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A practical approach to improve safety and management in chemotherapy units based on the PROCHE – Programme for optimisation of the chemotherapy network monitoring program

European Journal of Cancer, 3, 49, pages 541 - 544

Abstract

The PROCHE (PRogramme d’Optimisation du circuit CHimiothErapie [Programme for optimisation of the chemotherapy network]) initiative is an innovative oncology-monitoring program designed to reduce patient waiting time and chemotherapy wastage, ultimately improving patient care. Laboratory test results and side effects data were collected for patients in the PROCHE monitoring program group 2d prior to scheduled chemotherapy visits, allowing oncologists to confirm or delay each patient’s chemotherapy. Data from 1037 patients entered in the PROCHE program were compared with 513 control patients, who had been treated according to previous typical hospital procedures. Results demonstrated significant reductions in mean hospital stay i.e. decreased it by 66min and drug wastage decreased from 6% to 2% (95% CI (confidence interval) 0.21–0.59, P<0.0001), and a significant increase in bed occupancy rates with the PROCHE initiative (all P<0.0001 vs. controls). The incidence of pain and severity of fatigue were also reduced.

In conclusion, the PROCHE initiative resulted in improved patient quality of care and reduced chemotherapy toxicities, and improved hospital and pharmacy productivity. These encouraging preliminary results warrant further study.

Keywords: Cancer, Chemotherapy management, Quality of care, Symptom management, Supportive care.

1. Introduction

Cancer patients often report their dissatisfaction with the long waiting time for chemotherapy.1 At each scheduled visit, patients must initially undergo their examination then await laboratory test results and solution preparation prior to receiving chemotherapy. If the test results contraindicate treatment, then the patient goes untreated resulting in the loss of chemotherapy session as well as chemotherapy product wastage. We report an innovative oncology-monitoring program (PROCHE; PRogramme d’Optimisation du circuit CHimiotherapiE [Programme for optimisation of the chemotherapy network]), developed by the Oncology Department at Georges Pompidou European Hospital (HEGP), Paris. This management approach makes use of information technology to reduce patient waiting time and chemotherapy wastage.

The Oncology Department provides outpatient hospital care and is also involved in major cancer research. It has 15d hospital beds and receives approximately 5500 patients per year.

2. The Organisational process

Nurses from a medical call centre contact patients 2d prior to their chemotherapy session to collect side effects data based on the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 questionnaire.2 Laboratory test results are also collected. The chemotherapy preparation is only packaged once the laboratory test results are received. Clinical and biological data are then analysed in the oncology department database (flow chart Fig. 1). This is useful to keep the number of patients found unfit to receive chemotherapy at a minimum.

gr1

Fig. 1 PROCHE (PRogramme d’Optimisation du circuit CHimiothErapie [Programme of optimisation of the chemotherapy circuit]) flow chart.

Early access to clinical and biological data, i.e. 1d prior to the chemotherapy, permits oncologists to confirm or delay each patient’s chemotherapy session, to adapt protocols and to organise specific supportive care in advance when needed. The early approval process allows chemotherapy drugs to be prepared 24h ahead of time. Some situations may still occur, for example, patients may present at the last moment a worsening of their condition, develop an infection or be unable to get to their appointments. To avoid loss of non-stable drugs, chemotherapies stable for less than 24h were prepared, as a priority, at the arrival of the patient in day-hospital. The organisation of PROCHE allowed a short time preparation of this limited number of products, to maintain efficiency in terms of patient waiting time.

In order to assess the programme a total of 1037 volunteer patients (proposed by their physicians) were enrolled in PROCHE, and 8345 safety-related questionnaires were prospectively collected from January 2009 to February 2011. Data from a control group of patients (n=513), who had been treated according to standard HEGP procedures, were retrospectively collected from June to December 2008. Statistical comparisons were performed using a two-sided Z test and/or a Mann–Whitney U test.

The average length of stay of patients enrolled in the programme decreased by 66min compared with controls (131min vs. 65min, P<0.0001). Moreover, the mean bed occupancy rate significantly increased from 1.35 to 1.61 patients/bed/day (95% CI (confidence interval) 0.14–0.36, P<0.0001) and the proportion of wasted chemotherapy preparations decreased from 6% to 2% (95% CI 0.21–0.59, P<0.0001).

A review of the 8345 toxicity questionnaires collected from the 1037 PROCHE patients demonstrated that the most common side effects were fatigue (95.8% of patients), pain (70.3%), neuropathy (62.5%) and nausea (54.5%), and that toxicities were mostly Grade 1 and 2 in severity. Based on the symptoms reported in the questionnaire, supportive treatments were anticipated. The antiemetics are, for example, adjusted. In some cases, patients receive instructions by telephone, to better prepare for their treatment session. Others are visited by a specific supportive care team during their hospitalisation. In this case, contact with the team was anticipated to allow and ensure management of the patient upon arrival. Furthermore, patients enrolled in PROCHE reported reduced fatigue and pain over time (Fig. 2), which can be attributed to the multidisciplinary oncology team’s ability to schedule supportive care prior to a patient visit.

gr2

Fig. 2 Percent variation from baseline for the occurrence of fatigue (A) and pain (B) related to chemotherapy among 1037 patients enrolled in the PROCHE (PRogramme d’Optimisation du circuit CHimiothErapie [Programme of optimisation of the chemotherapy circuit]) program.

