Lessons learnt from establishing an Acute Oncology service. Dr. Pauline Leonard MD FRCP Consultant Medical Oncologist Whittington Health

Transcription

1 Lessons learnt from establishing an Acute Oncology service Dr. Pauline Leonard MD FRCP Consultant Medical Oncologist Whittington Health Over next 45 minutes.. Lessons learnt from: setting up a new service embedding a new service challenging traditional working practises Share the positive gains for an AOS Highlight the dynamics of an Acute Oncology Service 1

2 Rumsfeld principles... Known knowns NCAG 2009 NCEPOD 2008 National Patient safety alerts oral chemo Known unknowns Scale of the problem for each Trust/network Impact on current Oncology services Unknown unknowns Impact of doing things differently Both positive and negative A key recommendation from NCAG report 2009 Development of an Acute Oncology Service Management of patients who develop severe complications following chemo or as a consequence of their cancer Management of patients who present as emergencies with previously undiagnosed cancer AOS brings together expertise from oncology disciplines, emergency medicine, and general medicine and general surgery 2

3 What is an Acute Oncology Team? Emergency care medical & nursing staff Acute Medical on-take medical team Oncologist Palliative Care Clinical Nurse specialists Chemotherapy nurses AOS brings together expertise from oncology disciplines, emergency medicine, and general medicine and general surgery What is unscheduled care? Unscheduled or urgent care is care for those whose treatment is not planned in advance Examples in cancer Toxicity from treatment Diarrhoea Febrile neutropenia Symptoms from disease Pain Metastatic cord compression Patient with a previously undiagnosed cancer Medical and surgical emergencies not directly related to the underlying cancer 3

4 From the Patient perspective Accessing appropriate and skilled help when unwell Telephone advice Emergency services Delays in recognising complications of treatment or disease progression Timely antibiotics in febrile neutropenia Missed opportunities for intervention to prevent paraplegia in malignant spinal cord compression (MSCC) Poor experience of care Waiting in busy Emergency departments Wrong person sharing results Professional issues Limited access to clinical information on patient Especially out of hours Sometimes patients and their families unaware of prognosis Lack of specialist skills To recognise chemotherapy toxicities Ceilings of care not clear ITU or EOLC Organisational issues Pathways of care Education opportunities Challenging current culture 4

5 Lesson 1: Have a clear vision for an approach Be clear on what an Acute Oncology service is Working with those who deliver acute care to our patients Be accessible Share expertise Provide updated protocols Very clear on what is was not Oncologists in ED Clerking patients Carrying our interventional procedures Communicate experience from previous working practices Able to portray a better experience Attuned to current gaps Lesson 2: Define the role of Oncologist in AOS Sharing expertise in managing Oncological emergencies irrespective of tumour type Sub-specialisation has eroded confidence in generic skills Advisory capacity in how best to proceed in patients who present with a new suspected cancer Where case does not fit into recognised established pathways Individualised treatment plans incorporating PS & comorbidities 5

6 Be clear on what an Acute Oncology Service is not? Seeing patients with a past history of a resected cancer and now present with atrial fibrillation Seeing patients with a vague history and signs e.g. fatigue and anaemia with no clear clinical or radiological evidence of malignancy Acute Oncology should not supersede excellent diagnostic services but play a greater part in further management when malignancy suspected on radiology Lesson 3: Engage key stakeholders with your vision Set aside first 6 weeks after my appointment to meet all key staff from ED & AAU Spent day with Outreach critical care team to understand local landscape and issues Ensured I listened to feedback What was currently not good enough What needed fixing Stayed flexible around personal views My usual response is to solve Aim to deliver the shortfall 6

7 What did the acute clinicians want? Ready access to information on patients Chemo regimen given Treatment intention Patients to be better informed Admitted patients to be prioritised to Mercers Ward Approachable & accessible Oncology input Updated pathways on managing oncological emergencies Next steps Engaged with IM&T Setting up referral systems Setting up Rapid alert systems Discussed with Bed Managers Prioritising all admissions for patients with cancer to a designated medical ward Dr Leonard responsible for in-patient care Started a programme of Education ED Nurses Junior doctors & Medical Consultants 7

