Ambulatory home chemotherapy programme – a success story
“Chemotherapy requiring multiday or continuous infusions has traditionally been administered in inpatient settings or in day wards in hospitals. In recent years, the practice is shifting towards administration of chemotherapeutic agents via different routes, including intravenous, subcutaneous or oral administration at home, with or without on-site supervision by a nurse,” said Mak. [Boothroyd L, Lehoux P. Home-Based Chemotherapy for Cancer: Issues for Patients, Caregivers, and the Health Care System. AETMIS: Montréal, 2004; Health Serv Deliv Res 2015;3:14]
This shift is partly driven by an increasing incidence of cancer in Hong Kong. According to data from the Hong Kong Cancer Registry, the incidence of cancer is increasing at an average rate of 2.9 percent per year, with 30,318 new cases being diagnosed in 2015 alone. [http://www3.ha.org.hk/cancereg/pdf/overview/Summary%20of%20CanStat%202015.pdf] “This has resulted in a 6.4 percent annual increase in patient attendance for chemotherapy at public hospitals, an overwhelming workload for healthcare professionals, and an increased demand for hospital beds. The increase in demand for oncology services has been particularly huge since 2015. Home chemotherapy has thus become a practical solution for healthcare professionals to cope with the situation of packed day centres and tight hospital bed supply,” said Mak. [Hospital Authority Executive Information System]
Benefits and impact of home chemotherapy service
PWH introduced the use of portal infusion device in treatment of multiple myeloma using the combination chemotherapy regimen of VAD (vincristine + doxorubicin + dexamethasone) as early as in the 1990’s. As experience accumulated, the use of portal infusion device was then extended to the treatment of colorectal cancer (CRC) using combination chemotherapy regimens such as FOLFOX (folinic acid + 5-FU + oxaliplatin) or FOLFIRI (folinic acid + 5-FU + irinotecan), with or without anti-epidermal growth receptor (EGFR) antibodies such as cetuximab or panitumumab, giving cancer patients the option of receiving chemotherapy at home through a portable infusion device. (Figure 1)
“A cohort study in 102 CRC patients treated at PWH showed considerable quality of life benefits with ambulatory home infusion compared with inpatient infusion of chemotherapy,” said Mak. [Int J Nurs Pract 2010;16:508-516]
“Besides higher work efficiency with home chemotherapy, obviating the need for hospitalization has resulted in significant cost savings, reduced treatment delays due to unavailability of inpatient beds, and reduced patients’ risk of acquiring nosocomial infections. The waiting time for treatment beds has decreased from an average of 4 days [before implementation of the service] to 1 day, while the average duration of hospital stay has shortened from 49 hours to approximately 3 hours even for patients on anti-EGFR antibodies plus FOLFOX or FOLFIRI,” Mak pointed out. “With the home chemotherapy programme in place, the number of saved inpatient bed-days has increased from 919 to 1,310 despite an increase in patient attendance numbers from 450 in 2016 to 641 in 2018. The reduced bed occupancy means that hospital beds can be reallocated to patients with greater need for inpatient care, such as those requiring more intensive care or palliative care.” [Support Care Cancer 2011;19:971-978; Clin Microbiol Rev 2011;24:141-173; J Oncol Pharm Practice 2002;8:97-103; Int J Nurs Pract 2010;16:508-516]
A 2018 survey in 22 patients receiving ambulatory home chemotherapy from PWH revealed a high level of satisfaction with the service. (Figure 2)
Components of an effective ambulatory chemotherapy programme
“Multidisciplinary collaboration is crucial for the provision of ambulatory home chemotherapy to patients. Protocols and guidelines providing a well-structured mechanism with clearly defined workflow involving oncologists, vascular surgeons, nurses and pharmacists, together with good communication among team members, are critical for the smooth delivery of the service,” said Mak. (Figure 3)]
“The most common problems during chemotherapy delivered through peripheral cannulation are thrombophlebitis and pain. To solve this problem and facilitate home chemotherapy, implantation of a central venous catheter is needed to allow concentrated drugs to directly enter the central vein and become rapidly diluted by blood, which protects peripheral blood vessel walls from drug irritation, thereby solving the problems of drug extravasation and pain,” Mak continued. “Therefore, patients prescribed FOLFOLX or FOLFIRI by oncologists are sent to the oncology nurse clinic for prechemotherapy assessment and counselling. Patients deemed fit for home chemotherapy will be referred to Dr Yih and her vascular surgery team for central venous access device [CVAD] insertion.”
“Reliable central venous access is crucial for patients who need continuous infusion of chemotherapy. At PWH, CVAD insertion is done in the operating theatre or in the treatment room of the day ward by a vascular surgeon,” said Yih.
“If implantable port or Hickman tunnel catheter is chosen as the mode of infusion, the insertion procedure would need to be done under local anaesthesia in the operating theatre,” explained Yih. “If peripherally inserted central catheter [PICC] is chosen, catheter insertion could be done in the operating theatre or in the treatment room of the day ward, as we do not need to surgically make a pocket for port insertion and the tunnel for the catheter.”
“The advantage of performing CVAD insertion in the operating theatre is that X-ray facilities are available on the spot for us to check that the catheters have been positioned correctly. If the procedure is done at the day ward, the patient will be sent to the X-ray department separately for checking of inserted catheter position,” she noted. (Figure 1)
Equipment, staff training and practice review
Reliable equipment is also important for maintaining the service. At PWH, portal infusion devices from two different brands, including programmable infusion pump (electronic) and elastomeric infusion pump (nonelectronic), are used to enhance flexibility while keeping the service uninterrupted when various situations arise.
To ensure smooth operation of the ambulatory home chemotherapy service, a dedicated team with expertise in chemotherapy administration, CVAD and portal infusion device manipulation, troubleshooting and emergency management is indispensable. Therefore, training, audit, and practice review and update should be conducted regularly for staff involved.
Patient and caregiver counselling/education
“To enable patients and their caregivers to better cope with chemotherapy at home, assessment and counselling are provided at the oncology nurse clinic on topics such as management of treatment-induced side effects and symptoms, care of the implanted CVAD and ambulatory infusion device at home, simple troubleshooting and management of emergencies such as drug spillage or disconnection of the tubes, as well as do’s and don’ts while on ambulatory home chemotherapy,” said Mak.
“Patients are concerned about whether and how they would be able to carry out normal daily activities while having the pump on their bodies. To address these concerns, we educate them on the precautions they should take, how to check whether the pump is delivering medication into the body, how to protect their devices when taking a shower, and where to position the pump and catheters when they sleep,” explained Mak. “One important precaution is that the pump should be kept at room temperature at all times so as not to affect the infusion flow rate. Therefore, patients should not go for sauna or steam baths. Patients and their caregivers are also given information booklets and materials to aid them in self-care at home.”
Importantly, a dedicated number is provided for patients to call in case of emergencies when they encounter problems with their pumps and are not able to troubleshoot on their own. “Patients are advised to go to the hospital immediately or to the Accident and Emergency Department [A&E] after office hours if their body temperature rises above 38oC twice within an hour. Those at risk of neutropenic sepsis, are given an alert card so that they would be given immediate attention when they present to the A&E,” said Mak.
Patient and CVAD selection
“During prechemotherapy assessment at the nurse clinic, patients are assessed on whether they understand and are suitable for home chemotherapy. Generally, they need to be mentally and cognitively fit enough to care for themselves,” said Mak. “There is no financial means assessment. Patients living alone are eligible as long as they have access to phone calls for emergencies.”
“When choosing the type of CVAD and size of catheter for patients, we need to consider several factors. For example, if frequent blood taking is required, a double-lumen catheter would be more appropriate [ie, one tip for blood taking and the other for infusion]. Hence, the Hickman catheter would be preferred for haematology-oncology patients. If patients require stem-cell treatment, catheters with wider lumen would need to be used,” said Yih.
“The implantable port goes completely under the skin and hence, there are no protruding tips or tubes hanging from the body. As such, it allows patients to carry out normal daily activities, such as taking a shower, more conveniently, although it requires surgical insertion and stitching of the incision wound. PICC has the advantage that insertion can be performed in a treatment room, which provides greater flexibility in scheduling,” Yih explained.
Hurdles to overcome and moving forward
“Other than a rare few cases that were more challenging, we have not encountered major problems in the ambulatory home chemotherapy programme so far as we review our practice continuously and have taken measures to prevent potential issues. For example, to minimize problems due to incidental clamping of the infusion tubing causing probable treatment interruption, we work with frontline staff to revise the workflow, resulting in changes in both staff and patient habit in infusion tubing handling,” said Mak.
“We hope our experience in the ambulatory home chemotherapy service can be shared with others, especially since inpatient bed shortage is common in all hospitals,” said Yih.
“The lack of a dedicated vascular surgery team to provide reliable and safe venous access may be one of the reasons why some hospitals in Hong Kong do not offer home chemotherapy. However, other specialties could be involved to perform CVAD insertion,” Yih suggested. “For example, interventional radiologists could perform PICC insertion as they have equipment in the department to ensure that the insertion is done accurately, while general surgeons could perform implantable port insertion. In mainland China, PICC insertion is done by oncology nurses in the day ward at some centres as line insertion is relatively not difficult, requiring expertise and experience mainly in handling needles, guide wires and catheter insertion.”
“Moving forward, we are exploring the feasibility of including treatments other than FOLFOX and FOLFIRI for ambulatory home chemotherapy, due to the positive feedback we have received from patients and the positive impact we have seen on the healthcare system,” said Mak.