The role of the pharmacy is to check the prescription, to ensure the safe centralised preparation of chemotherapy and to conduct a final check of the packaged chemotherapy before dispensing to the relevant department. Strict monitoring during this process helps to avoid accumulation of mistakes, enforce better use of treatments. As with all oncology departments, this process generally takes place upon the patient’s arrival at the hospital, resulting in prolonged waiting time before the administration of essential drugs. This waiting time is a source of anxiety to both the patient and medical team, leading to impaired quality of care and quality of life. Under these conditions, efficiency promoted as part of the French National Cancer Act is not achieved.3

The use of modern communication tools has been shown to result in improved toxicity management.4, 5, and 6 A 60-min telephone call to the patients prior to their appointment can optimise reception capacities on the day of their hospital visit, and the number of patients seen at the hospital per day can be increased. The number of patients cared by each nurse is one of the major factors associated with the burden of patient care, but the time saved by the proposed care model provides greater nurse availability and improved management. In addition, the prior compounding of chemotherapy enables improved risk management and fewer errors. In an interesting paper by McCann et al., patients reported many benefits of using ASyMS©, a mobile phone-based advanced symptom management system. The benefits included improved communication with health professionals, improvements in symptom management and feeling reassured of their symptoms were being monitored while at home.7 As reported in our letter (see Bonan et al.8) by using the PROCHE chemotherapy management system, compared to 6months prior to initiating the programme, we were able to demonstrate a significant saving of approximately 37.000€ for a same period as in our study, on the cost of ungiven doses.

Evaluation of clinical complaints of patients the day before their hospital visit enables the oncologist to anticipate supportive treatment requirements, leading to better tolerance of chemotherapies and optimal organisation of supportive care teams. As shown by the results of our study, the decrease in the incidence of fatigue and pain illustrates how better management of treatment and supportive care teams can help improve patient care. This optimisation of the management of patients should also permit a reduction in costs associated with lost hospital appointments and in costs related to complications associated with chemotherapy side effects.

Secondary objectives of this programme are to use weekly calls to evaluate tolerance to treatment over longer periods of time; to assess long-term tolerance and quality of life of patients treated remotely; and to follow-up patients treated with orally administered targeted therapies. These patients are currently monitored only during the consultation; thus closer monitoring of these patients should allow better prediction of adverse reactions enabling improved management of complications and compliance to therapy.

This programme, developed in a day-hospital delivering chemotherapy, can be applied to any other oncology unit (or any other day care department), which manages ambulatory patients (e.g. radiotherapy, surgery, etc.), and could also be developed to include home help in the coordination of supportive care. Hospitals could potentially profit from such improved organisation and management of patient safety.

3. Conclusion

The pilot programme reported here resulted in optimal hospital and pharmacy operational performance, and improved patient quality of care, including reduced incidence of adverse events. These preliminary results must be confirmed by subsequent studies, including patients treated at home with oral therapy. Nevertheless, our results suggest that this practical approach could be useful to improve safety and efficacy in the management of chemotherapy units.

Conflict of interest statement

None declared.

Acknowledgement

The authors are grateful to Richard Medeiros, Medical Editor, Medical Editing International, for editing the manuscript.

References

  • 1 M.A. Kallen, J.A. Terrell, P. Lewis-Patterson, J.P. Hwang. Improving wait time for chemotherapy in an outpatient clinic at a comprehensive cancer center. J Oncol Prac. 2012;8(1):e1-e7 Crossref.
  • 2 Common Terminology Criteria for adverse events version 3.0 (CTCAE). Published date: August 9, 2006. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf.
  • 3 Circulaire N°DHOS/SDO/2005/101 du 22 février 2005 relative à l’organisation des soins en cancérologie.
  • 4 N. Kearney, L. McCann, J. Norrie, et al. Evaluation of a mobile phone-based, advanced symptom management system (ASyMS©) in the management of chemotherapy-related toxicity. Support Care Cancer. 2009;17:437-444 Crossref.
  • 5 R. Maguire, L. McCann, M. Miller, et al. Nurse’s perceptions and experiences of using of a mobile-phone-based advanced symptom management system (ASyMS©) to monitor and manage chemotherapy-related toxicity. Eur J Oncol Nurs. 2008;12:380-386 Crossref.
  • 6 D.E. Wennberg, A. Marr, L. Lang, et al. A randomized trial of a telephone care-management strategy. N Engl J Med. 2010;363:1245-1255 Crossref.
  • 7 L. McCann, R. Maguire, M. Miller, N. Kearney. Patients’ perceptions and experiences of using a mobile phone-based advanced symptom management system (ASyMS) to monitor and manage chemotherapy related toxicity. Eur J Cancer Care (Engl). 2009;18(2):156-164 Crossref.
  • 8 M. Berhoune, H. Aboudagga, A. Jacob, et al. Effect of requiring advance approval of chemotherapy on number and cost of ungiven doses. Am Health Syst Pharm. 2011;68:557-558 Crossref.

Footnotes

a Oncology Department, Georges Pompidou European Hospital, Paris, France

b Pharmacy Department, Georges Pompidou European Hospital, Paris, France

c Pharmacy Department, Hôpital Foch, Suresnes, France

lowast Corresponding author: Address: Department of Medical Oncology, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015 Paris, France. Tel.: +33 1 56 09 34 73; fax: +33 1 56 09 24 52.


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