CONCISE COMMUNICATION BJD British Journal of Dermatology Self-administration of hospital-based narrowband ultraviolet B (TL-01) phototherapy: a feasibility study in an outpatient setting S. Yule, S. Sanyal, S. Ibbotson, H. Moseley and R.S. Dawe Photobiology Unit, Department of Dermatology, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, U.K. Summary Correspondence Susan Yule. E-mail: susan.yule@nhs.net Accepted for publication 7 March 2013 Funding sources None. Conflicts of interest None declared. DOI 10.1111/bjd.12312 Background Self-administration of narrowband (TL-01) ultraviolet (UV)B phototherapy by patients at home is a safe and effective mode of treatment. Could selected patients self-administer phototherapy in hospital? Objectives To assess the feasibility of outpatient self-administration of UVB phototherapy as a potential service development. Methods A total of 20 patients with psoriasis (n = 15) and eczema (n = 5) (13 female, mean age 32 years, range 17 56 years) were included in this pilot project. Patients underwent a training programme over 2 days, which included a minimal erythemal dose test and supervised treatment, prior to commencing self-administration of phototherapy. Questionnaires were used to gather feedback from patients and staff. Results Treatment data were collected for 18 of the 20 patients. The mean number of exposures was 25 (range 3 45), and the mean cumulative dose was 16 J cm 2 (range 023 4127 J cm 2 ). No unexpected adverse effects were noted. These results were similar to those of a sample group of outpatients who had nurse-administered UVB phototherapy, for whom the mean number of exposures was 24 (range 4 49) and the mean cumulative dose was 17 J cm 2 (range 053 7116 J cm 2 ). Thirteen patients completed the questionnaires. All concluded that the training programme sufficiently prepared them for selfadministering phototherapy, and 12 reported that they would be happy to selfadminister treatment in the future. Conclusions Self-administration of UVB phototherapy is practicable, safe and effective for most selected patients. This mode of treatment provides training and support for patients to gain more control over management of their skin disease, empowering them to take an active role in their treatment. Self-administration of UVB phototherapy by outpatients provides an intermediate level of care between nurseadministered hospital phototherapy and self-administered home phototherapy. What s already known about this topic? Self-administration of ultraviolet (UV)B phototherapy by patients in the home environment is as safe and effective as nurse-administered UVB phototherapy in the outpatient setting. UVB phototherapy administered by patients at home has been shown to increase patient satisfaction and lead to a lower burden of treatment compared with hospital-based phototherapy. Other physical treatments such as haemodialysis administered in hospital, and sometimes at home, are now also self-administered by selected patients using equipment sited in hospitals. 464
Self-administered hospital phototherapy, S. Yule et al. 465 What does this study add? This is the first clinical study showing that self-administration of UVB phototherapy by outpatients is a safe and effective mode of treatment for selected patients. Self-administration of phototherapy empowers patients to take a more active role in the management of their skin disease. The availability of phototherapy for patients would be further enhanced with the use of a dedicated UVB cabinet for self-administration of treatment. Nursing time is saved during a course of self-administered treatment, which may help to increase the efficiency of the phototherapy department. Self-administered ultraviolet (UV)B phototherapy at home is as effective and safe as UVB phototherapy administered in an outpatient department. Home UVB phototherapy gives greater patient satisfaction and leads to a lower burden of treatment than hospital therapy. 1 In the photobiology unit in Dundee, we have 14 years of experience in home phototherapy, providing training to enable selected patients to self-administer narrowband (TL-01) UVB phototherapy at home using Waldmann UV100 units (Herbert Waldmann GmbH, Villingen-Schwenningen, Germany). 2 Self-administration of phototherapy by outpatients would provide an intermediate level of care between those patients requiring closely supervised nurse-administered treatment and those administering treatment to themselves at home. Self-administration of UVB phototherapy by outpatients has not previously been reported. However, there are other types of treatment that patients self-administer at home and in hospital, such as immunoglobulin therapy, haemodialysis and peritoneal dialysis. 3 5 The Healthcare Quality Strategy for National Health Service (NHS) Scotland was the NHS driver for change that encouraged us to undertake this pilot project. 6 We wanted to empower our patients to take a more active role in shared decision making, thus encouraging self-management of disease, which is of particular importance in chronic disease management. Shift work and demanding lifestyles can make it difficult for patients to fit in with treatment appointment times. Self-administration of phototherapy could provide this group of patients with more flexibility when attending for appointments, and help reduce the overall time they spend in the department. It also has the potential to reduce pressure on nursing staff, allowing them more time to spend with those patients who require a greater level of care. The main objective of this study was to assess the feasibility of outpatients self-administering narrowband (TL-01) UVB phototherapy as a potential service development. We assessed the adequacy of the patient training programme, safety, efficacy, compliance, and satisfaction rates among patients and staff. Materials and methods For this pilot study patients referred only for whole-body narrowband UVB phototherapy for psoriasis and atopic eczema were invited to participate. Patients were free to withdraw from the project at any time during the treatment course, and have phototherapy administered by the nursing staff. Local management were consulted and they had no concerns. Formal ethical approval was not required for this service development project. The training programme, which included a minimal erythemal dose test and one supervised treatment, was adapted from our home phototherapy patient training programme. Patients were trained by the phototherapy nurses over 2 days in safe self-administration of the treatment, accurate recording of the treatments and reporting of adverse effects. The patients then continued to self-administer treatment. If required, further treatments were supervised, depending on the needs of the individual. For this project, self-treating patients attended the Ninewells outpatient phototherapy treatment centre. One of the whole-body UVB phototherapy cubicles, also used for conventional nurse-administered treatment, was used for this project (Fig. 1). Maintenance and cleaning of the unit was carried out as per standard departmental practice. To monitor progress and compliance, each patient was reviewed by a phototherapy nurse after the first week of treatment, and every 2 weeks thereafter throughout the treatment course. Patients kept their own treatment recording sheets, which were assessed by the phototherapy nurses at review visits to ensure compliance and accurate recording of treatment. The treatment regimen followed the standard departmental protocol with treatment three times weekly. Treatment time sheets, showing 20% and 10% incremental treatment time scales (patients started with 20% increments, reducing to 10% increments following erythema) were adapted from those used for nurse-administered phototherapy (Fig. 1). In the event of adverse effects such as erythema, the patient was asked to inform the nurse prior to administering the next treatment to ensure clinical assessment and advice on treatment time adjustments.
