The use of oral cancer systemic therapies (OST) is growing and these carry a higher potential for error compared to intravenous treatments. OST are self-administered which can lead to errors in dose, frequency or omission of intended treatment breaks. At our rural clinic, oncologists attend fortnightly, but there has not been a clear process for managing OST. Without specialist pharmacists, oncology nurses must provide education and supervise OST.
To develop a systematic process for electronic prescribing and management of OST. To establish a nurse-led model for education and supervision of OST including toxicity management.
A preliminary audit reviewed current processes surrounding OST. A team of oncology nurses, oncologists and pharmacists utilised quality improvement methodology (process flow charts, driver diagrams, Pareto plots) to identify root-causes and modifiable factors. Plan-Do-Study-Act cycles testing various interventions were implemented (October 2019 to June 2020) including staff education, establishing processes for OST education and toxicity management. Run charts were used to monitor progress. The primary outcome was the proportion of OST patients who received formal nurse education.
The initial audit uncovered difficulty in identifying patients as OST were not electronically prescribed and often dispensed offsite. During the study period there were 22 evaluable patients identified with a range of primary malignancies (breast 36%; colorectal 32%; genitourinary 23% and lung 9%). OST included: capecitabine (45%); tyrosine-kinase-inhibitors (25%) and CDK-4/6 inhibitors (14%). A new OST process mandated electronic prescription and clinical handover. Current nurse-led OST education rates are at 90% with growing confidence and experience in managing toxicity.
In our rural clinic, systematic quality improvement methodology generated a robust process and an oncology nurse-led model of care which has significantly improved OST management. Teamwork and communication between multiple stakeholders was critical for success. Future audits and interventions are planned for continuous quality improvement.