Acute Oncology Martin Eatock Consultant Medical Oncologist NICaN Medical Director

Transcription

1 Acute Oncology 2014 Martin Eatock Consultant Medical Oncologist NICaN Medical Director

2 Patients admitted with cancer have a longer than average stay Berger et al. Clin Medicine (2013)

3 Questions If your relative was admitted and initial tests suggested cancer when would you want an oncologist involved in their care? Two weeks after discharge? Day before they went home? After MDT discussion? After all the tests were completed? As soon as cancer was suspected? If your relative was admitted with complications of cancer treatment would you want an oncologist in charge of their care?

4 cenario 1 Day 1 - admitted P-1 abdominal pain Day 2 & 3 - CT scan liver metastasis Day 5 - Colonoscopy & Day 6- Endoscopy & Bone scan Day 5-11 Await liver biopsy (bank holiday) Day 14 Discussed at MDT with liver biopsy result - refer oncology Day 15 Discharged awaits oncology clinic appointment

5 Day 1 Admitted P-3 dementia cenario 2 Day 2 & 3 - CT scan & ascitic tap Day 5 - Diagnosis ovarian cancer Day 5-12 Await MDT discussion Day 12 een by oncologist Not fit for chemo Day 13 Palliative care planning Day 26- Nursing Home

6 cenario 3 Day 1 Pt with metastatic Ca colon on IMDG Admitted with diarrhoea and vomiting IV Fluids, anti-emetics, PRN Imodium Day 2 Morning ward round by general physician Patient stable - review by visiting oncologist after weekend Days 2 +3 HO review, diarrhoea continues Febrile commenced oral antibiotics Day 4 (Monday). Bloods done Not reviewed as due to see oncologist Day 4. Afternoon Oncology review Unwell, eptic, Neutropenia, renal impairment Transfer to HDU Patient Dies after 48 hours

7 Is there really a problem with current practice models? NCEPOD report For Better For Worse. (2008) NCAG Report - Chemotherapy ervices in England: Ensuring quality and safety (2009)

8 For Better, For Worse. Examined process of care of patients dying within 30 days of receiving systemic anti-cancer therapy Appropriateness of decision to treat Prescribing and administration of ACT Monitoring of toxicity and management of complications End of life care Communication patient information, MDT working, referral pathways\clinical governance, clinical audit and risk management issues

9 Deaths Within 30 days of Chemotherapy 85% admitted to hospital 55% to cancer centre 18% to different hospital 42% under general medicine

10 Quality of Care 35% 57%

11 Room for improvement Decision to treat Process of care Prescribing, dispensing and administration of ACT Communication Patient information, medical records ACT toxicity Admission, assessment and treatment Management of neutropenic sepsis End of life decisions

12 NCEPOD: Time to Oncology Review

13 Quality and afety Requirement for appropriate safeguards NCEPOD for better, for worse NCAG report Chemotherapy ervices in England: ensuring quality and safety 19 recommendations Acute Oncology ervices

14 NCAG Report Acute oncology service: all hospitals with an A+E should establish an AO Decisions on initiation of treatment should be made at Consultant level Networks should have a regularly updated, easily accessible protocol book and electronic prescribing should be used Patients should receive verbal and written information about treatment and toxicities 24 hour telephone advice should be available Patients should know which hospital to go to, there should be policies for management of complications and 24 hour access to advice from a consultant oncologist

15 Hospitals without an AO should have treat and transfer arrangements. The Acute Oncology Team should be informed within 24h of any patient on chemotherapy attending A+E Each Trust must have a policy for the management of febrile neutropenia Toxicities of chemotherapy must be recorded The deaths of all patients within 30 days of ACT caused or hastened by treatment should be reported to the Coroner Leadership should be provided by AOT

16 Acute Oncology Workshop -25 th eptember 2010

17 Key Messages 2010 clear consensus that Acute Oncology ervices must be commissioned and developed across NI. need to develop Acute Oncology Teams within each Trust which have identified membership as outlined in NCAG. There needs to better joined up working and collaboration between ED, medicine, surgery, oncology, primary care, and palliative care across the patient journey. AO awareness raising and training programmes should be delivered to relevant staff There is a need to establish a Network Acute Oncology Group should develop a range of guidelines and protocols

18 There is a need to further develop 24/7 patient advice line/s There is a need for an integrated regional flagging system that alerts the Acute Oncology Team to the fact that patients are in ED or admitted to medical wards. Fast track clinics should be developed with agreed criteria and referral mechanisms..next step formal agreement with key stakeholders (Centre/Units/ Commissioners/ Network etc.). The steering Group should agree on pump priming to create the necessary momentum and that ultimately Units accept this as future efficiency savings.

19 o What is Acute Oncology?