466 Self-administered hospital phototherapy, S. Yule et al. Fig 1. Treatment times only were shown (with doses removed to prevent possible confusion) on the treatment time sheet displayed on the self-administration phototherapy cabinet. The Waldmann UV5001 phototherapy cabinet was used as it allows the patient to programme the treatment time before entering the cabinet, with treatment starting once the patient is inside and the door is closed. Patient and staff feedback questionnaires (Table 1) assessed (i) the effectiveness of the training programme and usability of the accompanying documentation, (ii) concerns that the patients and staff may have had about the treatment, and (iii) opinions regarding the overall feasibility of self-treatment as a potential service development. Results Of the 15 patients who completed their course, one failed to return her treatment sheet and the treatment outcome is unknown (Fig. 2). Six patients cleared, seven patients achieved minimal residual activity and one had moderate clearance (atopic eczema). Of the 18 patients on whom relevant data were available, the mean number of exposures was 25 (SD 9, range 3 45) and the mean cumulative dose was 16 J cm 2 (SD 11, range 023 4127 J cm 2 ). These results are very similar to a sample of 16 consecutive patients having nurse-administered outpatient phototherapy from January 2011, for whom the mean number of treatments was 24 (SD 7, range 4 49) and the mean cumulative dose was 17 J cm 2 (SD 17, range 053 7116 J cm 2 ). The nursing time required for patient training was less than initially anticipated. The typical time for training a patient was 1 h over the 2 days. The total nursing input required for a self-administered course was 1 h 45 min: training (1 h), review visits (25 min) and further advice during the course (20 min). Conventional nurse-administered treatment typically requires 3 h 15 min of nursing time: explanation of treatment and orientation to the treatment area (50 min), treatment visits (2 h 5 min) and advice (20 min). Adverse events Fourteen episodes of grade 2 (well demarcated) erythema were recorded among eight patients. Two developed polymorphic light eruption during the treatment course. There were no episodes of more severe erythema, and no unexpected adverse effects. This frequency of grade 2 erythema was similar to that for contemporaneously, conventionally treated patients, with 15 episodes among nine patients in the sample group. Table 1 Patient and staff questionnaires Patient feedback (n = 13) Training Problems Treatment appointments Nursing support Use of a dedicated UVB cabinet Future treatment Staff feedback (n = 4) Training Compliance issues Use of a dedicated UVB cabinet Feasibility as a service development All patients felt training was sufficient. Two would have liked more guidance with administration of phototherapy and equipment operation Four patients encountered problems during the treatment course. Examples given were erythema and a broken ultraviolet (UV)B lamp None felt rushed or under pressure when attending for treatment All patients felt able to ask the nurses for advice Seven patients felt a dedicated phototherapy cabinet would be useful, stating that this would mean a more efficient use of time and resources, help make the treatment process quicker, and possibly free the phototherapy nurses to assist other patients Of the 13 respondents, 12 would be happy to self-administer phototherapy in the future Two nurses felt the length of the training programme was adequate. Two felt the duration of training depended on the individual patient. Three of the nurses suggested releasing staff from their other duties for a longer period in order to train patients Issues highlighted among patients were: failure to report episodes of grade 1 erythema (six), confusion with treatment times (one), forgot treatment recording sheets (two), failure to return treatment sheets (two) and incomplete documentation (two) Two nurses felt a dedicated cabinet would be beneficial. Two nurses were unsure, with concerns raised regarding appropriate site of a separate cabinet (area outside the phototherapy unit suggested) Two nurses felt this was feasible as a service development. Concerns were raised about the suitability of some patients, and the need for a dedicated UVB cabinet
Self-administered hospital phototherapy, S. Yule et al. 467 Fig 2. Flowchart showing patient screening and recruitment details. Satisfaction Thirteen of the 20 patients completed feedback questionnaires (Table 1). Ten of these had previously received conventional outpatient narrowband UVB phototherapy. In July 2012, questionnaires were issued to the four phototherapy nurses responsible for training and reviewing the patients who took part in the project (Table 1). Discussion Self-administration of UVB phototherapy by outpatients was safe and effective for most selected patients, and required less nursing input. It was not suitable for everyone, even for those whom we had expected to manage with this treatment approach. This approach to care is a way of providing education and training to patients, and supporting them to gain more control over management of their skin disease, thus empowering them to take a more active role in their treatment. There is good evidence to suggest that promotion of self-management of chronic diseases can lead to improvement in health-related outcomes. 