07 to 4.79) vs Friday 5.25 days (95% CI, 4.86 to 5.64), but not between any other days. There were no statistically significant differences in TTI when comparing by day of week, physician order status, or chemotherapy regimen. Again, a non-significant trend toward increased TTI was observed for patients not seen in clinic on the same day as admission. Conclusions This study serves as a starting point towards identifying modifiable factors that are essential to delivery of safe, satisfying inpatient care to our hematological malignancy patients.Our noteworthy finding regarding patients who were admitted on Friday having a longer LOS than those admitted on Monday requires further exploration. This study is ongoing with mature data to be presented at the meeting. Disclosures No relevant conflicts of interest to declare.

1837P - Impact of routine screening and preemptive treatment on hepatitis B virus reactivation (HBVr) in patients receiving chemotherapy

BackgroundGuidelines diverge about the need for systematic HBV screening for all patients starting chemotherapy. At the Centre hospitalier de l’Université de Montréal (CHUM), systematic HBV screening is requested on pre-printed chemotherapy order (PPCO) at high risk of HBVr with follow-up by a pharmacist. For all other PPCO, doctors can request HBV screening and follow-up. A decision algorithm is available for all clinicians. The aim of this study is to assess whether patients undergoing routine HBV screening could reduce the incidence of HBVr. MethodsThis is a retrospective observational study including patients who received an IV chemotherapy for cancer between July 2017 and June 2018 at the CHUM. We compared the incidence and complications of HBVr in patients with HBV screening as requested on PPCO (group 1) or on demand from the medical team (group 2) to patients who were not screened (group 3). ResultsOn a total of 1374 patients, 179 of 206 (13%) patients were screened as requested on PPCO (group 1) and 421 (30%) by the medical team (group 2). Patient characteristics, duration of treatment and follow-up for all groups are listed in the table. No difference was seen on the incidence of HBVr between screened and unscreened patients (0% vs 0.1%; p=0.36) probably because of a lack of follow-up after chemotherapy. Optimal follow-up for HBVr based on the decisional algorithm appears to be better in group 1 than group 2 (50% vs 25%; p=0.13). For patients on anti-CD20 therapy in group 1, HBV screening was done for 92% of patients which is a higher rate compare to previously reported data. In group 3, 89 patients had ALT elevation (>100U/L and x3 baseline value) during chemotherapy but only 17 patients (19%) were tested for the possibility of HBVr.Table1837PTableGroup 1 n=206 (%)Group 2 n=421 (%)Group 3 n=747 (%)Screening before chemotherapy179 (86.9)421 (100)0 (0)Nb of pts who had finished chemotherapy treatment at the time of analysis174 (84.5)402 (95.5)699 (93.6)Median duration (months) of chemotherapy (IQR)10.5 (6.4-14.4)4 (1.4-9.1)3.6 (1.6-5.6)HBsAg + Anti-HBc + HBV-DNA +0 (0) 17 (8.3) 1 (0.5)2 (0.5) 36 (8.6) 2 (0.5)-Incomplete screening5 (2.8)31 (7.4)-Antiviral prophylaxis required Antiviral prophylaxis initiated8 (3.9) 7 (3.4)3 (0.7) 3 (0.7)-Follow-up required Follow-up Optimal follow-up18 (8.7) 10 (4.9) 9 (4.4)36 (8.6) 13 (3.1) 9 (2.1)-Number of patients who had a follow-up after chemotherapy3 (1.5)5 (1.2)HBV reactivation0 (0)0 (0)1 (0.1) ConclusionsSystematic HBV detection requested on PPCO is an effective way to increase HBV screening and prevent HBVr in patients receiving chemotherapy. However, this method does not guarantee optimal follow-up and requires improvements. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureD. Martel: Honoraria (self): Abbvie Canada; Honoraria (self): Gilead Sciences Canada; Honoraria (self): Merck Canada. V. Martel-Laferrière: Research grant / Funding (self), Clinical Research Scholars - Junior 1: Fonds de la recherche en santé du Québec. S. Doucet: Honoraria (self), Advisory / Consultancy: AbbVie Canada; Honoraria (self), Advisory / Consultancy: Gilead Sciences Canada; Honoraria (self): Merck Canada; Advisory / Consultancy: Roche; Advisory / Consultancy: BMS; Honoraria (self), Advisory / Consultancy: Janssen; Honoraria (self): Seattle Genetics. J. Adam: Honoraria (self): Amgen Canada; Advisory / Consultancy: Celgene; Honoraria (self), Advisory / Consultancy: Novartis; Advisory / Consultancy: Janssen; Honoraria (self), Advisory / Consultancy: AbbVie; Advisory / Consultancy: Lundbeck. All other authors have declared no conflicts of interest.