20 A large and complex service Chemotherapy toxicity + safety Malignancy of undefined origin MUO/CUP Urgent symptom control and End of Life Acute Oncology Urgent diseaserelated problems Metastatic spinal cord compression Admission Avoidance

21 Endpoints Improved quality and safety of care for cancer patients Admission avoidance Reduced Length of stay Reduction in use of inappropriate investigations and procedures

22 Acute Oncology Team Minimum of 2 oncologists providing acute oncology input Provide a 5 day service with one PA of Acute Oncology time per day The acute oncologists will deliver site specialised services for at least 2 of the 3 common cancers 2 specialist acute oncology nurses to provide: rapid input into the care of patients suffering complications of chemotherapy, complications related to the disease itself and those admitted as emergencies with previously undiagnosed cancers, contribute 1.0 wte, but have other cancer related activities in the hospital There is an Acute Oncology Team (AOT) office and part time secretary (probably also shared with other cancer related activity) to take referrals and provide a physical focus for all clinical enquiries on cancer patients.

23 cenario 1 Day 1 - admitted P-1 abdominal pain Day 2 & 3 - CT scan liver metastasis Acute Oncology Review Day 6 liver biopsy Day 7 Discharged Day 10 Review in Acute Oncology clinic for discussion of results and treatment planning after discussion at CUP MDT

24 Day 1 Admitted P-3 dementia cenario 2 Day 2 & 3 - CT scan & ascitic tap Acute Oncology review P = 3/4 Best supportive care decision day 3 Day 3 Palliative care planning Day 16- Nursing Home

25 cenario 3 Day 1. Pt with metastatic Ca colon on IMDG Admitted with diarrhoea and vomiting IV Fluids, anti-emetics, PRN imodium Acute Oncology team notified - ame day assessment by Acute Oncology CN Advice about toxicity management and appropriate management of diarrhoea Ensures Management protocols in case notes Days Over Weekend Nausea controlled with D (per protocol) Fever assessed by HO, neutropenic, commenced on IV antibiotics + fluids Discussed with On-call Oncologist in CC Day 4 (Monday) Reviewed by Acute Oncology Consultant Improving Case logged for N audit Day 8 Discharged

26 Where are we now? England 2014 AO is a success story Already, 190+ Trusts making AO PR returns 130+ Trusts have CUP MDTs after just 1 year 50% improvement in median PR compliance between 2011/12 and 2012/13 (33% 50%)

27 Hospital Peer-reviewed components 11-3y 1 - Acute Hospital 11-3y 3 - General AO 11-3y 4 AO IP service 101 Designated, fully staffed and resourced AO Team 301 Designated and resourced AO Lead clinician 401 Designated and resourced AO Consultant staff* 102 AO induction training for A+E staff 302 Flagging system 402 Designated and resourced AO specialist nursing staff 103 AO induction training for staff on Acute Medical take and MAU 303 Telephone access to on-call Consultant Oncologist 403 Training of AO Team members 104 Protocol for fast-track access to oncology OP 304 MCC Coordinator service 404 Operational Policy for assessment of admitted AO patients** 105 Fast-track access to defined oncology OP slots 305 AO Training for on-call Oncologists 106 Notification following A+E attendance / non-elective admission 306 Protocol to inform Consultant when patient admitted or seen in AO 307 Treatment protocols for AO presentations in all relevant areas hour door-to-needle antibiotic pathway hour door-to-needle antibiotic pathway audit 310 MCC service specification and pathway 311 Patient information about MCC *To ensure patient review by Consultant within 24 hrs of admission. ** Monday- Friday. Not necessarily Consultant Oncologist review.

28 Major weaknesses in 12/13 PR Official report identified: Lack of staffing Lack of training Lack of flagging system Failure of 1 hr door-to-needle process in A+E Lack of Consultant review within 24 hours Failure to audit neutropenic pathway Lack of CUP service Weaknesses in MCC pathway (Improvement in 2013 / 14 PR, but same areas deficient)

29 o what about the other devolved nations?

30 NH Grampian NH Grampian NH Grampian Highland NH Borders Individual board approach Piloting an acute oncology nursing role (senior nurse) Develop, test and introduce a formal a system of reviewing individual case where a death occurs within 30 days of treatment Nurse led acute oncology model. focused on data capture and proof of concept testing. If demonstrates benefits, business case for maintenance will be submitted. NH Fife WoCAN Testing a new acute oncology model. Acute medicine physician working one session per week to develop acute oncology model. Benefits include: improved communication with acute medicine, improve pathway for CUP, Can identify all know cancer patients admitted as an emergency Review, further develop and fully embed oncological emergencies communication & access to patient management information

31 North Wales Wrexham Maelor Formalised Acute Oncology ervice (2012) after 2 year pilot programme as per NCAG recommendations Ysbyty Glan Clwyd Established full AO 2012 IT system to flag patients still awaited Ysbyty Gwynedd Acute Oncology CN service Provide daily input to Acute Medical Unit

32 Rest of Wales ingleton Hospital, wansea 6 month pilot AO from March 2013 Nurse led AO Cancer Centre Hospital At National level Working with MacMillan to standardise approach across 7 Welsh Health Boards Development of Welsh Acute Oncology tandards Likely that final model will involve both acute oncology CN and Consultants

33 Questions If your relative was admitted and initial tests suggested cancer when would you want an oncologist involved in their care? Two weeks after discharge? Day before they went home? After MDT discussion? After all the tests were completed? As soon as cancer was suspected? If your relative was admitted with complications of cancer treatment would you want an oncologist in charge of their care? YE