8 Used in house systems to bolt on referral systems Engaged with IM&T To set up referral systems using existing software E.g. order comms Sunquest ICE To set up Rapid alert systems To alert staff when known cancer patients on chemo present to ED With known bone mets present with back pain, weak legs Possible to use in house resources Used ACCESS database with PAS & Business Objects 8

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10 Understand workforce available Scope existing expert personnel May already be doing the role without knowing it May have been waiting for a leader Biggest investment required is TIME Starting a new service on top of a busy timetable not do-able Sabbatical for 6 months versus a new appointment Advantages of having someone senior to engage Lesson 4: Data is King 10

11 Understand your local Oncology Landscape Cancer unit with a population 440,000 Within 3 miles of UCLH & RFH 583 new cancer diagnoses in 2008 at Whittington Majority referred via OPA 9.9% self-referred via ED Number of emergency medical admissions per day 30 (25-33) large seasonal variation 1-2 patients with cancer per day Data to understand the usual pathway King et al BMJ Qual Saf 2011;20: Process mapping the patient pathway for medical presentations 59% self referral Delay awaiting procedure Delay awaiting report Delay awaiting MDT A&E Admit Radiology report suggests cancer Refer for endoscopy/ biopsy for tissue diagnosis Cancer confirmed on histology MDT review imaging And histology Refer to oncology 41% GP referral 9 days 1.6 days 34 medical patients presented via ED 2008 and found to have a new cancer diagnosis Median Los 19 days Blood tests 42 Number of tests 3 47% referred to palliative care 26% Oncology 60% upper GI/HPB 11

12 GP/OP referral Two Week Wait Emergency presentation Other outpatient Screen detected Inpatient elective DCO Unknown Total Number of patients Relative one year survival: by cancer type Malignant registrations, South West 2007, excluding multiples and DCOs GP/OP referral (+TWW) Emergency Other route EUROCARE Cancer type Relative Relative Relative Relative 95% CIs 95% CIs 95% CIs Survival Survival Survival Survival Acute leukaemia 39.7 ( ) 39.4 ( ) 40.4 ( ) Bladder 78.3 ( ) 34.0 ( ) 79.2 ( ) 85.3 Brain & CNS 68.4 ( ) 34.0 ( ) 60.6 ( ) 39.1 Breast 97.7 ( ) 50.8 ( ) 98.2 ( ) 95 Colorectal 84.5 ( ) 48.4 ( ) 79.5 ( ) 74.7 Kidney 81.1 ( ) 24.0 ( ) 72.4 ( ) 74.7 Lung 39.8 ( ) ) 32.4 ( ) 36.1 Multiple myeloma 83.6 ( ) 53.1 ( ) 73.0 ( ) 70.5 Non-Hodgkin's lymphoma 86.6 ( ) 43.7 ( ) 80.9 ( ) 73.1 Oesophagus 43.8 ( ) 22.4 ( ) 45.5 ( ) 36.3 Other 81.1 ( ) 27.2 ( ) 77.8 ( ) Ovary 83.4 ( ) 38.8 ( ) 72.1 ( ) 70.7 Pancreas 21.0 ( ) 6.0 ( ) 22.3 ( ) 19.2 Prostate 98.0 ( ) 48.2 ( ) 98.3 ( ) 92.2 Stomach 49.1 ( ) 17.7 ( ) 47.6 (41-54) 44.1 Routes to Diagnosis Acute leukaemia 17% 3% 61% 12% 0% 4% 0% 4% 100% 380 Bladder 22% 36% 18% 13% 0% 6% 1% 5% 100% 1,167 Brain & CNS 18% 2% 49% 20% 0% 5% 0% 5% 100% 740 Breast 8% 40% 5% 5% 28% 2% 0% 13% 100% 5,646 Cervix 21% 17% 12% 8% 23% 3% 1% 15% 100% 308 Chronic leukaemia 26% 6% 45% 13% 0% 4% 1% 4% 100% 629 Colorectal 19% 29% 24% 12% 0% 8% 0% 7% 100% 4,515 Kidney 22% 26% 23% 16% 0% 5% 0% 8% 100% 928 Larynx 35% 34% 8% 14% 0% 5% 0% 3% 100% 216 Lung 15% 26% 38% 10% 0% 4% 1% 7% 100% 3,893 Melanoma 23% 39% 4% 8% 0% 5% 0% 22% 100% 1,686 Multiple myeloma 20% 14% 44% 13% 0% 4% 1% 5% 100% 606 Non-Hodgkin's lymphoma 25% 22% 25% 13% 0% 6% 1% 9% 100% 1,349 Oesophagus 15% 32% 21% 14% 0% 13% 0% 4% 100% 912 Oral 32% 27% 5% 14% 0% 4% 1% 17% 100% 458 Ovary 20% 29% 28% 11% 0% 3% 1% 8% 100% 853 Pancreas 13% 20% 45% 10% 0% 5% 1% 7% 100% 917 Prostate 26% 28% 11% 11% 0% 7% 0% 16% 100% 4,865 Stomach 14% 24% 31% 13% 0% 11% 1% 6% 100% 801 tbc (other) 21% 18% 34% 12% 0% 4% 1% 9% 100% 4,323 Testis 14% 47% 9% 15% 0% 4% 0% 11% 100% 259 Uterus 28% 36% 8% 12% 0% 5% 0% 12% 100% 918 Total 19% 28% 22% 11% 5% 5% 1% 10% 100% 36,369 All cancer Routes to Diagnosis: by cancer type All malignant registrations South West 2007 excluding C44 and multiples 12

