North Trent Cancer Network. NSSG Constitution for the Acute Oncology Service Group 2011

Transcription

1 North Trent Cancer Network North Trent Cancer Network NSSG Constitution for the Acute Oncology Service Group 2011 Agreements / Cover Sheet This NSSG Constitution was reviewed by Dr David Hughes, Network Lead Clinician, Consultant Histopathologist, Sheffield Teaching Hospital NHS Foundation Trust, Chair of the Acute Oncology Service Task Group, on 9 th September 2011 This NSSG Constitution was agreed by Annette Laban Chief Executive, NHS Doncaster Chair of the Network Board on 9th September 2011 This NSSG Constitution was agreed by the Acute Oncology Service Task Group members on 20 th October 2011 Agreement for this Constitution was sought from Trust Chief Executives, Trust Lead Cancer Clinicians, Chair of Network Chemotherapy Group, Chair of Network Radiotherapy Group, Specialist Commissioner and Trust Acute Oncology Leads Also agreed by Network Leads for MSCC Mr Neil Chiverton and Dr David Brooks PCT Cancer Leads Lead Clinicians of the MDT s The NSSG Constitution was developed in accordance with the NTCN Terms of Reference. NSSG Constitution Review Date: July 2012 Produced by the North Trent Cancer Network Acute Oncology Network Group July

2 The North Trent Cancer Network (NTCN) serves a population of approximately 1.8 million who live in the South Yorkshire, Bassetlaw and North Derbyshire area. The North Trent Cancer Network includes large areas of deprivation and as the map below shows. The GP practices across the network are highlighted by blue dots and are concentrated in high population areas. The Network Acute Oncology Group is:- the network's primary source of advice on issues relating to acute oncology in the network; the group with corporate responsibility, delegated by the Network Board for ensuring co-ordination and consistency across the network for implementing the acute oncology measures and for ensuring co-ordination and consistency across the network for the acute oncology practice in hospitals. the group for consulting with the NSSGs and the Network chemotherapy and radiotherapy groups on the acute oncology treatment and referral guidelines. 2

3 Network Configuration Acute trust provision is provided in the following organisations Designated Lead AOS Clinician/Team Hospital Host Organisation Referring PCT Population (not weighted) Dr Julian Humphrey Consultant in Emergency Medicine Barnsley District General Hospital Barnsley Hospital NHS Foundation Trust Barnsley Primary Care Trust 234,397 Dr Mansur Reza Consultant in General Medicine Dr Joe Joseph Consultant Haematologist Dr Ahmed Arefin, Consultant Physician Dr Matthew Winter Consultant Medical Oncologist Dr Peter Kirkbride Consultant Clinical Oncologist Chesterfield Royal Hospital Doncaster Royal Infirmary and Bassetlaw Hospital Rotherham Hospital Sheffield Teaching Hospitals Chesterfield Royal Hospital NHS Foundation Trust Doncaster & Bassetlaw NHS Foundation Trust Rotherham Hospital NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust Derbyshire County Primary Care Trust Doncaster Primary Care Trust Bassetlaw Primary Care Trust Rotherham Primary Care Trust Sheffield Primary Care Trust 320, , , , ,513 3

4 NETWORK CONFIGURATION 11-1A-301Y NTCN Acute Oncology Service Hospice Palliative care beds Chesterfield Royal A+E Haem beds OP Chemo Acute medical beds Hospice Palliative care beds Northern General A & E Palliative Care Unit Acute Medical Beds No OP Chemo STHFT Hospice Palliative care beds Royal Hallamshire No A+E No Acute Medicine beds Haem beds OP Chemo Weston Park Hospital No A+E No Acute medicine beds Hospice Palliative care beds Barnsley A+E Acute medical beds OP Chemo (Onc) Haem Beds Rotherham A+E OP Chemo Haem beds Acute medical beds Bassetlaw A & E No OP chemo Doncaster Haem beds OP Chemo (Haem + Onc) A & E Hospice Palliative care beds There is a Specialist stand alone cancer hospital, Weston Park Hospital (Group2) based within Sheffield Teaching Hospital trust and based at the South Campus. Weston Park Hospital has Oncology beds Out patient chemotherapy Radiotherapy Oncology Acute assessment unit The Royal Hallamshire Hospital also falls into Group 2. All other hospital trusts in NTCN are categorised as Group 1. Haematological services are locality based but participate in a centralised weekly MDT 4

5 All trusts are in the process of developing acute oncology pathways within their localities and developing plans to investigate a sustainable acute oncology service. 11-1A-301y Agreed named adult Clinical Chemotherapy Services and oncologypharmacies within the Network and the hospitals designated to treat MSCC Hospital Trust and Head of Service Sub-specialty and Hospital(s) covered Associated Oncology-pharmacy and Hospitals covered and Lead pharmacist Designated to Treat MSCC Barnsley Hospital NHS Foundation Trust CCS for haematologyoncology As left Trust s own (single) pharmacy service Hospital as left No Keira Hall Keira Hall The trust hosts an outreach service from the WPH CCS. Chesterfield Royal Hospital NHS Foundation Trust CCS for haematologyoncology As left Trust s own (single) pharmacy service Hospital as left No Rebecca Hill Martin Shepherd The trust hosts an outreach service from the WPH CCS. 5

6 Hospital Trust and Head of Service Sub-specialty and Hospital(s) covered Associated Oncology-pharmacy and Hospitals covered and Lead pharmacist Designated to Treat MSCC Doncaster and Bassetlaw Hospitals NHS Foundation Trust CCS for haematologyoncology Doncaster Royal Infirmary Bassetlaw DGH Trust s own (single) pharmacy service Hospitals as left Ben East No Dr G Majumdar The trust hosts an outreach service from the WPH CCS. Rotherham Hospital NHS Foundation Trust CCS for haematologyoncology As left Trust s own (single) pharmacy service Hospital as left No Dr Peter Taylor Susan Gibbons The trust hosts an outreach service from the WPH CCS. Sheffield Teaching Hospitals NHS Foundation Trust Dr Nick Morley Dr Linda Evans CCS for haematologyoncology Royal Hallamshire Weston Park Hospital (level II) CCS for solid tumour oncology Weston Park STH oncology pharmacy service Onco-pharmacy at Royal Hallamshire (part of trust s own pharmacy service) Hospitals as left Graham Marsh Onco-pharmacy at Royal Hallamshire (part of trust s own Yes Sheffield Teaching Hospitals is the only Trust in the Network to definitively treat MSCC. Surgery at Northern General Hospital or Radiotherapy at Weston 6

7 Hospital Trust and Head of Service Sub-specialty and Hospital(s) covered Associated Oncology-pharmacy and Hospitals covered and Lead pharmacist Designated to Treat MSCC Hospital pharmacy service) Park Hospital The WPH CCS provides an outreach service at the 4 hospital trusts above. Hospital as left Graham Marsh 11-1A-303y Each Hospital will diagnose and treat with appropriate consultation with the cancer centre the following caused by the systemic treatment of cancer in line with NTCN agreed guidelines. Weston Park Hospital does not manage either Pleural or Pericardial effusions The following caused by chemotherapy Neutropaenic sepsis * Uncontrolled nausea and vomiting Extravasations injury Acute hypersensitivity reactions including anaphylactic shock Complications associated with venous access devices Uncontrolled diarrhoea Uncontrolled mucositis Thrombocytopenia induced haemorrhage not requiring surgical intervention Hypomagnesaemia The following caused by radiotherapy Acute skin reactions 7