Optimization of inpatient chemotherapy administration utilizing evaluation intervals.

75 Background: Inpatient chemotherapy requires an interdisciplinary approach to achieve shorter hospital stays and decrease cost. A quality improvement project at Hahnemann University Hospital was undertaken to identify delays in the process from admission to chemotherapy initiation in this population. Methods: Time stamps were recorded for patient arrival (door to floor), order placement (floor to order), and administration (order to chemo) to establish a baseline. A multidisciplinary team of pharmacy, nursing, and physicians was developed to address inefficiencies. There were three evaluation intervals: May - October 2015 (Part I), January 2017 - October 2018 (Part II) and October - December 2018 (Part III). Data collected from Part I established a baseline door-to-chemo time (DTC) of 7.2 hrs. Post Part I, prompt communication of patient arrival and delays in chemotherapy hanging were addressed. Part II interventions were outpatient consents and labs, timely order placement, and utilization of order sets. Pharmacy-nurse communication and equal distribution of patients through the week was implemented in Part III. The primary outcome measure was difference in DTC. Results: 200 admissions were reviewed. Results of the evaluation intervals are shown in Table. After the first evaluation interval, DTC improved from 7.18 to 5.96 hrs. DTC further decreased to 5.78 hrs post intervention II. The longest delay was between chemotherapy order and administration. Conclusions: DTC significantly improved between intervals with the above interventions. Utilizing a standardized nursing checklist and biweekly multidisciplinary meetings to emphasize prioritization will further decrease DTC. DTC reduction will decrease cost and increase patient satisfaction. [Table: see text]

Increasing fertility preservation counseling prior to chemotherapy.

225 Background: The 2018 ASCO Guidelines recommend that physicians document discussions about fertility with all female patients < 49 years old at the time of cancer diagnosis. Patients interested in fertility preservation (FP) should be referred to Reproductive Endocrinology and Infertility (REI) prior to chemotherapy. Retrospective review of oncology patients at our academic medical center over 6 months found that 33% of females < 49 years old had FP discussion documented. We aimed to increase FP discussions and help expedite referrals to REI from 33% to 75% within 5 months. Methods: All new chemotherapy orders were reviewed weekly. Female patients between ages 18-49 were identified and charts were abstracted for the following: age, race, diagnosis, stage, type and line of chemotherapy, and FP discussion. If FP was not discussed, the physician was contacted in real time via email to address FP with the patient and document the discussion. Charts were reviewed 2-4 weeks later to determine if FP was documented. To better understand barriers to FP documentation, fellows and attendings were surveyed to target future interventions. Results: From Dec. 2018 to Apr. 2019, 6/27 (22%) patients had documented discussions of FP. Post intervention, this number increased to 17/27 (63%) with one referral to REI. Intent of chemotherapy was curative in 56% of patients, and 67% were receiving their first line of chemotherapy. 2/15 (13%) patients receiving curative treatment and 4/12 (33%) patients receiving palliative chemotherapy had documentation of FP, both of which increased with intervention to 8/15 (53%) and 9/12 (75%), respectively. Conclusions: Our intervention successfully increased FP discussion from 33% to 63%, but we did not meet our goal of 75%. Per our survey results, the most common barriers to FP discussion were time constraints, inexperience discussing FP, and perception of prohibitive cost to the patient. We are designing our next intervention to address provider inexperience with FP discussion. This will include education regarding the financial aspects of REI and discussion of the new Oncofertility law in Illinois (HB2617), which ensures insurance coverage for oncofertility as of Jan 2019.