13 Prospective audit of emergency admissions of cancer Dec 2012 March 2013 Cancer New ED diagnoses Total Dec Feb Percentage of diagnoses by ED (Dec Feb) National figure for percentage of diagnoses by ED (06-08) Examples of CUP pathways which ensure early triage to specific tumour MDT Lung % 39% Pancreas % 50% Hepatobiliary + GB % 48% NHL % 27% Myeloma % 37% MUO % 37% Gynae % 15% Colorectal % 26% CNS % 62% AML % 54% Bone sarcoma % 25% H&N- Oropharynx % 9% Mesothelioma % 36% Oesophagus % 22% Stomach % 33% Prostate % 10% Prospective audit of emergency admissions of cancer Dec 2012 March 2013 Cancer New ED diagnoses (RIP) Total Dec Feb Percentage of diagnoses by ED (Dec Feb) National figure for percentage of diagnoses by ED (06-08) Examples of CUP pathways which ensure early triage to specific tumour MDT Lung % 39% Pancreas % 50% Hepatobiliary + GB 3 (2) 5 60% 48% NHL % 27% Myeloma % 37% MUO % 37% Gynae % 15% Colorectal 2 (1) 14 14% 26% CNS % 62% AML 2 (1) 2 100% 54% Bone sarcoma % 25% H&N- Oropharynx % 9% Mesothelioma % 36% Oesophagus % 22% Stomach % 33% Prostate % 10% 13

14 Number of patients In-patient admissions during pilot Acute Oncology admissions to Mercers ward July- Dec Breast Lung CRC Upper GI HepBil Ovarian CUP Bladder Brain Other Treatment related Disease related Cancer type In-patient admissions to Mercers Ward 89 pts in 6 months - 78/89 = 88% disease related 7/89 = 8% treatment related 4/89 = 4% other 3 consecutive years audit data on unplanned admissions admitted under care of Dr Leonard Year (June December ) Type 2 known cancer treatment toxicities Type 3 known cancer progressive disease/symptom control 2009 (n=89) 8% (7) 88% (78) 2010 (n=42) 17% (7) 83% (35) 2011 (n=18) 17% (3) 83% (15) Total 17 (12%) 128 (88%) 14

15 The Acute Oncology service and admissions to Mercers ward Admission secondary to treatment related toxicity e.g. febrile neutropenia Admission secondary to symptom related to disease e.g. bone pain, increasing ascites End of life care episode Admission caused by medical event e.g. PE, UTI, fast AF, TIA, chest infection etc Known cancer patients (Dr Leonard) If admitted to Mercers Dr Leonard will take over care over If admitted to Mercers Dr Leonard will take over care over If admitted to Mercers Dr Leonard will take over care over To remain under care of admitting physician please inform Dr Leonard Known cancer patients (other Oncologist) If admitted to Mercers Dr Leonard will take over care over If admitted to Mercers Dr Leonard will take over care over To remain under care of admitting physician please involve Palliative care team To remain under care of admitting physician Dr Leonard & AOS happy to give advice re:ceiling of care if appropriate Previously undiagnosed Cancer patient To remain under care of admitting physician please refer to Dr Leonard & AOS via ICE To remain under care of admitting physician please involve Palliative care team To remain under care of admitting physician Dr Leonard & AOS happy to give advice re:ceiling of care if appropriate Lesson 5: Embedding the service 15

16 Reach all health care professionals A study or induction day is not enough High turnover of staff All levels needed to be engaged Consultants are territorial and set in their ways Repetitive & consistent Grand rounds FY1/2 teaching core trainee ST At the bedside 16

17 Introducing new pathways of care The Gatekeepers are the Radiologists Referral direct from Cons Radiologist 35 yr old female 6m history back pain & lethargy GP referred for CT on basis of abnormal CXR Called on day of CT to explain Within 24 hrs mediastinoscopy Within 4 working days diagnosis HD 17

18 MR WM 71yrs Non-smoker Hx RUQ pain GP rang for advice liver mets on US Seen by PL Fast track OPA (4/7) PS 1 Keen for all interventions understood treatment plan and intention CT results & diagnostic plan (11/7) EBUS UCLH (12/7) MDT presentation on (14/7) EBUS results & 1 st day treatment (21/7) Lung MDT presentation (26/7) Compare & contrast Fast track v Best 2WW MR WM 71yrs Non-smoker Hx RUQ pain GP rang for advice liver mets on US Seen by PL Fast track OPA (4/7) PS 1 Keen for all interventions understood treatment plan and intention CT results & diagnostic plan (11/7) EBUS UCLH (12/7) Unkown Primary MDT presentation (21/7) EBUS results & 1 st day treatment (21/7) Lung MDT presentation (26/7) MR WM 71yrs Non-smoker Hx RUQ pain GP sends 2WW - liver mets on US Seen by Gastro team (14/7) PS 1 Keen for all interventions understood treatment plan and intention CT results & discussion at unknown primary MDT (21/7) Outcome refer Lung MDT MDT discussion - outcome refer EBUS UCLH (26/7) EBUS UCLH (33/7) MDT presentation (40/7) PL Onco clinic & 1 st day treatment P a t i e n t e x p e r i e n c e (46/7) 18

19 Traditional pathway same outcome GP U/S Peritoneal cake CT done same day MUO MDT (D2) PL rang GP to offer fast-track OPA for assessment on yrs female Short history fatigue, nausea & reduced appetite (D6) Informed by GP for PP Saw HPB surgeon - biopsy Meets PL (D23) PS 2 Doesn t want chemo GFR 29 mls/min Dex & community Pall care 19

20 Early AOS can improve experience of care-celebration of generic skills 28 yrs female 6m history back pain Abnormal x-ray reported & orthopaedic team alerted MRI pelvis & CT Thorax/Abdo done AOS involved Seen at RNOH Sarcoma MDT Prof Whelan no chemo RIP Liver metastases only How do we manage this case? -determine fitness -PS -renal & liver function -assess symptoms -explore wishes -Biopsy if chemo appropriate 20

21 Why do clinicians over investigate? Fear of missing the treatable? Unwillingness that CUP is advanced disease? Do something is easier than having an honest discussion about poor prognosis? Belief that histological diagnosis a stronger determinant than prognosis determined by PS/co-morbidities Metastatic Spinal cord compression 59yrs female Short history of weakness & loss of sensation right hand with pain in neck Contacted directly by MRI Vertebral collapse C7, T1,T2 & T3 with impending cord compression Organised by phone urgent RT & team approach Patient transferred UCLH and treated Post RT biopsy Metastatic breast ca 21