8 Uncontrolled nausea Uncontrolled diarrhoea Uncontrolled mucositis Acute radiation pneumonitis Acute cerebral/other CNS oedema *The current network policy is that the all patients receiving chemotherapy treatment for solid tumours contact Weston Park Hospital directly and are admitted to WPH for treatment. However, in view of the fact that some patients will present locally despite this, all units need to have processes in place to ensure that patients who present directly to them via A&E are promptly assessed and treated in discussion with WPH. When patients are stable they should then be transferred to WPH at the earliest opportunity. Each hospital within the Network undertakes to be responsible to diagnose and manage patients presenting with the following conditions, referring to specialists were appropriate. Conditions presenting as an urgent acute problem Patients with a known malignancy or patients with a previously unknown malignancy Pleural effusion Pericardial effusion Lymphangitits carcinomatosa Superior mediastinal obstruction syndrome including superior vena cava obstruction Abdominal ascites Hypercalcaemia Spinal cord compression including MSCC Cerebral space occupying lesions Any other cases where A&E staff or acute medical firm decide an urgent oncology assessment needed 8

9 11-1E-110y (see page 43) Metastatic spinal cord compression All trusts within the Network may diagnose patients with MSCC but treatment interventions are only carried out in Sheffield Teaching Hospitals Trust at either Northern General Hospital site for surgical intervention or Weston Park hospital site for Radiotherapy treatment. This takes place after the relevant discussion with appropriate personnel. See MSCC Referral Proforma Appendix 2 The MSCC Referral Guidelines are attached as Appendix 3 to the NTCN Acute Oncology Annual Report document. All Patients with the potential to develop MSCC should be provided with suitable agreed information see examples Appendix 1(Both Sheffield and Doncaster and Bassetlaw Hospitals have been Beacon sites for the Information Prescriptions project) All organisations provide information to patients at risk. At the time of information provision clear advice is given on the relevant person to contact if they have concerns. This method of providing information has been agreed at the appropriate NSSG s Hard copies of agreed local information is available These key actions should be undertaken for any suspicion of MSCC Contact MSCC Co coordinator urgently (within 24hours) to discuss the care of the patients with cancer and any of the following symptoms suggestive of spinal metastases Pain in the middle (thoracic) or upper (cervical) spine Progressive lower (lumbar) spinal pain Severe un remitting lower spinal pain Spinal pain aggravated by straining (e.g. coughing sneezing) Localised spinal tenderness Nocturnal spinal pain preventing sleep Contact the MSCC co coordinator immediately to discuss the care of patients with cancer and symptoms or signs suggestive of MSCC and view them as an oncological emergency Neurological symptoms including radicular pain Any limb weakness Difficulty in walking Sensory loss or bladder or bowel dysfunction Neurological signs of spinal cord or cauda equine compression 9

10 11-1A-302Y Review the provision of chemotherapy, oncology pharmacy and acute oncology services across the Network 1 Introduction NORTH TRENT CANCER NETWORK BOARD Friday 11 th February 2011 Update on Acute Oncology Service implementation The National Chemotherapy Advisory Group Report (Chemotherapy Services in England; ensuring quality and safety) published in August 2009 was a response to the concerns identified through the NCEPOD report and the cancer peer review process regarding the safety and quality of chemotherapy services. One aspect of the report drew specific attention to the provision of emergency care not only for patients developing complications following chemotherapy, but also for those patients known to have cancer, suffering from acute symptoms of their disease. This includes actions to support the management of patients not yet known to have cancer, but who are suffering from symptoms which may be cancer-related. In a response to the issues identified above the report recommends that all hospitals with an Accident and Emergency department establish an acute oncology service (AOS), which requires that the relevant staff from A&E, general medicine, haematology and clinical/medical oncology, oncology nursing and oncology pharmacy work together as a single acute oncology team. The draft AOS Cancer Peer review measures are currently out for national consultation and it is expected that Trusts will have to perform a Self assessment against the measures when they are finally issued in time for August Internal Validation will take place in September The issue of Acute Oncology has been discussed previously at Cancer Board and this paper summarises the approach that the North Trent Cancer Network has taken and the progress to date. 2 Progress to date A meeting was held in January (that had been delayed from December) with trust representatives in order to: a) Agree a set of network wide working principles b) Acknowledge that there may be a range of clinical models of delivery as models will be developed locally shaped by existing clinical arrangements and specialist input 10

11 c) Identify the patient groups the acute oncology service clinical model will address d) Agree next steps 3 Local Progress The trusts within the North Trent Cancer Network have local implementation groups in place and are currently working on plans for delivery and making progress in a range of areas. At the workshop progress in a number of areas was noted including: a) Rapid alert systems were under development or in the implementation phase in a number of the trusts b) Data on the number of emergency admissions and length of stay was being collected but that more standardisation and learning from others could support this c) Patient pathways were under development at most trusts d) There was a shared understanding that oncologist could include haematologists and therefore service models were being developed with that possibility in mind. However differing views were expressed on the possible role of Haematologists in solid tumour acute oncology. 4 Challenges Although some good progress has been made locally there is still a considerable amount of work to do, some of which requires significant change both at service level and at a professional level. For the acute oncology service and team to work well a number of issues will be challenging including: a) Developing appropriate clinical models relevant to each local trust and resourcing it appropriately in order to fulfil the anticipated cancer peer review requirements. b) The roles of the individuals comprising the acute oncology team will be critical and this will inevitably require that oncologists, haematologists, palliative care consultants and the specialist nursing staff will be affected. c) More network and local protocols and pathways will be required particularly for the management of metastatic spinal cord compression and cancer of unknown primary both of which have either a NICE clinical guideline available or under development as part of AOS measures. d) The clinical local pathways, policies and escalation process ensuring timely connectivity to the Oncologist either locally or at Weston Park are crucial, therefore ensuring that the impact on Oncology time is co-ordinated. Determination of front door policy is a key factor. e) Robust data is required to understand the current position so that the changes can be quantified, in particularly reductions in length of stay at 11

12 trust level f) Optimising existing resources and developing cost effective new ways of working 5 Next Steps As outlined within this paper there remain many challenges to developing an Acute Oncology Service within each hospital in North Trent. Some progress has been achieved already but in order to meet the expected national milestone it is now necessary to take this work forward quickly and this will require that: a) The Task subgroup will be set up as soon as possible ( first meeting end of February) and will report to Chemotherapy Strategy Group and Cancer Board on progress b) The Group take forward the development of protocols, generic pathways and provision of 24/7 advice both in and out of hours. c) The Group will work to develop a consistent Network education package to support the services. d) Investigation should take place about the numbers of patients involved and whether emergency and neutropaenic pathways could possibly be delivered locally. e) The group will ensure that work is coordinated across the network, and with changes already planned/underway on reduction of Follow Up and how this might support AOS. f) Support should be given to the work underway to develop Health Care Professional assessment of chemotherapy patients to potentially release oncologists time for the AOS. The work of this group should be prioritised. 6 Recommendations The Cancer Board is asked to note the progress to date, the challenges identified and to support the view that a high priority must be given to this work by the trusts and the network team for this work. Kim Fell Cancer Director David Hughes Network Lead Clinician 12