Medication errors in a cohort of pediatric patients with acute lymphoblastic leukemia on remission induction therapy in a tertiary care hospital in Mexico.

IntroductionMedication errors (MEs) are the main type of preventable adverse events in medical care, as well as safety indicators in the medication processes. Advances in the quality of care in pediatric acute lymphoblastic leukemia (ALL) have enabled to improve clinical outcomes. However, ME epidemiology in pediatric oncology is still incipient in developing countries. In view of this, the objectives of this study were to estimate the incidence of MEs, determine their types and consequences, as well as their preventability in the induction treatment of children with ALL at Hospital Infantil de Mexico Federico Gómez.MethodsWe reviewed the remission‐induction chemotherapy records of children with ALL between January 2015 and December 2017. A two‐phase review was carried out for ME identification and verification. The consequences of errors were determined by agreement between reviewers.ResultsWe reviewed 1762 chemotherapy orders involving 181 children. MEs were observed in 16.9% of orders and in 57.5% of patients. Prescription errors were the most common (93.3%), with wrong dose errors (90.2%) being predominant. Only 3.7% of wrong dose errors were intercepted, while 12.2% of the children experienced adverse drug events (ADEs) preceded by some wrong dose error.ConclusionsMEs were common, since they occurred in 57.5% of children with ALL on induction treatment and involved 16.5% of chemotherapy orders. Only 3.7% of MEs were intercepted, while 12.2% of children had ADEs related to overdose. Measures are required to prevent calculation error in prescriptions, as well as training of the nursing staff to intercept MEs.

Multidisciplinary Effort to Decrease Time From Admission to Chemotherapy on an Inpatient Oncology Unit.

There are no national standards for time between patient arrival and the initiation of scheduled chemotherapy (time to chemotherapy [TTC]). Delays in this process have a negative impact on patient care and the use of health care resources. At the University of Virginia Cancer Center, mean TTC in 2015 was 12.1 hours and mean length of stay (LOS) was 5.45 days at baseline. We formed a multidisciplinary team that participated in ASCO's Quality Training Program. We aimed to improve TTC by 10% over 6 months. We used Plan-Do-Study-Act (PDSA) cycles as quality improvement (QI) models and used XmR charts to evaluate the interventions. The first PDSA cycle involved amending the chemotherapy consent process; mean TTC and LOS improved to 9.3 hours and 4.65 days, respectively. The second PDSA cycle involved shifting pharmacist review of chemotherapy orders to before admission rather than after patient arrival. Mean TTC remained at 9.4 hours (net 22% improvement from baseline) and LOS improved to 4.33 days (net 21% improvement). Our team surpassed the 10% improvement goal for TTC. This QI project faced a few limitations. Our baseline data set was a retrospective cohort review. In addition, oncology patients have a wide range of individual clinical needs that may have an impact on TTC. Delays in TTC have an impact on oncologic care at many medical centers. Our project highlights the need for guidance on this issue. We recommend that other institutions form multidisciplinary teams and also use QI tools to assess delays and implement changes.

A chemotherapy privileging process for advanced practice providers at an academic medical center.

