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Cancer chemotherapy and immunotherapy is associated with infusion reactions, which are unplanned and range from mild, moderate to severe and life-threatening anaphylaxis. This is an oncologic emergency requiring the interdisciplinary team to have a well-developed, evidence-based approach, where all clinicians demonstrate competency and can respond immediately and ensure safe recovery from the reaction. First responders and the support team need to know their roles and responsibilities and depend on others to do the same during emergency reaction management. The purpose of this project was to share one institution's approach in reviewing and updating a hypersensitivity treatment algorithm in an adult ambulatory oncology clinic. An interdisciplinary team (nursing, pharmacy, allergy service) met to review current practice and outcomes associated with acute infusion reaction management. A literature search was conducted to update the algorithm with current evidence-based interventions needing to be adopted. Based on this review, the existing algorithm was updated, clinicians were educated, and a new algorithm was adopted and implemented. Key updates in this algorithm include: a standard grading scale for reaction severity, guidelines for medication administration based on symptoms and severity, when to draw tryptase levels, administration of glucagon for patients not responding to epinephrine taking beta-blockers, significance and appropriate use of epinephrine, when not to re-challenge with causative agent and the documentation of the allergen in the medical record. This presentation will describe the team review of current practice and evidence-based literature, interventions supporting algorithm implementation, the updated algorithm and ongoing implementation support strategies. Clinician education was the main intervention for implementation of a new acute infusion reaction management algorithm. One month before go-live, an online, interactive education module was assigned to nurses, physicians, pharmacists, nurse practitioners and physician assistants. Successful achievement of this education included completion of the interactive module and a passing test score of 100%. Evaluations of this offering will be presented along with ongoing strategies for compliance. Standardizing an approach for acute infusion reactions in oncology is equally as important as the standards in place for providing basic life support. Interventions must be based on evidence, roles and competency must be defined and re-evaluated and the interdisciplinary team needs to be involved at all phases of reaction management. [ABSTRACT FROM AUTHOR]

1. Outline an innovative model for integrating pharmacist-led patient care into a palliative care clinic. 2. Review two patient-centered outcomes that are improved by a pharmacist-led clinic and highlight clinical characteristics of patients who benefit from pharmacy involvement. Pharmacists play several roles within the outpatient palliative care setting, and their involvement in patient care is associated with improved patient safety and clinical outcomes. At Dana-Farber Cancer Institute, pharmacists have participated in co-visits with the primary palliative care clinician since 2001, and in July of 2020, a collaborative drug therapy management clinic, "PharmPAL," was piloted. PharmPAL clinic allows credentialed pharmacists to lead follow-up palliative care visits encompassing patient assessments, counseling, education, ordering of laboratory tests, and prescribing and managing medication regimens. The goal of PharmPAL is to increase access to palliative care by expanding the availability of follow-up care to patients with intense symptom management needs. Primary reasons for PharmPAL referral include new consult requiring close follow-up, education and counseling, stable patient for refill review, schedule availability, and patients with recent or anticipated medication changes. PharmPAL volume has grown from 24 visits in its first quarter of operation to 96 visits in the most recent quarter. We have increased pharmacist availability to support this growth and have plans for further expansion with a third pharmacist joining PharmPAL clinic in 2023. Surveys have confirmed clinician satisfaction with the various models of pharmacist support, and we continue to use feedback to plan pharmacist involvement within the palliative care clinic and PharmPAL. The increase of patient encounters in the pharmacist-led clinic has aligned with a concomitant increase in outpatient clinic volume overall. In this session we will share data around the implementation and growth of this model as well as lessons learned and practical tips around developing a similar model in your own setting. We will further describe two case examples of oncology patients managed in the PharmPAL clinic to demonstrate the comanagement between the pharmacists, oncologists, and palliative care clinicians as well as give examples of patient-related outcomes. [ABSTRACT FROM AUTHOR]

