Non-medical prescribing: A nurse-led treatment clinic for myeloma and AL amyloidosis patients

Jackie Quinn, Myeloma Clinical Nurse Specialist at Belfast City Hospital, reflects on setting up the first nurse-led systemic anti-cancer therapy clinic in Belfast Health and Social Care Trust, and how the clinic has developed since. Jackie completed a non-medical prescribing course in 2009 and started the clinic in 2010.

Why was the clinic started?

The clinic was prompted by frail patients struggling to attend up to twice weekly to receive their treatment, and the resultant complaints regarding the long waiting times for treatment. Patients had bloods taken, were assessed, and had their treatment ordered and made up by pharmacy on the same day. Patients noted that there was limited space and comfortable seating available. The Consultant Haematology Team and registrars were frequently called out of clinic or from the ward to assess patients and prescribe treatment on the day unit.

I wanted to set up a safe, high-quality service for myeloma patients, and develop a clinic that would make a difference to patient experience and improve quality of life. The clinic was designed to make better use of consultant time, reduce their presence on the day unit, and support nursing colleagues on the unit itself. Using a baseline patient experience questionnaire, we identified a number of issues. Patients felt there was a lack of communication, and that their concerns were being overlooked. They were experiencing fatigue, exhaustion, and reduced quality of life.

What was the process of setting up the clinic?

Setting up the clinic was very daunting as no nurses had prescribed SACT before in Belfast Health and Social Care Trust. It was difficult to get all stakeholders on board, and there were lots of discussions with medical, nursing and pharmacy colleagues as well as with our Haematology Service Manager. We had to consider policies and legalities within the Trust, as well as practicalities. I initially agreed to proceed with the clinic as a supplementary prescriber, to build up my experience and have the support in place from my practice supervisor. Within a couple of months I was working as an Independent Prescriber. When the clinic was set up I could not prescribe IMiDs (as unable to complete an electronic prescription authorisation form). Mentorship from the Consultant Haematology Team was crucial in establishing the clinic, as was support from pharmacy colleagues.

What does a typical clinic day involve?

Patients have a telephone appointment the day before clinic to assess their fitness for treatment. If well, treatment is pre-ordered, the patient is given a time slot for clinic, and self-administers pre-medications. If unwell and there are concerns around toxicities, an assessment is arranged, or the patient is given an early appointment time to assess fitness for treatment in-person. There is minimal drug wastage as very little tends to change overnight. We’ve stopped using blood tests on the day to inform medication orders. Blood results rarely affected our decision to treat, so we now use results within the previous 7 days.

The clinic runs twice a week on Tuesdays and Fridays with approximately 10-20 patients per clinic. In addition to myself, there are two clinic nurses. Patients range from being on first to fourth line therapy and might receive combination therapy including: subcutaneous bortezomib, daratumumab, carfilzomib, isatuximab and IMiDs (pomalidomide, lenalidomide and thalidomide). They also receive supportive medications such as bisphosphonates and IV immunoglobulins. We have a clinic room for advanced clinical assessment and management of myeloma and treatment-related toxicities, and a nurse allocated for bloods, observations and administration of treatment.

As part of the clinic, I use the MyPos myeloma-specific quality of life questionnaire when patients start treatment, cycle 4 or 5, and end of treatment. If patients score highly on the MyPos questionnaire, I will refer them to colleague Clinical Nurse Specialist Christine Coyle’s Holistic Needs Assessment clinic for further support.

How does the clinic benefit patients?

Patients know who they are seeing, what time to arrive, and that their medication is waiting for them. They benefit from knowing their day will be more structured and that waiting time has been greatly reduced, which has been confirmed by patient experience surveys completed every six months. Patients and their families also emphasise how well supported they feel by the clinic staff.

The telephone appointment on the day before clinic has allowed more time to develop relationships with patients, and for patients to have the opportunity to raise issues. Pharmacy colleagues support patients starting new regimens, and any patients who need additional help with medication or compliance. Patients are reviewed on a more regular basis for side effects, meaning any toxicities are better managed. A designated physiotherapist and occupational therapist have been incorporated into the clinic to provide patients with respiratory exercises and advice on falls prevention and keeping mobile, reducing the need for additional appointments.

How does the clinic benefit colleagues?

The clinic benefitted the medical team immediately be reducing their presence on the day unit, with consultants and registrars no longer called at all. Consultant clinic numbers reduced as eligible patients were transferred to the nurse-led clinic. The clinic also benefitted nurses on the day unit as I became the point of contact for questions, mentoring and learning resource. The workload of the day unit nurses became more structured as they would know in advance if patients needed bloods taken etc. Similarly, colleagues in pharmacy benefitted from receiving pre-ordered treatment and knowing what time patients would be attending. Finally, the clinic provides education and support for junior colleagues, and I teach as part of the in-house SACT non-medical prescribing quality group.

What is next?

The clinic is ever evolving to keep pace with new lines of therapy and delivery methods of treatment. We have moved from intravenous to subcutaneous treatment and offer more oral therapies. We’ve expanded the clinic to provide support to patients on long term therapy, and I’ve honed my skills in managing toxicities to keep patients on track with their treatment. We also now have approval for non-medical prescribers to complete electronic prescription authorisation form for IMiDs. The clinic has limited resources so requires efficiency and innovation, including team work, to run effectively. The clinic has been used as a model of best practice, and going forward I welcome the opportunity to learn from colleagues’ experiences and practice in other centres.

Jackie Quinn
Myeloma Clinical Nurse Specialist
Belfast City Hospital