Nurse practitioners, physician assistants, and pharmacists are advanced practice providers who are highly trained and qualified healthcare professionals that can help support traditional demands on oncologists' increased time in direct patient care. The purpose of this study was to detail and assess the creation of a privileging process for this group of medical professionals within an academic medical center. Obtaining the designation of limited oncology practice provider (LOPP) gives the right to modify chemotherapy orders and to order supportive care medications. An interdisciplinary team developed a comprehensive training process inclusive of required educational domains, knowledge goals, and educational activities to become an LOPP. In 2018, five years after the implementation of the privileging process, a survey was distributed to assess perceptions of the training process and integration of LOPPs within oncology practice. Most oncologists noted that working with LOPPs is beneficial to oncology practice (94%) and that they make modifying chemotherapy orders more efficient (87%). Greater than 82% of LOPPs also reported that their privileges streamline the chemotherapy process and make them feel valuable. The creation of the LOPP designation is an effective way to integrate nurse practitioners, physician assistants, and pharmacists within oncology practice. The inclusion of a focused privileging process ensures the safety of cancer care provided and has created a streamlined process for chemotherapy modifications and supportive care.

Current evidence of education and safety requirements for the nursing administration of chemotherapy: An integrative review.

The administration of chemotherapy is a complex task which has many safety issues. Safe administration of chemotherapy by nurses should be evidence-based. The aim of this integrative review was to synthesise the evidence about education and practice requirements for safe administration of chemotherapy by nurses. A systematic search of four databases identified 17 studies for inclusion in this review. Key words: Nurse, chemotherapy, cytotoxic drug, administration, safety, education. Data extracted from the studies included author, year, aims, design, sample, outcome measures and findings. After screening the articles, extracting study data and completing a summary table, critical appraisal of the studies was completed using the Mixed Methods Appraisal Tool (MMAT). All the studies focused on strategies to promote patient and nurse safety during nursing administration of chemotherapy. Content analysis identified five themes: governance, process safeguards, communication, interdisciplinary collaboration and education. Key strategies or interventions that increased patient and/or nurse safety identified were standardised computer-generated chemotherapy orders, barcodes, medication safety procedures, education and simulated learning. This review found low-level evidence exists about the education and safety requirements for nursing administration of chemotherapy. High-level research is needed to assist healthcare services to select evidence-based educational and safety strategies and provide appropriately resourced work environments to support the safe nursing administration of chemotherapy and deliver the best possible patient outcomes.

Oncology Pharmacist’s Role and Impact on the Multidisciplinary Patient-Centre Practice of Oncology Clinic in Public Hospitals

Oncology pharmacy service was developed and integrated into the multidisciplinary team of oncology clinic in 2013 at the United Christian Hospital aiming to enhance the holistic patient-centre practice of the clinic through the optimization of the safety and efficacy of anti-cancer treatment. This review aims to describe the role and impact of oncology pharmacists (OPs) in clinical setting to optimize anti-cancer treatment for cancer patients in a multidisciplinary care approach. From selection, prescribing, procurement to monitoring and patient education, OPs significantly contribute to the safety and effective use of anti-neoplastics in any circumstances. OPs provide professional advices to oncologists in choosing the appropriate anti-cancer agents for specific cancer and designing personalized anti-cancer treatment according to patients’ fitness and appropriateness for chemotherapy. Parenteral and oral chemotherapeutic agents carry heightened risk of causing significant patient harm when they are used in errors. Thus, OPs also develop standardized chemotherapy orders and ensure the final dose is appropriate in terms of both hematological and non-hematological responses and tolerability. Moreover, OPs play an important role in procuring anti-cancer drugs and sourcing alternative drug choices that will deliver similar clinical outcomes. In addition, OPs also assure the clinical integrity of anti-cancer drugs for full anti-neoplastic activity and safe administration of these drugs by nursing staff to minimize potential occupational risk. Most importantly, OPs play a vital role in providing direct patient care functions such as drug therapy monitoring and management (e.g. ensure that patients receive sufficient pre-medications for administration of anti-cancer drugs), and medication counseling for patients and their carers to better understand their anti-cancer treatment. The positive impact of integrating OPs into the multidisciplinary patient-center practice of oncology clinic includes (1) reduction in potentially life-threatening medication incidents and cancer drug administration errors in public hospitals; (2) collaboration with oncologists to select the most suitable cancer drug regimens for patients; (3) prevention of potential occupational risk to the healthcare professionals who handle cancer drugs; and (4) provision of optimal therapy treatment, monitoring and counseling to patients to reduce side effects and hospital readmission. The professional drug knowledge of OPs adds value to the multidisciplinary team in oncology clinics and the growth of OPs into effective direct patient care in oncology clinics should be encouraged to optimize medication-related outcomes.