22 75% of all presentations of MSCC are from Breast, Lung & Prostate 5-10% will be myeloma or lymphoma Total number of AOS admissions proportion referred via ICE (blue) April October

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24 ED alerts April March alerts 651/1171 (55%) admitted Cf 2009/ % Cf 2010/11 64% Cancer type Numbers admitted CRC 153 Lung 138 Breast 114 Prostate 46 Oesophageal 35 Gastric 12 Bladder 8 Ovarian 6 Pancreatic 6 Melanoma 4 Example of Rapid alert changing management 40 yrs male Completed neoadjuvant chemo for synchronous sigmoid & liver CRC 4 weeks post hepatic resection Presented ED with headache over weekend 24

25 Updated algorithim NICE

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27 Summary of patients who presented with FN in a 6 month period in 2011 Patient ED Arrival time ED Triage time Medical assessment time Time Tazocin given Time gentamicin given 60 min pathway time met Y N Cipro N Need to ensure antibiotics to be given by ED team in resus 27

28 Collaborating with other teams Patient Specific Protocols Individualised Consent Involve the patient and the entire treatment team LAS Letterhead Medical Director s signature London Ambulance Service NHS Trust 56 28

29 Headline data from pilot Pilot ran from patients treated with chemo 63 assessed as high risk 18/63 (29%) admitted via ED 14/18 were on chemotherapy 6/14 (55%) confirmed FN (3.4% of all patients treated) 10/14 on chemo Ca Breast ( 7/10 FEC-T - curative) 3/14 Lung 1/14 Neoadjuvant GOJ Small proportion of all treated door to needle time improved with PSP Results Pilot 24/7 telephone helpline Pilot time 30 th July 21 st October treatment episodes Rota with each participant taking a week Mon -Sun 64 calls ( 37% pts treated) 65% hrs Monday Friday 42% hrs 21% Weekend 14% hrs anytime 29

30 Careful provision of care by teams who communicate well How do we communicate? One point of referral for AOT (electronic system) All referrals triaged daily by Dr Leonard/Dr Mohamed & AOS CNS Refer to Palliative Care Refer to Haematology Dr Leonard, Dr Mohamed or AOS CNS to review Refer to site specific CNS All suspected and/or confirmed cancer cases are discussed at site specific or malignancy unknown MDT 30

31 The Whitt MUO referral pathway PS = Performance Status AOS = Acute Oncology Service AOT = Acute Oncology team MUO= Malignancy unknown origin OPA = out-patient appointment Patient presents as an emergency with alarm symptoms or suspicious imaging Make a decision to admit or fast track to OPA assessment Communicate suspicion of cancer Needs admission Assess PS 0-1 or >2 Measure renal & liver function Determine patient preferences for possible treatment interventions Arrange discharge NO obvious primary site or unclear if fit for further intervention book to fast track AOS OPA within week Clear primary site refer site specialist team for OPA Good PS & fit and willing for further interventions refer site specific or MUO MDT involve AOT to help tailor timely & appropriate investigations Poor or borderline PS/comorbidities/patient or physician unsure refer AOS within 24hrs of suspicious scan Refer MUO or site specific MDT for completeness OPA review Good PS with good renal, haem & liver function & willing to undergo biopsy arrange biopsy of site which maximises staging information if unclear from imaging Refer MUO MDT What could be the benefits of embedding comprehensive AOS Improved patient experience Improved patient outcomes Equipping on-call teams with AOS training & updated protocols to : Achieve door to needle time of 60 minutes in patients with FN Referral of appropriate patients for neurosurgical opinion in MSCC Up skilling all front-line staff to recognise the emergency and manage appropriately Lending expertise Avoid duplication of resources Improve efficiency of services Timely assessment after admission from experienced Oncologist can ensure the most appropriate in management is undertaken More satisfied patients (and staff!!) Reduced length of stay 31

32 Overcoming challenges Engage and share vision Ensure all key stakeholders are involved Collect data Only way to challenge perception Listen To all feedback Reflect When things have not gone so well Stay responsive and dynamic Service needs change Ensure you have authority to deliver change 32