13 North Trent Cancer Network Work Plan Measure 11-1A-303y Aim To ensure that there is an Acute Oncology Service in every hospital with an A+E department and acute admission wards. 1. Safe ensuring that the services are as safe as they should be Robust Governance 2. Effective focused on delivering best outcomes for patients 3. Personalised meets the needs of individuals providing access to services at the time and place of their choice 4. Fair available to all, taking account of personal circumstances and diversity 5. Cost Effective value for money Objectives and Requirements Commissioners working with providers will determine the appropriate balance of services across a network at both cancer centre and DGH or at a Community Hospital or in a patients home. Different models will suit different trusts and services but the following key components will need to be met 1. A minimum of two Oncologists are responsible for providing acute oncology (haematologists and oncologists) input 2. The oncologists provide 5 day service for acute oncology 3. The oncologists is likely to provide site specialised services in the same unit 4. Two specialist oncology nurses to provide rapid input into the care of patients suffering from complications of chemotherapy 5. There is an acute oncology team office with part time secretarial support to take referrals and provide a physical focus 6. Oncologists will not usually have their own beds but will be available in the hospital Monday to Friday 7. The extended acute oncology management team is defined as the acute oncologists, the acute oncology nurses, the lead haematologist, the lead haematology nurse, the lead A&E physician, the lead general physician, the hospital cancer manager / lead nurse, and the palliative care lead. 8. An information system that automatically flags up to the AOT when known cancer patients are seen or admitted 9. The oncologists and specialist oncology nurses will be fully integrated within the trust pathways and protocols, clinical meetings etc 13

14 10. The AOT will be a service integrated into the hospital s portfolio of cancer services Patient Groups Included Chemotherapy (and radiotherapy) patients currently on treatment (and within 30 days of treatment) Treatment of acute symptoms in patients known to have cancer but not currently on active treatment Treatment of patients who have not yet been diagnosed with cancer, but who have acute symptoms which might be cancer Management of patients with spinal cord compression Management of patients with cancer of unknown primary 14

15 Outcome Theme Action Lead Clinical Models Accountability i. Subgroup of the Chemotherapy Strategy Group (NCAG Implementation oversight group) ii. Agree membership iii. Leads to be identified by each Trust iv. Formalise terms of reference Kim Fell AOS Working group April 2011 Principles Local Implementation Group 1. Principles defined 2. Local clinical models to be determined based on the NCAG recommendations and network principles 3. On call / 7 day cover arrangements Each Trust to identify a project team Each trust to develop local proposals for discussion at the Subgroup meetings Cancer Managers Identified Lead Dec 2010 May 2010 Sept 2010 Roles and Responsibilities Role of Oncologists Role of Haematologists CNS KF / PF December 2010 Testing new clinical models Examples Each Trust is working on a number of areas including Data collection Length of stay Patient flagging/ rapid alert systems Emergency Admission process Workshop December

16 Outcome Theme Action Lead Review Network protocols e.g. neutropaenic sepsis, extravasations Chemo nurses group Ongoing On website August 2011 Safe Service Existing protocols Review locality protocols to ensure they meet Network policy Chemotherapy Strategy Group Sept 2011 Robust Governance Ensure these are embedded into the organisation - audit Monitor and support localities to develop Acute Oncology Team Define principles relating to safe pathways Trust Oncology / Haematology Governance leads Workshop Pilot in Haematology December 2010 Governance Ensure effective communication Agree lead arrangements in each trust to support: Pathways reviews Mortality reviews Adherence to policies/procedures Defining standards door to needle time Work with cancer managers Links to Information systems Escalation to Weston park defined triage practitioners Haematology and Oncology leads in each Trust Subgroup Workshop December 2010 December 2010 June 2011 Implement the agreed principles relating to good service level Trusts to develop plans in line with network principles and the nationally described key components Agree action plan Implementation of the plans Develop links with Engage with primary care once models Primary care lead November 2010 December

17 Outcome Theme Action Lead Monitor and support localities to develop Acute Oncology Team primary care Optimising resources Work on service Improvement with AOS Nurse group agreed Reduce length of stay need figures Reduce follow-up appointments to free up oncologist time Phone triage Capacity in clinic urgent clinic appointments? Conference Call to establish locality position Monthly reporting from Doncaster AOS pilot Capture baseline for all localities Support lead nurses re retrospective and prospective audit data collection Identify with NTCN Info Team if dataset can be sourced from HES or CCT Discuss with Zoe NSSGs/ SILs Karen Leivers Judith Bird Karen Leivers Karen Leivers Ongoing work 31August Sept Dec 30 November 30 November 31 August Policy Development Define policy for managing complications of a. chemotherapy b. radiotherapy acute symptom management for cancer patients Define policy for managing patients not yet diagnosed with cancer Define policies for managing spinal cord compression Define policies for managing cancer of Review Network protocols NSSG guidelines Review locality protocols to ensure they meet Network policy 17

18 Outcome Theme Action Lead unknown primary Implementation Phase Ensure that the Network protocols in line with NICE guidance Ensure that the locality protocols to ensure they meet Network policy Obtain patient and carer views from across on their experience ALL AOS Nurses 2012 Effective Time and Place Information Technology Plans for: Flags on hospital systems Learning across the network Alert systems with connections to MDT s within 24hours Trust leads December 2010 Ensure effective communication Robust communication processes in place in each Trust Trust Leads 18

19 Outcome Theme Action Lead Cost Effectiveness Optimising resources by reducing length of stay and follow up Data by cancer diagnosis Admissions by cancer diagnosis Quantify the financial value and potential savings Quantify additional workforce required as part of the AOS Develop a fully costed proposal for each trust Detail an audit programme post implementation Cancer Managers / Service Improvement Lead Ongoing work December

20 NORTH TRENT CANCER NETWORK Local Chemotherapy Work Programme 2009/ Strategic Aims Deliver services locally where possible creating easier access and reducing inequalities in areas of greater deprivation Reducing Death rates / improving survival rates for a number of cancers Greater access to Oncologists in areas of greater need Local access to research trials improve survival rates Equal access to chemotherapy by reducing travelling to the tertiary centre 2. Change Management tasks to ensure that the objectives are met Identify key stakeholders and benefits User / Public involvement at all levels and all stages Executive leadership at a network and local level to ensure integrated, co-ordinated care through a single integrated team approach but separate management arrangements Local Implementation teams with a designated local manager lead. Network implementation (Project Board) with regular updates via Director to Cancer Board Contracting arrangements, reporting and data management / outcomes to be developed and agreed. Links to national tariff arrangements / cost / activity changes demonstrate value for money. QUALITY improvement 20

21 3. Service Issues Desired Outcome Objective Action Monitoring Measurement People with cancer will have an improved health outcome People with cancer will receive safe care Delivery in line with NCAG recommendations To ensure the people with cancer and their family members will have access to local treatments where possible Safe and consistent working practices. Practice meets national standards and Cancer Peer Review measures Facilitated Sessions User Engagement Clinical Engagement Local Engagement Oncology buy-in Haematology buy-in Identifying Risks / Benefits Develop, agree and implement clinical pathways Oncology leads in place July 08 Develop services in line with Peer Review measures Timescales met Strategic Aims agreed Objectives agreed Business plans produced LDP Submission Out of hours cover in place Training complete Staff recruited Network Chemotherapy Lead clinician will develop Operational policies (clerical activities/treatment options/ clinical trials) in place Board papers presented Papers supported and agreed Funding agreed COMPLETE Timed pathways monitored Adverse events monitored COMPLETE Self assessments complete Co-ordination and Integration of patient Care Ensure oral chemotherapy guidance (NSPA) in place. Local policies implemented by local teams Chemotherapy data set Data collection points agreed Recruitment complete audits take place Clinical activities and checking Each locality working up with oncology Operational policies in place point leads as part of operational policies Develop processes for sharing clinical information Joint access to clinic booking Each locality working up with oncology leads as part of operational policies Critical assessment points/ trigger points for onward referral to WPH agreed Comparable data reports Activity data / drug usage / Adverse events reported Comparable data / network reports Audit of the process available Each locality working up with oncology leads as part of operational policies Referral back to DGH asap Audit Explore and develop locally held clinical Communication pathway Patient experience survey records Develop a patient satisfaction survey for Manual systems in place in the Adverse events reported 21

22 Desired Outcome Objective Action Monitoring Measurement 2. People with cancer will receive safe care arrangements using web technology Define the standards all parties will work towards. Clinical Leadership & Governance use per and post change Oncologist lead to develop local governance arrangements short term Network lead clinician agreed all arrangements Clinical leadership development requirements for new leads chemotherapy contracting framework defining Peer review and safety measures - monitored Practices are audited and benchmarked at network and national level Peer Review All sites visited once. Starting second round of visits Start preparation for 2011/12. Compliance with Peer review measures at the visits Waiting times met Audit against JCCO/ RCR Guidelines Include within peer review Waiting time Data Breaches comparative nationally 3. Patients with cancer will receive NICE approved cancer drugs National Chemotherapy Advisory Group report issues Integrated governance arrangements (Oncology and Haematology) are in place at each local DGH. To ensure people with cancer are able to access cost effective care Network Lead identified Lead Oncologist sessions identified and funded Joint working in place Funding agreed at all sites. Engaged with STH IT and meeting held across all sites. Phase 1 and 2/3 identified. To proceed with individual procurement for PH1 urgently. Capacity and Demand studies Implement C Port WPH close to completion of baseline. In place In Place Recruitment of staff at DGH E prescribing implemented Explore potential for phase 2 haematology and interfacing 2009/10 Implement CRF integration and co-ordination of care a. capacity and demand C-PORT complete Reduce bed utilisation in patient and WPH development of short stay LoS Incident reports Adverse events Planned activity transfers have taken place Audit of protocols used by tumour type and Consultant Use of NICE drugs Comparative costs for day case activity Utilisation of resources 22

23 Desired Outcome Objective Action Monitoring Measurement 4. Improved survival More self management Ensure people have access to trials locally Sufficient, trained staff to deliver a local service Less centralisation chemotherapy complications Work with the Primary care Group to develop proposals Clinical Trials increase recruitment, develop trained workforce Ongoing nursing and pharmacy Nursing package in place. Implemented with support from WPH. Pharmacy standard training package being developed. Assessment of implications of reduced activity in WPH unit Links/protocols with primary care to reduce need for admission Bid agreed for pharmacist for a. STH haematology and b. cross locality liaison/oversight Planned staff recruited in DGHs (nursing, pharmacy) complete All staff trained and recruited complete Access the Impact at the tertiary centre Adverse events Emergency admissions Readmission rates % patients entering trials Patient feedback Activity versus capacity Comparable quality adverse events peer review Activity / costs and comparable data Increasing the rollout of local chemotherapy - nursing subgroup Review the additional regimens for local delivery Work with NCAT to develop effective clinical outcome measures Assess capacity, efficiency and working practices Pilot to be done in WPH over 1 year period and then results used in other sites Funding to match activity To be agreed 5. Achieve positive patient outcomes through Contract for Quality Determine Data requirements Patient outcomes agreed and defined across the pathway Increases local delivery - activity Include pathway measures in contracts Review Service Level Agreements Access improved Patient satisfaction / feedback Clear links to pathway performance contracting Demonstrate value for money Review activity day case Drug costs/usage Comparable costs in all Trusts or defined quality benefit a) Chemotherapy (and Network to support the development of: Local meetings 23

24 Desired Outcome Objective Action Monitoring Measurement 6. Develop Acute Oncology Services See full work plan radiotherapy) patients currently on treatment (and within 30 days of treatment) b) Treatment of acute symptoms in patients known to have cancer but not currently on active treatment c) Treatment of patients who have not yet been diagnosed with cancer, but who have acute symptoms which might be cancer Governance arrangements Clinical Models Effective communication Protocols Optimising resources Links to Primary Care Information Technology Network meetings d)management of patients with spinal cord compression e) Management of patients with cancer of unknown primary Small local meetings throughout July/August 24

25 11-1A-304y MEMBERSHIP OF ACUTE ONCOLOGY TASK GROUP CORE MEMBERS CHAIR Dr David Hughes AOS lead - Network Lead Clinician Sheffield CLINICAL LEAD Dr Patricia Fisher Consultant Clinical Oncologist Sheffield (WPH ) Dr Ahmed Arefin Consultant Physician Rotherham Lesley Barnett Lead Cancer Nurse Doncaster Judith Bird Network Lead Nurse NTCN Janine Birley Lead Cancer Nurse Rotherham Dr Linda Evans Consultant Medical Oncologist Sheffield (WPH) Network Chemotherapy Deputy Chair Kim Fell Network Director NTCN Current Network Chemotherapy Chair Mark Gilmore Lead Cancer Nurse Barnsley Nicky James Lead Nurse Chesterfield Dr Joe Joseph Consultant Haematologist Doncaster Graham Marsh Pharmacist - Oncology Sheffield Dr Simon Pledge Consultant Clinical Oncologist Chair of the Network Radiotherapy Group Sheffield (WPH) Pauline Pledge Matron Outpatient and Chemotherapy Day case Services Sheffield (WPH) Nurse member of AOAS service Dr Mansur Reza Consultant Physician Chesterfield Martin Salt Lead Nurse Sheffield Michel Thompson Matron Rotherham Sue Tonge Senior Sister, Chemo Day Unit Doncaster Lucy Walkington Medical Oncology SpR Sheffield Dr Emma Welch Consultant Haematologist Chesterfield 25

26 Dr Matthew Winter AOS Lead Sheffield From August 2011 Alison Morton Patient Representative * Dr David Brooks From September 2011 Jane Harding From August 2011 Dr Christopher Dalley From August 2011 Macmillan Consultant in Palliative Medicine AHP Lead Lymphoedema specialist - Physiotherapist Haemato-oncologist Chesterfield NTCN Sheffield *The agreed mechanism for obtaining further user advice if necessary, is via the Network Macmillan User Facilitator and the Network Patient Partnership Group Terms of Reference The Network Acute Oncology Group is a Network Cross Cutting Group (CCG) and the Terms of Reference for the group are the Network generic terms of reference used for both NSSGs and CCGs. A list of responsibilities included in list of responsibilities identified in Network CCG Terms of Reference 26

27 NORTH TRENT CANCER NETWORK (NTCN) NETWORK SITE SPECIFIC / CROSS CUTTING GROUP(s) COMMON TERMS OF REFERENCE 1 February 2011 NAME OF GROUP: ACCOUNTABLE TO: PURPOSE: Network Site Specific Group (NSSG) Cross Cutting Group (CCG) The North Trent Cancer Network Board The NSSG/CCG Chair is a member of the Network Lead Clinician Forum and as such is responsible for ensuring risks associated with the delivery of services across the relevant pathway are fed into the network planning process. The NSSG/CCG has responsibility, delegated by the Board, for ensuring the co-ordination of the cancer pathway and the consistency of care for the relevant client group within the cancer network. This includes: Service planning Service Improvement / Redesign Service Quality Monitoring and evaluation including clinical performance and outcomes Workforce Development Research and Development The Network tumour-site specific groups should have the active engagement of all MDT leads from the relevant constituent organisations in the network. NSSGs should ensure that all agreed operational changes are discussed with local managers to ensure that changes are integrated into constituent organisational structures and processes. Discussions to explore other changes to existing patient pathways may be initiated by commissioners including Primary Care. NSSG provides advice in respect of all significant service changes (e.g. IOG) particularly if there are financial consequences, and will make recommendations to the Cancer Board. The NSSG has a key role in: Developing plans to implement Improving Outcomes Guidance Monitoring the implementation of the agreed Improving Outcomes guidance action plans. Raising concerns and areas of risk to the Board via the agreed governance arrangements. COMPOSITION OF NSSG: Chair of the NSSG The MDT lead clinician from each MDT in the network Nominated Oncologist Pathologist 27

28 Specialist Surgeons / Physicians At least one nurse core member of a MDT A service improvement staff representative Two user representatives* All the above are core members common to every NSSG. The following members are optional: As many other members of those MDTs e.g. Physiotherapy, Speech and Language therapy as appropriate A representative of palliative care A Primary Care Cancer Lead A manager representative (from a PCT, provider or NORCOM HQ) As a minimum, involve users in their service planning and review COMPOSITION OF CCG: CHAIR: CHAIR S EXTRA- MEETINGS ROLE INDIVIDUAL ROLES: * For any one NSSG, the network partnership group can agree an alternative mechanism for obtaining user advice. Each NSSG will list all its members. The composition of each cross cutting group includes a representative from each locality of each specific cross cutting group, and where appropriate wider membership will reflect National Guidance. All groups will review membership annually, and record attendance as per National Guidance. The NSSG/CCG will select its own chair and deputy. Tenure in each role should be reviewed after 3 years. The Chair should have an annual appraisal. The Chair will: - Ensure engagement of constituent members. Attend development programmes organised for the Lead Clinicians Facilitate the identification and agreement of the service priorities for the NSSG/CCG Recommend priorities to the Network Board. Ensure an annual report of the NSSG s work is written Have an annual (review) meeting with the Network Lead Clinician and the outcomes agreed by the Network Chair. Be an ambassador for service improvement locally and the NSSG/CCG, regionally and nationally. Each core member should attend 50% or more of the NSSG/CCG meetings. It is assumed that their employers will protect the time commitment entailed. One of the NHS-employed NSSG members will be named as having specific responsibility for users' issues. One of the NHS-employed NSSG members will be named as having specific responsibility on information for patients and carers. One of the NHS-employed NSSG members will be named as having specific responsibility on service improvement* ie being a champion for it. 28

29 None of the above three roles are mutually exclusive. Members should ensure that all decisions become integrated into constituent organisational structures and processes * but not the member of service improvement staff. DECISION MAKING PROCESS: QUORUM: RESPONSIBILITIES : All attendees at the NSSG meeting will have a vote. Recommendations to the Board will normally be achieved through consensus; however, when a vote is required it is essential that the split of votes is recorded to aid the understanding of the Board in the decision making process The meeting is quorate when 50% of the constituent core members are represented at the meeting, but the chair can declare a larger meeting non-quorate if key members are not present. NB this (long) list of responsibilities assumes the regular input of provider managers and network officers. Service Planning is in line with: 1 National guidelines and advising commissioners and provider trusts of the implications of that guidance for the whole network. 2 Identifying any risks within the service and developing a networkwide service delivery plan to deliver the NHS Cancer Plan. 3 Responding to Improving Outcomes Guidance recommendations and advising commissioners on appropriate patient pathway (or model options) developments within North Trent, which will deliver patient care within those recommendations. Developing efficient working models aligned to good practice guidance and national policy drivers. 4 Agreeing common standards including referral pathways, revised in light of national policy or guidance, patient care pathways (from primary care, both into and out of tertiary services). This includes updating and revising referral guidelines as appropriate. In time a service specification will be generated. 5 Agree on priorities for data collection, produce audit data and participate in open review including the user experience and service user evaluation 6 Monitor progress on meeting national cancer measures, trial entry and ensure action plans agreed at Peer Review are implemented. 7 Reviewing approved clinical trials, and other research, once a year. Agreeing a single list of clinical trials and studies into which the network s MDTs should give priority for patient entry. 8 Develop clear cancer workforce recommendations that foster new 29

30 FREQUENCY OF MEETINGS: SERVICED BY: ways of working so that services are robust in the face of recruitment difficulties and emergent technologies. 9 Foster strong working relationships to develop network-wide resolution to workforce issues 10 Liaising and consulting with the relevant "cross cutting" network groups to identify issues that have wider implications and consequent knock on effects. This includes chemotherapy; imaging; histopathology (and other laboratory investigations); specialist palliative care, with the Head of Service for radiotherapy, Children and Young People and Primary Care. At least once every 6 months to a maximum of 4 times per year. Additional meetings may be necessary for short term task and finish projects e.g Peer Review preparation, IOG implementation Cancer Network Office (2 days per meeting, but 9 days pa max) 2 COMMUNICATIONS : Outward NSSG/CCG lead to give feedback to the Lead Clinicians Forum and present findings, with recommendations, to Cancer Board - MDT leads to share items of news with fellow MDT members and with local managers - NSSG (lead) to write an annual report - NSSG to write an annual work programme for Board endorsement News can be placed on the network s website Agreed guidelines will be downloadable from there. MINUTES CIRCULATED TO: NSSG members Network Lead Clinician Cross-Cutting Groups Leads Primary Care Cancer Leads REVIEW DATE: July E-101y The Network AOS Group holds quarterly two hour meetings. Details of these meetings are outlined in the Annual Report. The meeting has administrative support to record the details of the discussions and those in attendance. 11-1E-103y There is a 24/7 on call consultant oncologist via the on call rota at Weston Park Hospital 9.00am to 5.00 pm 7 days per week they are contactable via the hot mobile telephone or the on call bleep, out of hours contacted via the hospital ( WPH) switchboard, Please see extract from specimen rota below 30

31 31

32 32

33 11-1E-104y Guidelines for Emergency Admissions Page 34 The example used in Rotherham (developed by Doncaster from work done by the Sherwood Forest Foundation Trust) has to been adapted for each trust and used across the network. All trust may have slightly different formats but all contain the same criteria. Treatment protocols have been adapted into a generic form for use across the Network (see the example for anaphylaxis below page 36.) Guidelines for referral for MSCC are included in Appendix 3 Annual Report Other protocols included are:- Radiotherapy Radiotherapy Radiotherapy Radiotherapy Radiotherapy induced mucositis.doc induced nausea.doc induced oesophagitis. induced nausea.doc induced mucositis.doc Radiotherapy Radiotherapy Radiotherapy Radiotherapy induced diarrhoea.do induced cerebral oedeinduced acute skin reainduced acute skin rea Radiation induced pneumonitis.doc Thrombocytopenia Induced Bleeding.doc SOL AOS.ppt Neutropenic Sepsis Policy network.doc lymphangitis hypomagnesaemia carcinomatosis AOS.p AOS.ppt extravasation2aos. doc extravasation1aos. doc ascites AOS.ppt AOS SCC.pdf AOS CVAD.ppt Chemotherapy Chemotherapy Chemotherapy Emergency induced nausea and vinduced mucositis.doc induced diarrhoea.domanagement of Spina Pleural Aspiration.doc Hypercalcaemia pathway comments.d Hypercalcaemia pathway 2.doc SUPERIOR VENA CAVA OBSTRUCTION 33