7 9 Having a group of carefully selected and trained patients to self-administer phototherapy has the potential to reduce pressure on phototherapy nurses, allowing them to provide more input for those patients who require a greater level of nursing care and supervision. A dedicated UVB cabinet, as suggested by both patients and staff, would provide patients with more flexibility when attending for appointments, helping to reduce the time spent in the department and increasing the efficiency of the existing phototherapy service. Also, if such a cabinet can be appropriately sited (such as on the dermatology ward), this would make treatment available to appropriate patients 24 h a day, 7 days a week. This is currently being implemented. This plan has the support of local NHS management. No legal issues beyond those pertaining to other supervised patient-administered treatments have been identified. With any treatment selfadministered by patients there is a possibility of accidental (or deliberate) administration of incorrect doses. A serious event occurring due to an overdose may be less likely to have serious consequences than with some other interventions (for example, patient self-administered oral methotrexate). However, appropriate patient selection and education is clearly important. The maintenance and cleaning of a ward-sited unit will be supervised by dermatology nurses and medical physics staff. Narrowband UVB phototherapy is an effective and safe treatment for many conditions. One disadvantage when compared with more toxic and expensive systemic treatments is that access may be difficult in some areas. An overall policy of promoting access to phototherapy through sufficient hospital units (in Tayside we have four separate hospital phototherapy outpatient services), adequate opening hours and a supervised home phototherapy service allows more patients to benefit from phototherapy than would otherwise be possible. A dedicated unit for self-administration of phototherapy treatment based in a dermatology ward would (i) allow some patients not currently able to access phototherapy to have this treatment, and (ii) further empower patients and encourage selfmanagement in a cohort with various chronic skin diseases. This would likely be cost-effective; a small narrowband UVB unit can be purchased for around 3000. The Tayside dermatology service serves a population of approximately 500 000, and in the last year treated 1500 patients with phototherapy (data retrieved from photonet
468 Self-administered hospital phototherapy, S. Yule et al. database). 10 Even if only a few of these people are suitable for self-treating we estimate that a dedicated unit for self-administration of treatment could easily be used by 100 patients per year (both existing patients and those previously unable to access current phototherapy services). The introduction of self-administered hospital phototherapy is a further development in the process of increasing the availability of phototherapy to patients. We currently continue to offer self-administration of phototherapy to selected patients attending our outpatient treatment centre. This is open only 7:30 18:00 h, Monday to Friday, and on Saturday mornings; our dermatology ward staff are about to undergo training to allow them to supervise patient self-administered phototherapy safely and in a treatment unit that will be sited within the constantly staffed dermatology ward. We will continue to assess the efficacy, safety and economic aspects of this service development. Acknowledgments We are grateful to Professor James Ferguson, Consultant Dermatologist, and June Gardner, Clinical Trials and Project Coordinator, for their advice and support, and to all the staff involved in the project. References multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009; 338:b1542. 2 Cameron H, Yule S, Moseley H et al. Taking treatment to the patient: development of a home TL-01 ultraviolet B phototherapy service. Br J Dermatol 2002; 147:957 65. 3 Gardulf A, Nicolay U. Replacement IgG therapy and self-therapy at home improve the health-related quality of life in patients with primary antibody deficiencies. Curr Opin Allergy Clin Immunol 2006; 6:434 42. 4 Wong J, Migram P, Halifax NVD et al. Patients experiences with learning a complex medical device for the self-administration of nocturnal home hemodialysis. Nephrol Nurs J 2009; 36:27 32. 5 Su CY, Lu XH, Chen W, Wang T. Promoting self-management improves the health status of patients having peritoneal dialysis. J Adv Nurs 2009; 65:1381 9. 6 The Scottish Government. The Healthcare Quality Strategy for NHSScotland. Available at: http://www.scotland.gov.uk/ Resource/Doc/311667/0098354.pdf (last accessed 4 April 2013). 7 Deakin TA, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2005: CD003417. 8 Garcia-Alamino JM, Ward AM, Alonso-Coello P et al. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev 2010: CD003839. 9 Gibson PG, Powell H, Wilson A et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2002: CD001117. 10 National Health Service Scotland. Photonet National Managed Clinical Network for Phototherapy in Scotland. Available at: http:// www.photonet.scot.nhs.uk/index.htm (last accessed 4 April 2013). 1 Koek MB, Buskens E, van Weelden H et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic