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Sunday, March 16, 2008

Routine Monitoring Visits

Routine or Interim Monitoring visits are basically any visit that occurs after the site is initiated and up until the site is closed out. As monitors, we visit our sites periodically to ensure that they are compliant with all the regulations, subject safety is being adequately followed, data is being captured in a timely and reliable manner, the Investigational Product is being handled as per protocol and relevant regulations/guidelines, there are no significant deviations from the planned study protocol, all important study documentation is being generated and stored properly, and that the research site is adequately supplied in regards to lab kits and other pertinent study materials. The ultimate purpose of our job is to protect subject safety by monitoring the trial conduct for ICH/GCP compliance.

When planning your monitoring visits
it is helpful to have a reasonable expectation
of how think the medical records and source
documents will be. Know in advance how much
you will need to review so you budget enough
time to successfully complete your objectives.
Your agenda from visit to visit may vary slightly based on the length of the study and how many times you plan to visit, the amount of time you spend to plan at the site for this particular visit, the site's progress to date (if a site has yet to enroll any subjects you surely won't have any CRFs to review or pull), and where you are at with the general monitoring plan (for example, drug accountability may be done all along or just at close-out).

Prior to your visit you will contact the site to set up a suitable time for your visit. Visits typically last a day or two. Ideally, the PI would be available to meet with you during the visit. You will send a confirmation letter to the site once a date is set (be sure to confirm the address before you go if you haven't been there before!). More often than not, your study lead will provide you with a monitoring visit checklist or at the very least, a monitoring report template so you will know exactly what tasks you are expected to perform on-site and what topics to cover. Here are some of the specific tasks that are routinely performed at these visits:
  1. Informed Consent Form (ICF) review: You are ensuring that every subject was adequately informed and consented to the study before any study procedures were completed (I recommend checking lab draw times and ECG times - if required at the screening visit - against the consent time to be extra sure that the consent was the first study procedure to occur). There are other state specific regulations you will need to know and monitor for. For example, in some states subjects must be 19 to participate and in California every subject must sign the 'CA Bill of Rights' document, etc. Sometimes there are multiple versions of a consent due to a change in the facility address or the details of the protocol. Ensure that all subjects signed on an IRB approved version (each page will be stamped in the upper right hand corner and the version date will be printed on each page). Proper consenting of subjects is critical to ensure the security and privacy of health data and that subjects are adequately informed of the study procedures, risks and, benefits. If the consent is not signed or properly completed inform the Study Coordinator and do not review this subject's medical chart until consent has been properly obtained.
  2. Check for Serious Adverse Events (SAEs): Per the guidelines, an SAE is any untoward event that results in death, prolonged or new hospitalization (longer than 24hrs), significant disability, or congenital anomaly (birth defect). If the event has not been reported, assist the Study Coordinator in doing so and inform the sponsor immediately.
  3. Review Protocol Compliance: In your chart and source document review, you can verify that subjects were sign at the right times and the right procedures were conducted as per the protocol. You will have study-specific procedures for reporting deviations. Deviations of a serious nature may be reported in an expedited manner and may need to go to the IRB (dosing errors, unblinding of study treatment, subject enrolled that did not satisfy entry criteria, etc.)
  4. Compare source documents to Case Report Forms: You are checking that the data in the chart matches the Case Report Forms (which will be later entered into the clinical database and combined with other subject's data to complete the safety and efficacy analysis for the Investigational Product). Determine whether or not CRFS being completed in a timely manner. You also want to verify that the source is complete, neat (all corrections must be compliant with the regulations - white-out is not OK), attributable (who wrote it? Is it initialed and dated), contemporaneous (was it written at the time the procedure was completed?), valid (is the data collected even possible?), etc. Sometimes you will be asked to pull the case report forms and send them in to data management and other times they will stay at the site until the end of the study.
  5. Review Investigational Product (IP): The study protocol will explain how the IP is to be stored, dispensed, and returned. Verify that all of this occurred properly by reviewing temperature logs, storage facilities, administration records, IVRS entries/reports for subject-specific IP accountability, and speaking to the relevant personnel.
  6. Regulatory Binder / Essential Documents Review: Determine if any forms need to be updated or pulled for the Trial Master File (TMF). The TMF is meant to be an exact replica of all the documentation at the site. Specific information regarding the contents of the essential documents binder are covered in section 8 of the guidelines.
  7. Confirm Site Adequacy / Site Status: Determine if there are new staff at the site or if staff have left. Can the site manage with current staff? Has the site or the lab moved? Confirm that there are adequate study supplies
  8. Study-Specific Monitoring Tasks: Depending on the protocol, you may need to perform additional tasks such as shipping materials back to headquarters (for example lab specimens, xrays, etc.), calibrating or reviewing calibrations of equipment, site training, checking eDiary compliance, etc.
  9. Review Ongoing or Pending Issues from Previous Visits: At some point during every visit work with the staff to resolve any items identified at previous visits as ongoing issues. Indicate in your report once these are resolved.
  10. Review of findings with the site: Whether or not you find issues during your visit, keep the site staff posted on your progress and how things are going. Especially, if the Principal Investigator is not available during the visit, be sure to summarize everything accurately and completely in your follow-up letter.
Try to schedule your next (or next several) visits before you leave the site. After the visit, write your report and send the follow-up letter within a week or per your monitoring plan and refer to your company's SOPs. Always report significant compliance issues to your management, the sponsor, IRB, and QA as appropriate. Remember that you must document everything because of the adage, "if it isn't documented, it didn't happen". Please contact me if I can elaborate on anything or if you think I've left something important out.

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NewToo said...

I am new to the CRA role. I understand that different companies have different policies but I appreciate your sharing your experiences. It gives all of us a better idea of what we can expect as we start our new careers. Thank you for now only sharing your experiences but also sharing enough detail so we can be better prepared to follow the same path. The references along the side of the blog are great also. Thanks for all your work.

Anonymous said...

Very nice writing. It is like reading a very interesting story.
One question, is there a template or examples for the follow-up letter? I am thinking when a new CRA starts his/her job, how he/she knows how to write these letters?

Nadia said...

Hi, thanks for your comment and sorry I have been so long to respond! Many people come to my blog looking for templates for confirmation or follow-up letters for monitoring visits. Blogger makes it really difficult to attach word documents (or at least not obvious) but as soon as I come up with an elegant way to do this I will definitely post some examples. Any advice on how to attach a word doc to blogger would be appreciated.

CYC said...

I suggest you can use Google Docs to upload Word documents or PDF files. This is the easiest way to share documents with other people I think.

Anonymous said...

Good description of the proper monitoring visit. Could you please give an advice about how to deal with the "difficult" PI who doesn't want to meet you despite the numerous efforts to persuade him? Any recommendation would be very appreciated!

Anonymous said...

What a great informational website...Quick question: what is industry standard in conducting or determining the last RMV to be performed. Is is based on LPI or LPLV? If so, how many weeks are allocated?

Nadia said...

It seems a bit behind on responding to comments but these last two questions may certainly be of interest to others. I'm going to address them in their own blog posts. Thanks!

Nadia said...

Here is my position on making time to meet with PIs during the visit (link).

Anonymous said...

I have a site really upset with the findings of my FU letter. Any tips on how to handle this?

NadiaBoBadia said...

I try to keep my follow-up letters as brief as possible to avoid exactly this type of friction. If your letter is so sensitive, perhaps your Lead CRA or Project Manager can give you tips to deliver negative information more politically? Perhaps you blind-sided them?

You can extend your visit to resolve items on-site rather than leaving many open action items behind. If the site is upset, maybe they weren't expecting a negative outcome? When you are on-site you should be meeting with the PI and coordinator to review your findings from the visit. The letter should be a recap, not a shock. In this instance, I am hearing that the site was not prepared for a (possibly long?) detailed letter. Remember, you are not going out to audit but instead to partner with the site. Why were they taken by surprise by your letter?

Try viewing this from the site's perspective. If they are upset then it is your charge to help them understand the findings and address their concerns. It sounds like your relationship with the site is at risk; give this immediate attention and bring in the expertise of your Lead or PM to smooth things over as needed.

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