34 34

35 35

36 Example of a protocol for AOS - anaphylaxis Action to be taken if patient presents with anaphylaxis Action Rationale 1. Stop infusion/ treatment. The hypersensitivity reaction is affected by the quantity of the trigger 2. Assess airway, breathing, circulation To determine extent of reaction and help required 3. Call for immediate emergency help Patients condition may deteriorate stay with the patient and provide very quickly reassurance 4. Place the patient in a reclined position of comfort 5. Start oxygen at high flow rate (10 to 15 litres per minute) 6. If the patient has stridor, wheeze, respiratory distress or clinical signs of shock administer adrenaline (epinephrine) 1:1000 solution 0.5 ml (500 micrograms)* IM 7. Change IV giving set and administer rapid infusion of IV 0.9% sodium chloride Lying flat may help hypotension but breathing difficulties also need to be supported To increase oxygen saturation levels To reverse peripheral vasodilatation and reduce oedema. The IM route is more effective and associated with less complications than other routes of administration To increase circulating volume of blood. A crystalloid may be safer than a colloid 8. Check vital signs BP, pulse, respirations, oxygen saturations 9. Repeat adrenaline (epinephrine) 1:1000 solution 0.5 ml (500 micrograms)* IM if there are no signs of clinical improvement 10. Administer chlorphenarimine mg by slow IV injection or IM injection 11. If severe anaphylactic reaction administer hydrocortisone 100 mg IV 12. If hypotension does not respond to drug treatment administer rapid infusion of 1-2 litres IV 0.9% sodium chloride 13. If patient has bronchospasm consider giving nebulised salbutamol 14. Discuss with the doctor the need to monitor the patient post anaphylaxis event. If the patient is discharged from hospital warn them of the possibility of recurrence of symptoms and the need to seek urgent medical attention if they do occur 15. Document the episode in the medical and nursing notes. Inform the patients general practitioner of the event. Advise the patient that they need to try and avoid future exposure to the suspected allergen trigger. To aid assessment of the patients condition To reverse peripheral vasodilatation and reduce oedema. To counteract histamine mediated vasodilatation Plays a role in preventing late effects of the reaction To increase circulating volume of blood. A crystalloid may be safer than a colloid To treat bronchospasm To ensure appropriate post anaphylaxis care. Anaphylaxis reactions can recur in some cases 8-24 hours after the initial reaction. To try and prevent repeat anaphylaxis reactions. 36

37 The Network agrees that all localities will adhere to common agreed best practice guidelines specifying Where a patient will be managed Referral processes Treatment guidelines / indications for each tumour site Oncological emergencies 11-1E-105y Network information on early detection of MSCC Patient Information MSCC, examples from Sheffield and Chesterfield are included in Appendix 1 It is expected that all patients at risk of this condition are advised of their risk and provided with appropriate information. Information leaflets are available from all relevant MDT teams. Leaflets are available on NTCN website Local contact points are via patients GP s and links to acute oncology services available for primary care. All patients and advised of their local contact points The referral process is outlined in NTCN Referral guidelines Appendix 3 of the Annual Report document and Appendix 3 for 2WW pathway in this document. 37

38 11-1E-106y/107 Acute Oncology Training in the use of services. Each locality within the Network should provide induction training to inform all their staff of Acute Oncology services and how to access them. There should be a local plan to ensure that it is given to all new starters to organisations and particularly to all staff working on Medical admissions units, A&E and junior doctors. The training should include and cover at least the following:- 1. A description of the network configuration of the acute oncology service and where they are based in each of the localities 2. An awareness and understanding of the acute oncology referral guidelines and how individual patients should be managed 3. The protocols associated with the acute oncology service 4. The roles and responsibilities and relevant contact points for the following:- a) The Network Acute Oncology Group b) The Hospital Acute Oncology Teams c) The Acute oncology assessment service in their area d) How to access the North Trent 24/7ChemotherapyPatientAdvice service e) The process to access Fast Track referrals for patients to attend the appropriate Outpatients clinics in their organisations f) Awareness of The Consultant On Call service and how to access this g) How to contact the MSCC Hospital Coordinators h) How to contact the MSCC Clinical Advisors for both surgery/radiotherapy It is important that the information should contain locally specific information. It is expected that this training will be individual to each locality and will be delivered locally due to understanding of their own geographical location and processes. All organisations will have different emergency access configurations so requiring this approach There is a requirement for localities to keep written records of the training completion The training itself maybe delivered in a variety of formats i.e. face to face, e learning. Within North Trent cancer network, all organisations have developed their own individual training packages, which incorporate the above requirements. As example of training already undertaken, the South Yorkshire Programmes for Education in cancer care have developed a programme to 38

39 cover issues around Acute Oncology services and will continue to be delivered. Please see full Training Policy in Appendix 4 Training for MSCC Co-ordinators. Within North Trent we operate a system where Clinical advisors act as the coordinators for this emergency condition. The Clinical advisors are Consultant surgeons, Oncologists and Radiologists Please see MSCC Referral Guidelines (Appendix 3 Annual Report) 11-1E-108y There is a separate Network MSCC subgroup The Network Metastatic Spinal Cord Group Core Group Joint Chairs Mr N Chiverton Spinal Surgeon Sheffield Teaching Hospitals Dr D Brooks Consultant in Palliative Medicine Chesterfield Royal Hospital Medical Members Dr A.Cheema Consultant in Acute Medicine Sheffield Teaching Hospitals Dr M. Fernando Consultant in Palliative Medicine Doncaster & Bassetlaw Dr B Foran Consultant Clinical Oncologist Sheffield Teaching Hospitals Dr C Ingram Consultant Radiologist Sheffield Teaching Hospitals Dr O Purohit Consultant Clinical Oncologist Sheffield Teaching Hospitals Dr A Arefin Consultant Physician Rotherham Hospital(June 2012) AHP Members Suzanne Hodson Physiotherapist Sheffield Teaching Hospitals Sarah Nichol Occupational Therapist Ashgate Hospice Imaging Lead Roles Assigned to Core Members Dr C Ingram Consultant Radiologist Sheffield Non Core members Management Support Judith Bird Network Lead Nurse NTCN Administrative Support Lin Jameson Groups & Projects Support Officer NTCN 39

40 Interested Practitioners Who Receive Minutes Dr P M Fisher Clinical Director Weston Park Hospital Sheffield Teaching Hospitals Dr Kevin Bolster Speciality Doctor in Rotherham Hospice Palliative Care Dr R Cullen Primary Care Cancer Lead NTCN D Hughes Lead Cancer Clinician Sheffield Teaching Hospitals N James Lead Cancer Nurse Chesterfield Royal Hospital 40

41 NORTH TRENT CANCER NETWORK (NTCN) NETWORK Metastatic Spinal Cord Compression Cross Cutting Group TERMS OF REFERENCE April 2010 NAME OF GROUP: ACCOUNTABLE TO: PURPOSE: Network Site Specific Group (NSSG) Cross Cutting Group (CCG) The North Trent Cancer Network Board (including clinical and corporate governance). The MSCC CCG Chair is a member of the Network Lead Clinicians Group and as such is responsible for ensuring risks associated with the delivery of services are fed into the network planning process. The MSCC CCG has responsibility, delegated by the Board, for ensuring the co-ordination of the cancer pathway and the consistency of care for the relevant client group within the cancer network. This includes: Service planning Service Improvement / Redesign Service Quality Monitoring and evaluation including clinical performance and outcomes Workforce Development Research and Development The Network tumour-site specific groups should have the active engagement of all MSCC leads from all the relevant constituent organisations in the network. MSCC should ensure that all agreed operational changes are discussed with local managers to ensure that changes are integrated into constituent organisational structures and processes. Discussions to explore other changes to existing patient pathways may be initiated by commissioners including Primary Care. MSCC provides advice in respect of all significant service changes (e.g. IOG) particularly if there are financial consequences, and will make recommendations to the Cancer Board. The MSCC has a key role in: Developing plans to implement Improving Outcomes Guidance Monitoring the implementation of the agreed Improving Outcomes guidance action plans. Raising concerns and areas of risk to the Board via the agreed governance arrangements. COMPOSITION OF Chair of the MSCC CCG 41

42 MSCC CCG: The MSCC lead clinician from each organisation in the network Nominated Oncologist Radiologist Specialist Surgeons /Emergency Physicians At least one nurse core member of a MDT A service improvement staff representative Palliative care lead Two user representatives* * For any one NSSG, the network partnership group can agree an alternative mechanism for obtaining user advice. The following members are optional: As many other members of those MDTs e.g. Physiotherapy, Speech and Language therapy as appropriate A Primary Care Cancer Lead A manager representative (from a PCT, provider or NORCOM HQ) As a minimum, involve users in their service planning and review COMPOSITION OF CCG: CHAIR: CHAIR S EXTRA- MEETINGS ROLE INDIVIDUAL ROLES: Each CCG will list all its members. The composition of each cross cutting group includes a representative from each locality of each specific cross cutting group, and where appropriate wider membership will reflect National Guidance. All groups will review membership annually, and record attendance as per National Guidance. The MSCC CCG will select its own chair and deputy. Tenure in each role should be reviewed after 3 years. The Chair should have an annual appraisal. The Chair will: - Ensure engagement of constituent members. Attend development programmes organised for the Lead Clinicians Facilitate the identification and agreement of the service priorities for the CCG Recommend priorities to the Network Board. Ensure an annual report of the CCGs work is written Have an annual (review) meeting with the Network Lead Clinician and the outcomes agreed by the Network Chair. Be an ambassador for service improvement locally and the CCG, regionally and nationally. Each core member should attend 50% or more of the CCG meetings. It is assumed that their employers will protect the time commitment entailed. One of the NHS-employed CCG members will be named as having specific responsibility for users' issues. One of the NHS-employed CCG members will be named as having specific responsibility on information for patients and carers. One of the NHS-employed CCG members will be named as having 42

43 specific responsibility on service improvement* ie being a champion for it. None of the above three roles are mutually exclusive. Members should ensure that all decisions become integrated into constituent organisational structures and processes * but not the member of service improvement staff. DECISION MAKING PROCESS: QUORUM: RESPONSIBILITIES : All attendees at the CCG meeting will have a vote. Recommendations to the Board will normally be achieved through consensus; however, when a vote is required it is essential that the split of votes is recorded to aid the understanding of the Board in the decision making process The meeting is quorate when 50% of the constituent core members are represented at the meeting, but the chair can declare a larger meeting non-quorate if key members are not present. NB this (long) list of responsibilities assumes the regular input of provider managers and network officers. Service Planning is in line with: 1 National guidelines and advising commissioners and provider trusts of the implications of that guidance for the whole network. 2 Identifying any risks within the service and developing a networkwide service delivery plan to deliver the NHS Cancer Plan. 3 Responding to Improving Outcomes Guidance recommendations and advising commissioners on appropriate patient pathway (or model options) developments within North Trent, which will deliver patient care within those recommendations. Developing efficient working models aligned to good practice guidance and national policy drivers. 4. Agreeing common standards including referral pathways, revised in light of national policy or guidance, patient care pathways (from primary care, both into and out of tertiary services). This includes updating and revising referral guidelines as appropriate. In time a service specification will be generated. 5. Agree on priorities for data collection, produce audit data and participate in open review including the user experience and service user evaluation 6. Monitor progress on meeting national cancer measures, trial entry and ensure action plans agreed at Peer Review are implemented. 7. Reviewing approved clinical trials, and other research, once a year. Agreeing a single list of clinical trials and studies into which the network s MDTs should give priority for patient entry. 43

44 FREQUENCY OF MEETINGS: SERVICED BY: 8. Develop clear cancer workforce recommendations that foster new ways of working so that services are robust in the face of recruitment difficulties and emergent technologies. 9. Foster strong working relationships to develop network-wide resolution to workforce issues 10. Liaising and consulting with the relevant "cross cutting" network groups to identify issues that have wider implications and consequent knock on effects. This includes chemotherapy; imaging; histopathology (and other laboratory investigations); specialist palliative care, with the Head of Service for radiotherapy, Children and Young People and Primary Care. At least once every 6 months. Additional meetings may be necessary for short term task and finish projects e.g Peer Review preparation, IOG implementation Cancer Network Office (2 days per meeting, but 9 days pa max) 3 COMMUNICATIONS : Outward NSSG/CCG lead to give feedback to the Lead Clinicians Forum and present findings, with recommendations, to the Network Strategy Group - MDT leads to share items of news with fellow MDT members and with local managers - NSSG (lead) to write an annual report - NSSG to write an annual work programme for Board endorsement News can be placed on the network s website Agreed guidelines will be downloadable from there. MINUTES CIRCULATED TO: CCG members Network Lead Clinician Cross-Cutting Groups Leads Primary Care Cancer Leads REVIEW DATE: July

45 11-1E-109y MSCC Clinical Advisor service - See Algorithm Appendix B in the MSCC Guidelines (extract below) In Annual Report document 11-1E-110y MSCC Case discussion policy - See Algorithm Appendix B in the MSCC Guidelines particularly the information in the extract below URGENT Referral/opinion- Spinal surgical team (Northern General Hospital-Sheffield) for decompression and spinal stabilization-tel: (08:00 17:00) Out of hours-spinal Surgeon on call via Northern General hospital switch board ( ) Referral proforma to be completed ( internet link) North Trent Cancer Network-guidance notes ( internet link) Note: Need Consultant to Consultant discussion Referral to Oncology team for Radiotherapy at Weston Park Hospital-Sheffield as appropriate depending on the outcome from discussion with the Spinal surgical team 11-1E-103y Consultant Oncologist Telephone On Call Service The detail required of this service is contained in the Cancer chemotherapy specification (full copy available).the specification was approved at the Chemotherapy Strategy group meeting on the 6 th September 2011 Minutes in hard copy evidence. Relevant extract from service specification below and Triage tool for calls to the service included:- 3.3 Pathways All providers are required to follow the generic network chemotherapy pathways and locally customised developed pathways, and to set up planned audit against the pathway. Outcomes (including morbidity and mortality, waiting times) will be monitored as part of the quarterly review. Where local pathways exist for solid tumour oncology they should be designed to show clearly the links with the Oncology Centre, including how a patient enters, is managed and discharged from the service. All pathways should include timelines and alert mechanisms for potential breaches, audit processes to ensure standards are met, and specification of provider and commissioner responsibilities. The provider(s) should meet standards for prescribing, adhere to the required competency checks and should foster a responsive and participative approach to including patients views about their care in the design of care pathways, and should collaborate with other organisations involved in the patient pathway to provide a seamless patient journey. At entry to pathway, the provider must have systems and processes in place to 45

46 register patients collect relevant clinical and administrative data manage the appointment process, (reappointment and DNA process, if appropriate) provide information to patients undertake initial assessment in the appropriate location At point of intervention, the provider must have systems and processes in place to ensure that: the intervention is conducted safely and in accordance with accepted quality standards and good clinical practice. the patient receives appropriate care during the intervention(s), including on treatment review and support, in accordance with best clinical practice where clinical emergencies or complications do occur they are managed in accordance with best clinical practice the intervention is carried out in a facility which provides a safe environment of care and minimises risk to patients, staff and visitors the intervention is undertaken by staff with the necessary qualifications, skills, experience and competence There are arrangements for the management of out of hours care according to best clinical practice There is communication with primary care At exit from pathway, the provider must have systems and processes, which are agreed with all parties and networks, in place to: undertake telephone triage make urgent onward referrals where life-threatening conditions or serious unexpected event occur during an intervention/assessment ensure that patients receive discharge information relevant to their intervention including arrangements for contacting the provider and follow up if required provide timely feedback to the referrer re intervention, complications and proposed follow up ensure that the patient receives required drugs/dressings/aids ensure that support is in place with other care agencies as appropriate 3.4 Treatment Protocols and Interventions All providers are required to follow evidence-based treatment protocols and interventions as agreed with the North Trent Cancer Network and adherence to the external accreditation and / or internal quality assurance processes for chemotherapy. Treatment protocols/interventions Include all individual treatment protocols in place within the service or planned to be used including: Individual systemic therapies 46