A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice.

Electronic health records are central to cancer care delivery. Electronic clinical decision support (CDS) systems can potentially improve cancer care quality and safety. However, little is known regarding the use of CDS systems in clinical oncology and their impact on patient outcomes. A systematic review of peer-reviewed studies was performed to evaluate clinically relevant outcomes related to the use of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. Peer-reviewed studies published from 1995 through 2016 were included if they assessed clinical outcomes, patient-reported outcomes (PROs), costs, or care delivery process measures. Electronic database searches yielded 2,439 potentially eligible papers, with 24 studies included after final review. Most studies used an uncontrolled, pre-post intervention design. A total of 23 studies reported improvement in key study outcomes with use of oncology CDS systems, and 12 studies assessing the systems for computerized chemotherapy order entry demonstrated reductions in prescribing error rates, medication-related safety events, and workflow interruptions. The remaining studies examined oncology clinical pathways, guideline adherence, systems for collection and communication of PROs, and prescriber alerts. There is a paucity of data evaluating clinically relevant outcomes of CDS system implementation in oncology care. Currently available data suggest that these systems can have a positive impact on the quality of cancer care delivery. However, there is a critical need to rigorously evaluate CDS systems in oncology to better understand how they can be implemented to improve patient outcomes.

QIM19-130: Quality Improvement Project to Standardize a Prehabilitation Pathway for Patients With Esophageal Cancer Receiving Neoadjuvant Chemoradiation

Background: At our institution, the standard treatment recommendation for esophageal cancer patients with stage IB–IIIB disease is for neoadjuvant chemoradiation per the CROSS regimen prior to surgery. This regimen can be difficult for patients to tolerate, and they may be unable to receive full dose therapy without treatment dose reductions and delays. Methods: We conducted a quality improvement (QI) project, STRENGTH (Seeking to Reactivate Esophageal and Gastric Treatment Health), to implement supportive care interventions in the prehabilitation phase of neoadjuvant treatment. Our QI program included a standardized chemotherapy order template with supportive care interventions implemented at specific time points. Following implementation of the STRENGTH pathway, a retrospective QI analysis assessed an equal number of patients in the pre-STRENGTH and STRENGTH group for chemotherapy and radiation therapy dose intensities, as well as treatment outcomes. Results: During the pre-STRENGTH period, patients received an average of 5 chemotherapy treatments (range, 2–6), with an average relative dose intensity of 91.8% for carboplatin and 86.7% for paclitaxel. During the STRENGTH period, patients received an average of 6 (range, 5–8) chemotherapy treatments, with an average relative dose intensity of 111.4% for carboplatin and 112.9% for paclitaxel. In the pre-STRENGTH group, one patient did not complete their planned radiation dose due to nausea, vomiting, and dehydration. All patients in the STRENGTH group received their planned radiation dose. In the STRENGTH group, there is a trend of improved pathologic response, longer progression-free survival, and shortened time to surgery. Conclusion: Implementation of the STRENGTH pathway improved chemotherapy dose intensity, with potentially improved oncologic outcomes in the STRENGTH group. We plan to further optimize the STRENGTH program with implementation of standardized dose reduction and delay protocols for both chemotherapy and radiation, and assess the effects of STRENGTH interventions on patient quality of life.

