Alison Coackley

Transdermal opioids: are we plastering over the cracks?

Introduction Transdermal opioids such as Fentanyl and Buprenorphine are recognised as effective analgesics in the treatment of moderate to severe pain in patients with both malignant and non-malignant disease. However there is evidence to suggest that the knowledge of appropriate indications, pharmacokinetics, and dose equivalencies of transdermal opioids is poor, particularly among non-specialist prescribers. This is supported by drug safety alerts from the Medicines and Healthcare products Regulatory Agency highlighting reports of life threatening adverse effects and even death from unintentional overdoses. Aim To explore the prescribing patterns of transdermal opioids in palliative care patients in a UK Cancer Network. Methods A prospective audit was conducted over a 6 month period at 3 different sites. This incorporated palliative care patients in hospice, hospital and community settings. Data was collected following the initial specialist palliative care assessment of patients already prescribed transdermal opioids at the time of referral. Information was recorded relating to the original prescriber, documentation of indications, evidence of toxicity and use of breakthrough medication. Results A total of 50 case notes were audited. Key findings revealed that indications for the use of transdermal opioids were only documented in 26% of patients. Over a quarter of patients had evidence of adverse effects, mainly opioid toxicity. The toxicity correlated with the strength of the transdermal opioid preparation rather than incorrect prescribing of breakthrough medication. However, results also showed that there appeared to be a lack of understanding as to appropriate doses of breakthrough medication. Conclusion There are clear situations in which transdermal opioids can be effective and well tolerated alternative step 3 opioids. However these audit results would suggest that there is a need for more education and training particularly among non-specialist prescribers in order to ensure the safe prescribing and administration of transdermal opioids.

Multi-professional-delivered enhanced supportive care improves quality of life for patients with incurable cancer

BACKGROUND: Enhanced supportive care (ESC) promotes the earlier implementation of supportive care within cancer care. While earlier supportive care has been demonstrated to improve patient outcomes, the model of delivery is variable. The Clatterbridge Cancer Centre has developed a multi-professional delivered model with clinical nurse specialists providing ongoing patient review and care. METHOD: A retrospective single-system design was used to assess longitudinal changes in Integrated Palliative Care Outcome Scale (IPOS) scores as indicators of quality of life. For other outcomes, a retrospective case control analysis was undertaken. RESULTS: Statistically significant improvements in all IPOS scores were observed for patients attending ESC. Compared to controls, quantitative outcomes included prolonged survival and reduced chemotherapy-related mortality. Multi-professional delivered ESC successfully improves quality of life and outcomes.

P-83 Enhancing bereavement support in a tertiary cancer centre: a quality improvement study

Background Grief is a natural response to the loss of a loved one but can have the potential for long term adverse effects. Bereavement services are therefore essential to provide support and to identify those at risk of harm. A ‘day after death service’ for bereaved persons is a longstanding component of bereavement care at our tertiary cancer centre. Bereaved persons are met by a clinical nurse specialist the day after the death for a face to face discussion and support needs assessment. This system aims to improve support and identify those at risk of pathological grief reactions. Aim Conduct a quality improvement project aimed at enhancing bereavement support at our centre by incorporating feedback from bereaved persons into trust-wide education and care quality indicators. Methods A 12 month retrospective audit was undertaken to evaluate bereavement service outcomes.This was combined with feedback from stakeholders to develop a PDSA quality improvement cycle. Results At baseline 51 deaths were recorded in 12 months. 42 people agreed to ongoing support following accessing the day after death service. 39 people did not require any further support following a single phone call. Three bereaved persons needed additional support due to prolonged/pathological grief, and were supported appropriately. Stakeholder satisfaction surveys revealed an 88% approval rating for emotional support and practical help, and 100% would recommend the service to others. Qualitative constructive feedback suggested enhancing methods of detecting people at high risk of pathological grief and developing an action-orientated approach to bereavement support. Conclusion Bereavement care incurs practical as well as emotional challenges. Despite positive feedback regarding the emotional support provided by our service, there are practical areas for development. The next step of our project is to incorporate these changes into education and information processing tools, before re-evaluating progress.

Mind the gap: do tertiary cancer centres need 24 hour access to specialist palliative care services?

Background The National Institute for Clinical Excellence recommended that Cancer Networks should provide 24 h access to specialist palliative care telephone advice. The Manual of Cancer Services 2004 suggested that a telephone advice service should be available to core members of cancer MDTs. Clatterbridge Centre for Oncology is a tertiary cancer centre with more than 7000 new patients every year. A specialist palliative care service is available 7 days per week 9–5 but the 24 h access is provided by an informal arrangement with a single clinician. Healthcare professionals working in tertiary cancer centres often have an increased knowledge of palliative care and it has been suggested that 24 h access to specialist advice may not be as important as for district general hospitals. Aim To explore the views of healthcare professionals working in a tertiary cancer centre about the need for 24 h access to specialist palliative care advice. Method A questionnaire was distributed to healthcare professionals in a tertiary cancer centre asking for their views on: areas of concern use of current informal advice provision impact of advice on patient care. Results The questionnaire was distributed to 129 staff. The response rate was 47%. In the previous 4 weeks advice had been required on 46 occasions. 54% of staff had requested advice. 97% found the advice very helpful.100% felt that the advice had a positive impact on patient care. Conclusion This survey demonstrated that staff in a tertiary cancer centre had palliative care educational needs and valued access to specialist palliative care advice believing that it had a positive impact on patient care.

Clinical innovation through leadership development

Background Senior clinicians and managers are at the forefront of innovation within Palliative Care. This places significant demands on professionals who need specific skills to maximise their effectiveness and their impact in the clinical workplace. Merseyside and Cheshire Cancer Network funded a Leadership Impact Programme for Consultants in Palliative Medicine. This links leadership style directly with engagement, wellbeing and performance which in turn helps individuals to encourage change and innovation in their organisation. Method Diagnostic management tools, participation in a coaching centre with feedback, development workshops, and peer support. Subsequent Action Learning Sets over 12 months then facilitated participants to use their skills to produce change and innovation in their workplace. Discussion/Conclusion The course was designed to meet the needs of the individuals and the group in general. Participants included seven senior clinicians and two senior clinical managers Evaluations were extremely positive with many specific examples of how learning and experiences from the course had impacted on clinical services across a range of organisations. 100% of participants felt the programme had met their personal objectives either very well or completely. All reported a marked improvement in strategic awareness and ability to influence. Results included enhanced team development and leadership leading to integration and improved communication; ability to deliver significant change in an organisation; sharing of new ways of tackling challenges and the commitment to collaborative ventures which were both cost effective and innovative The success of the programme has encouraged the Network to support a second 12 month course for a further cohort of senior clinicians.

Risk register: an integrated governance approach

Introduction While risk management is an integral component of high quality care it can be difficult to demonstrate effectiveness. A key aim of the Hospice Business Plan was to devise and develop a Risk Register that could incorporate Fundraising and Clinical activities as part of an Integrated Governance Framework. Aims ▶ To produce a Risk Register to identify areas and work practices most at risk ▶ To implement a Risk Register to minimise risks that could affect the running of the Hospice ▶ To use a Risk Register to monitor effectiveness of actions/initiatives. Methods ▶ Literature review ▶ Risk Matrix ▶ Risk scoring process ▶ Audit cycle. Example Risk Date Governance Area Description of Risk concern (x,y,z) Potential Impact including current controls Risk Score (Pre) Risk control processes to reduce or transfer risk Date for completion Risk Score (Post) Likelihood rating Impact rating RISK. Clinical effectiveness Administration of bisphosphonate infusions without adequate checks causing harm Patient condition compromised Develop hospice policy on bisphosphonate infusions with flow chart Training and education for nursing and medical staff Distribution of new regional audit guidelines Audit to check on process Results ▶ Organisational risks were identified and scored using likelihood and impact ratings ▶ Risks were categorised into seven key themes ▶ Potential impact including current controls were described ▶ Risk control processes to reduce/transfer risk were shown for each individual risk ▶ Following intervention 86% of high risks were significantly reduced within a 7 month period. Conclusions ▶ Use of a Risk Register clearly demonstrates effectiveness ▶ Heightened awareness; risk is everyones business ▶ Audit has shown improvements in identifying risks ▶ Strengthened communication across fundraising and clinical services. Recommendations ▶ Understanding of Risk Register to be part of induction training ▶ Use of Register needs to be an ongoing process and should be regularly monitored and updated.

Sign on the dotted line: opioid agreements in patients with a history of substance misuse

Introduction The management of pain in palliative care patients with a history of substance misuse can be challenging. Patients may have a low pain threshold, feel ill at ease in unfamiliar clinical environments and consequently compliance can be poor. Doctors may feel ill at ease prescribing opioids due to fears of exacerbating the addiction or contributing to overdose. Following a regional audit of the management of this patients group, regional guidelines were developed recognising the importance of close working between disciplines and the use of opioid agreements. The development of opioid agreements with patients can improve compliance and quality of life. Aims A reflection on our experiences introducing verbal and written opioid agreements within the palliative care setting. Methods Opioid agreements were utilised with two patients with cancer pain and a coexistent history of substance misuse, in both inpatient and outpatient settings. Written and verbal contracts were used detailing expectations of the patient, role of healthcare physicians, and the plan of care. Results The staff observed improvement in compliance with medication, relationships with staff members and symptom control. The agreements facilitated communication between the hospice, primary care, community pharmacy, and the addiction team. Conclusion Introducing opioid contracts to this group of complex patients ▶ Set clear boundaries for the patient and staff involved in their care ▶ Improved compliance and consequently relationships between patients and staff ▶ Empowered patients to take responsibility for their own analgesic management ▶ Facilitated clear communication between the numerous healthcare professionals involved in the patients care. We feel that the use of opioid agreements with patients with a history of substance misuse has improved the patient experience.

Meeting the need of general practitioners for palliative care education

Introduction The care of patients with advanced illness is now shifting into the community setting. As a result general practitioners will provide the majority of care for these patients but often lack the confidence and experience to deal with increasingly complex problems. Local GPs identified the need for education in palliative care. However workload can make the provision of education in an acceptable format with good attendance can be a challenge. The aim of this educational initiative was to offer an up to date, relevant and enjoyable course for doctors which improved knowledge, developed skills and influenced practice. The format was also designed to develop closer working relationships between specialists and generalists. Method of delivery A survey was conducted among local doctors asking for opinions on the need for palliative care education and optimum methods of delivery. The resulting education course was delivered by specialist palliative care professionals one evening a month for 6 months. Each session focused on a different aspect of symptom control and included pain, vomiting, emergencies, agitation, depression/anxiety/dyspnoea. A seminar was followed by small group workshops for case discussion. Results 42 doctors registered for the course and 75% attended all 6 sessions. There was evaluation of individual sessions and the course as whole. Results for relevance and appropriateness were excellent. Each session influenced practice for the majority of delegates and fully met the expectations of the participants. The course allowed extensive networking and has resulted in closer working relationships. Conclusion There is a demand for education in symptom control among generalists working in the community. Traditional ways of delivering education can be extremely successful in terms of acceptability and impact. Consultation with local practitioners is key in providing a successful education initiative.