Context: Entrustable professional activities (EPAs) translate competencies into explicit, practical terms that clearly state the expected roles and responsibilities of clinicians who have achieved proficiency and expertise in a field. EPAs are defined for Hospice and Palliative Medicine physicians but not for other members of Hospice and Palliative Care (HAPC) interprofessional teams, including pharmacists.Objectives: The objective of this study was to develop EPAs for HAPC pharmacists.Methods: An 11-member workgroup of HAPC pharmacists was convened to develop candidate EPAs using nominal group and modified-Delphi methods. Content validity index was used as a measure of consensus, defined a priori at ≥ 60%. Vetting occurred via intra- and interprofessional stakeholder reactor groups and a national survey of HAPC pharmacists.Results: Following an iterative process of workgroup and stakeholder consensus-building, 15 HAPC pharmacist EPAs were developed. Among the workgroup, all 15 EPAs reached ≥ 70% consensus, indicating appropriate internal validity. In a national survey of 185 HAPC pharmacists with a 20% response rate, 13 EPAs were rated by most respondents as "essential" and 2 were rated by most respondents as "important but not essential." Respondents indicated the 15 EPA set represented the core professional activities of HAPC pharmacists well (median rating of 5 on a Likert-like scale, IQR 1).Conclusion: Fifteen consensus EPAs describe essential activities of HAPC pharmacists in direct patient care, leadership, education, and scholarship. These EPAs will further guide pharmacist training programs, HAPC services seeking to incorporate a specialized pharmacist on the team, and currently practicing HAPC pharmacists. [ABSTRACT FROM AUTHOR]

1. Review the roles of palliative care pharmacists in the outpatient clinic setting 2. Summarize current practice models in the outpatient palliative care setting 3. Outline the development of PharmPAL and overall clinic metrics Pharmacists play several roles in the outpatient palliative care setting, and their involvement in patient care is associated with improved patient safety and clinical outcomes. At Dana-Farber we have two primary ways that our embedded palliative care pharmacists are involved in clinical care. Pharmacists have participated in co-visits with the primary clinician since 2001, primarily providing suggestions about medication management. In July 2020 a collaborative drug therapy management clinic called PharmPAL was piloted. PharmPAL allows credentialed pharmacists to lead follow-up palliative care visits encompassing patient assessments, counseling, education, ordering of laboratory tests, and prescribing and management of medication regimens. The goal of PharmPAL is to support the palliative care clinic by increasing the availability of follow-up care to patients with intensive symptom management needs. We aimed to determine whether clinicians were satisfied with this pilot or whether it hindered interdisciplinary care by decreasing pharmacist availability for co-visits. Surveys were disseminated to assess clinician satisfaction with the various models of pharmacist support, and we used that feedback to plan future pharmacist support of the palliative care clinic. Primary reasons for PharmPAL referral included new consult requiring close follow-up, education, and counseling, stable patient for refill review, schedule availability, and patients with recent or anticipated medication changes. The main barriers to using PharmPAL involved pharmacist availability. Based on an overwhelming percentage of providers in favor of increasing PharmPAL visits, the weekly availability increased from eight 30-minute appointments per week to twelve 30-minute appointments each week. Increased PharmPAL availability led to a 38% increase in patient encounters in the PharmPAL clinic and an increase in outpatient clinic volume overall. Additional surveys are used to address feedback for ongoing areas for improvement to continue increasing PharmPAL referrals and maintain overall provider satisfaction with pharmacy involvement. [ABSTRACT FROM AUTHOR]

Purpose: There is no consensus in the oncology community about the optimal model for anticoagulation management of ambulatory cancer patients. To understand oncologists’ preferences regarding anticoagulation management, we compared the characteristics of patients referred to an oncology-oriented anticoagulation management service with ‘‘usual care’’ patients managed by the patient’s primary oncologist. Methods: We performed a retrospective medical record review of ambulatory oncology patients’ anticoagulation care at a comprehensive cancer center. We examined the characteristics of 33 patients anticoagulated before implementation of a dedicated oncology anticoagulation management service. We compared this group with 33 patients managed by the anticoagulation management service and with 39 usual care patients managed by the primary oncologist after the anticoagulation management service was created. We also examined differences in laboratory test utilization, time in the therapeutic range (for patients anticoagulated with warfarin), and anticoagulation-related adverse events during a 3-month assessment period. Results: Anticoagulation management service patients were more likely to be treated for hematologic malignancies, use erythropoietin stimulating agents, and require warfarin management for previous venous thromboembolic disease compared to usual care patients. In contrast, oncologists were more likely to manage anticoagulation care of patients with advanced solid tumors undergoing active chemotherapy. Anticoagulation management service and usual care patients on warfarin therapy had comparable time in the therapeutic range and complication rates. Conclusion: Oncologists selectively referred patients to the anticoagulation management service. Anticoagulation management service patients’ warfarin control and complication rates were comparable to care provided by the primary oncologist, suggesting that an oncology-specific anticoagulation management service may be a feasible and effective option for anticoagulation management of ambulatory oncology patients. [ABSTRACT FROM AUTHOR]