BPI19-015: Reduction of Inappropriate Prophylactic Pegylated Granulocyte Colony-Stimulating Factor (pGCSF) Use for Lung Cancer Patients: Five-Year Follow Up of a Quality Improvement (QI) Initiative at the Cleveland Clinic Taussig Cancer Institute (TCI)

Purpose: National guidelines do not include routine pGCSF as primary prophylaxis (PP) for patients receiving chemotherapy associated with a low risk for febrile neutropenia (FN). Inappropriate pGCSF can increase patient morbidity, financial burden, and overall health care costs. In 2013, an interdisciplinary group at TCI implemented a QI project to reduce inappropriate PP pGCSF in patients with lung cancer; this included prescriber education and modification of chemotherapy orders by risk of FN in the electronic medical record (EMR). Inappropriate pGCSF was reduced from 28% to 4%. In this 5-year follow up study we analyzed pGCSF use in lung cancer patients. Methods: We conducted a review of lung cancer patients who received pGCSF with chemotherapy initiated between January 2016 and August 2018. PP pGCSF use was appropriate if prescribed with chemotherapy regimens with a high risk (>20%) for FN, or intermediate risk (10%–20%) if other accepted FN risk factors were present. PP use with FN low-risk (<10%) chemotherapy was considered inappropriate. Treating physicians were anonymously surveyed about their practices. Results: 294 patients with lung cancer received 1,353 doses of pGCSF during the study period. 58 (20%) were treated at TCI by subspecialty thoracic oncologists and 236 (80%) were treated at regional network sites. 100/294 (34%) patients received low-risk regimens. 62/100 (62%) patients treated with low-risk regimens received 311 doses of PP pGCSF (inappropriate use). 5/62 (8%) of inappropriate use occurred at TCI; 57/62 (92%) at network sites. Of 130 patients who received an intermediate risk regimen, 99 (76%) received PP pGCSF. At least one risk factor for FN was identified in 80/99 (80%) of these patients; age >65 and prior chemotherapy or radiation were the top-cited factors. 33/294 (11%) patients were hospitalized for FN during the study period; 7/100 (7%) received low-risk regimens, 15/130 (11.5%) intermediate-risk, and 11/46 (24%) high-risk regimens. All physicians responding to the survey indicated awareness of guidelines and EMR risk identification. Conclusion: After initial success at our center, we found that guideline-based alignment of pGCSF prescribing in lung cancer patients was not sustained. Despite reported familiarity with guidelines for PP pGCSF use, this analysis suggests an opportunity for re-education and further EMR modification. Based on July 2018 CMS average sales price, reduction in inappropriate use presents a potential cost savings of $1.5 million during the study.

QIM19-128: Improving Oral Chemotherapy Safety in Adult Neuro-Oncology Clinics

Background: The development of oral chemotherapies (OC) have transformed cancer care for millions of patients. Most patients with brain tumors have temozolomide (TMZ) delivered to their home. While this has improved the patient experience, it presents significant challenges to safety of prescription, administration, and side effect monitoring. While there are guidelines for documentation, there is not a best practices system for managing OC. This project identified areas of latent errors and implemented a standardized process for OC management. Methods: After review of the literature, we developed a process map for our institution’s practice and performed hazard analysis. We then evaluated the process at 3 other neuro-oncology practices. Based on these evaluations, changes were implemented at several stages (Table 1). Objective binary measures that could be recorded for every TMZ prescription were collected by chart review of the 6 months prior to process change. These measures were monitored every 2 weeks after process change implementation using run charts. A baseline process mean was calculated for each measure from the 6 months before program implementation. Successful change implementation was defined as 7 consecutive 2-week averages that were continually on one side of the process mean. Results: At the time of this abstract submission, we had successfully reduced refills for OC and increased documentation of dose calculation and dose ordered. There is improvement in independent dose calculation by 2 providers and dedicated chemotherapy teaching visits; however, these have not yet reached criteria for process change. Additionally, oral chemotherapy order sets were created in the electronic medical records system and an on-site specialty pharmacy was added as another safety measure in OC management. Conclusions: This project used published studies and multi-institutional process mapping and hazard analysis to implement a standardized ordering of TMZ for patients with brain tumors. This process can be implemented for OC management in other oncology practices.