Context The quality improvement project was conducted at our Haematology and Oncology department. This project was performed with the help of our specialist pharmacist.
Problem There are several adult studies to suggest that one dose of Rasburicase prevents Tumour lysis syndrome (TLS) in high risk patients. The paediatric data on the appropriate use of Rasburicase are limited. Current recommendations from the British Committee for Standards in Haematology (BCSH), suggest that in high risk children, one dose of 0.2mg/kg of Rasburicase should provide adequate prophylaxis for TLS. We audited the practice of using Rasburicase against BCSH recommendations.
Assessment of problem and analysis of its causes The lack of clear guidance in the use of Rasburicase led to multiple doses being administrated. This had a potential increase in drug toxicity as well as financial toxicity to the department. We therefore, decided to conduct a retrospective audit of children receiving prophylactic Rasburicase. The tumour burden was assessed by their total white blood cell count and computed tomography imaging performed on admission. We reviewed the efficacy of Rasburicase in children receiving a single dose and calculated the reduction in financial burden following a single administration. We found that Rasburicase was indicated in 44 out of 53 (83%) patients. Only 37% received a single dose, while the rest had up to five doses. Patients received a single dose had sustained normalisation of electrolytes and uric acid throughout treatment. Three patients received a second dose appropriately as the uric acid level increased by day four. The total cost spent was £62,431 and we calculated that £39,133 could have been saved if a single dose was administrated.
Intervention We developed local guidelines for high risk children emphasising the need for single dose of Rasburicase. This has been disseminated to all medical staff and saved to our departmental folder for future reference. The guidelines include the recommendation of a single dose of Rasburicase at 0.2mg/kg, with appropriately laboratory monitoring and hyper hydration. If a child requires a second dose of Rasburicase, consultant authorisation should be obtained.
Study design Retrospective analysis of 53 patients case record’s received Rasburicase.
Strategy for change This audit was presented at the departmental governance meeting and recommendations were discussed. A copy of our guideline was circulated to all medical staff and pharmacists.
Measurement of improvement This project will be re-audited in 6 months to assess the effect of changes.
Effects of changes Not applicable.
Lessons learnt TLS is an oncological emergency that can occur in haematological malignancies with high tumour burden. Rasburicase is an efficient drug for prophylaxis in high risk children. This audit confirms that a single dose of Rasburicase is cost-saving and as efficient as multiple doses.
Message for others Single dose of Rasburicase is effective in reducing the risk of tumour lysis in high risk children. This approach decreases the cost of Rasburicase by approximately 60%.
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