1. Identify candidates for topical morphine use in pain refractory to other analgesics and opioids. 2. Describe evidence behind use of morphine gel in palliative care and barriers to use in a practical setting. Opioids are a mainstay of treatment for moderate to severe cancer-related pain. Conventional opioids act on opioid receptors in the central nervous system; however, opioid receptors are also present in the skin, providing an opportunity for their use as a topical analgesic when there is skin breakdown and potentially limiting systemic side effects. Topical morphine has demonstrated effective pain relief in palliative care patients, but its use is uncommon and evidence is limited. As a result, it is not widely available or affordable. Ms. B is a 76-year-old female with a history of recurrent lung adenocarcinoma for which she underwent radiotherapy targeting a left lower lobe mass. After radiation she began to develop skin erosions on her back that caused significant pain and greatly reduced her functionality and independence. She was referred to the outpatient palliative care clinic after seeing multiple other specialists. She had previous trials of acetaminophen, gabapentin (oral and topical), lidocaine (patch and ointment), oxycodone, and intralesional anesthetics, which were all ineffective or resulted in intolerable adverse effects. Due to the size and nature of her lesions, she was a candidate for trial of topical morphine gel. Many logistical barriers were encountered, including availability and cost to the patient from a compounding pharmacy. She reported significant relief at her next visit with palliative care but expressed anxiety regarding whether she would be able to continue to afford it. Studies show topical morphine effectively provides local analgesia in palliative care patients without producing systemic effects, but sample sizes are limited and its use is still rare. This presentation will discuss topical morphine's place in therapy and appropriate patients for its use, as well as highlight the primary barriers to its use including out-of-pocket cost to patients from lack of coverage by most prescription insurance plans. [ABSTRACT FROM AUTHOR]

The article presents the American Society of Health-System Pharmacists (ASHP) guidelines on the palliative and hospice care roles of the pharmacist. Topics include the patient-centered care approach stipulated by the U.S. Department of Health and Human Services, palliative care description by the National Consensus Project for Quality Palliative Care of the National Quality Forum (NQF) as well as medical care tenets endorsed by the World Health Organization (WHO).

As authoritative resources on the optimal use of medications in symptom management, palliative care pharmacists exemplify several clinical, administrative, and educational roles within the outpatient clinic setting. Knowledge of medication-use processes allows pharmacists the ability to improve patient safety and outcomes. In 2018 a quality improvement project to optimize the scheduling of pharmacist-provider joint visits in the Dana-Farber Cancer Institute Outpatient Palliative Care Clinic led to overwhelming Adult Palliative Care (APC) provider satisfaction. Given this success and continued desire for pharmacy collaboration, the "PharmPAL" Clinic was initiated in July of 2020. PharmPAL is a collaborative drug therapy management (CDTM) clinic where credentialed pharmacists lead intermediary and follow-up palliative care visits encompassing patient assessments, counseling, education, ordering of laboratory tests, and selecting, initiating, continuing, and modifying medication regimens. The goal of PharmPAL is to support the growth of the palliative care clinic by providing care to patients with intense symptom management needs through interval visits with a pharmacist within their credentialed scope of practice, increasing the availability of follow-up to patients. Through a survey disseminated to all outpatient palliative care providers, reasons for referral for both joint visits and PharmPAL visits were gathered. Based on an overwhelming percentage of providers in favor of increasing PharmPAL visits, the weekly availability increased from eight 30 minute appointments per week in the first seven months to twelve 30 minute appointments each week. The top five reasons for PharmPAL referral include new consult requiring close follow-up, education and counseling, stable patient for refill review, schedule availability, and regimen or medication change in the previous visit or anticipated in visit. Barriers to utilizing PharmPAL include pharmacist availability, APC scheduling, and out-of-state patients. An increase in PharmPAL availability has led to an increased volume of patients and encounters for both PharmPAL and the outpatient clinic overall. Additional surveys will be employed to address feedback for ongoing areas for improvement in order to reach our goal of a 30% increase of PharmPAL referrals within the first three months and continued improvement in overall provider satisfaction with PharmPAL. As outpatient palliative care clinics are incorporating pharmacist-led visits into practice, identification of outcomes metrics is critical to the ongoing growth of these clinics. Over the next several months we plan to continue to assess the impact PharmPAL has on clinic operations and provider satisfaction in the Dana-Farber Cancer Institute outpatient palliative care clinic. [ABSTRACT FROM AUTHOR]