47 Drug reconstitution and handling Drug spillage Cytotoxic disposal Other, e.g. management of emergencies (anaphylaxis, cardiac arrest, extravasation etc), complications of systemic therapy, febrile neutropenia etc Information on how to contact clinical staff throughout the 24 hour period Services should ensure that patients do not have to wait longer than one hour before start of treatment where an appointment time has been given for chemotherapy to be administered on a subsequent day. Where chemotherapy is to be given on the same day as the assessment/consultation, any delays should be communicated to the patient immediately. 47

48 48

49 49

50 50

51 51

52 52

53 53

54 54

55 55

56 Appendix E-105y Examples of Patient information 1.Chesterfield 56

57 57

58 2. - Sheffield 58

59 59

60 60

61 61

62 Appendix 2 Acute oncology triage and assessment (Held 29 th September and 31 st October 2011) Programme Coffee and Registration 9.25 Welcome and introductions Kam Singh Acute oncology including renal failure, dehydration and tumour lysis syndrome Dr Kate Shankland Tea Telephone assessment review Kam Singh Lunch Telephone assessment guidelines and reporting forms Acute oncology complications of cancer treatment Nausea and Vomiting Infection and use of growth factor support Thrombosis Hypercalcaemia Management of hypotensive cancer patient Clare Warnock/ Charlie Osguthorpe Dr Matt Winter Tea Scenarios and workshops Evaluations and close 62

63 Target audience: CNS / triage nurses / allied health professionals / junior doctors Introduction to Acute Oncology at STH Background / Need for Acute Oncology service NCEPOD etc Service structure (Central campus vs. Northern Campus) How to contact us Patients we want to know about (This session will cover some of the peer review requirements of induction training for acute oncology. For people who could not attend could be available electronically with read receipt etc) Morning session To cover early recognition, evaluation and immediate management of o Acute oncology presentations caused by disease o Complications of systemic treatment of cancer o Complications / Adverse effects of radiotherapy o Triage Assessment tools (Clare Warnock) Afternoon session could include Malignant Spinal Cord Compression Palliative Care and Acute Oncology Update on specific areas e.g. cardiology in oncology, site specific updates Problem based scenarios and discussion e.g. off legs, nausea and vomiting, Fever, SOB (Group working) 63

64 Appendix 3 Proforma for Metastatic Spinal Referrals Emergency Referral (phone call already made) / Referral for urgent opinion* Delete as appropriate Please complete as fully as possible and fax to: Surname: Forename: Gender: D.O.B.: Address: Patient details Referrer details Hospital: Ward: Direct dial number: Consultant i/c: Contact number: Date of admission: : Time of admission: Date of referral: Telephone no: Time of referral: Current co-morbidities Is patient's Oncologist aware of referral? Y / N / NA 1) Is the patient anticoagulated? Y / N 2) Patient understanding 3) Has diagnosis been discussed with the patient? Y / N 4) Does the patient wish to consider surgery? Y / N Tumour presentation Available Imaging Known primary Whole spine MRI Y / N Unknown primary (investigations complete) (Date and time of MRI): Unknown primary (Investigations incomplete) CT chest / abdo / pelvis Y / N Prognosis >3 months Y / N /? Bone scan Y / N PLEASE ENSURE ALL IMAGING IS UPLOADED TO NGH PACS SYSTEM Performance status (prior to onset of spinal symptoms) 0 Fully active 1 Fully ambulant. Restricted with strenous activities only 2 Fully self caring. 3 Limited with self care. Resting for >50% of waking hours 4 Completely disabled. Totally confined to bed or chair PLEASE COMPLETE THE NEXT PAGE (tick) 64

65 Patient name: D.O.B.: Primary tumour site Pain Symptoms Breast Prostate Renal Pain Y / N since (date): Lung Myeloma Lymphoma Level / location: Thyroid GIT Urothelial Type Non-specific Mechanical Neuralgic Uterine/Cx Melanoma Pattern Nocturnal Diurnal Constant Other (specify): Analgesia Minor Major Date of diagnosis: VAS Score: / 10 Primary treatment: Describe: Neurological symptoms Adjuvant treatment Current walking status 1) XRT to spinal met Y / N Normal 2) Unsteady since (date): 3) Non-ambulant since (date): Metastases Continence Extra spinal bone mets Y / N Urinary incontinence Y / N since (date): Visceral mets Y / N Faecal incontinence Y / N since (date): Liver Lung Anal tone Normal Reduced Absent Brain Adrenal Perineal sensation Normal Reduced Absent Lymph nodes Other Catheter tug Felt Not felt N/A Other relevant Information: Sensation Normal Reduced Absent Most distal dermatome with normal sensation: Power Most distal myotome with normal power MRC grade of weakest muscle(s) Details of clinician to be responsible for ongoing care of the patient following surgery Name: Contact number: If you wish to discuss a referral please contact the on-call spinal surgeon on during office hours or otherwise via the NGH switchboard ( ) 65

66 Appendix 4 Network Training in Acute Oncology Services Measure 11-1E-106y/107 Review Date April

67 NTCN Acute Oncology Training in the use of acute oncology services. Introduction It is the networks view that all localities should provide training to all relevant staff as outlined in the Acute Oncology National Cancer Peer Review Measure 1 within their organisations about Acute Oncology services and provide regular awareness sessions and updates to existing staff in their organisations This policy is intended to introduce the concept of Acute Oncology and to provide guidance on the Acute Oncology process for all medical and nursing staff involved directly in the assessment and admission of known cancer patients presenting as unscheduled attendances. Background An Acute oncology service is designed to be a process to meet the needs of cancer patients who become acutely unwell or develop a new problem associated with their treatment and/or their disease and which needs urgent care, often by presentation to an emergency department. Some problems e.g. neutropenic sepsis following chemotherapy can be life threatening conditions unless treated promptly and correctly. Others such as spinal cord compression may lead to permanent disability and subsequent poor quality of life. Sometimes the development of a new, urgent medical problem is the presentation of an underlying undiagnosed cancer. Acute Oncology as a service is a relatively new development in Cancer Services. The development of an acute oncology infrastructure came from recommendations of the National Chemotherapy Advisory Group (NCAG): Chemotherapy Services in England: Ensuring Quality and Safety in 2009 and the NCEPOD Report: For Better, For Worse in 2008 which examined the incidence of deaths within 30 days of systemic anti-cancer treatment (SACT). These reports concluded that there were patient deaths due to complications of treatment that could have been avoided and that there was a need for better communication and coordination between services. Which patients does Acute Oncology apply to? Any patient with an existing cancer diagnosis (solid tumour or haematological) who has an urgent problem related to: A complication of recent cancer treatment (acute side effects during treatment or within 6 weeks of administration). Late effects of treatment 1 National Cancer Peer Review Programme Manual for Cancer Services: Acute Oncology - Including Metastatic Spinal Cord Compression Measures Version 1.0 April

68 can develop months and years after treatment but are less likely to present as an emergency A new problem caused by the cancer itself or a consequence of the cancer illness. e.g. a bleed from a tumour, a fit caused by a brain metastases or systemic infections. Some of these are extreme oncological emergencies and staff should to be familiar with the common causes and how to manage them. A new acute problem that might be the first sign of a recurrent cancer in patients who have had previous treatment e.g. surgery A presentation of a previously undiagnosed cancer particularly when there is evidence of widespread metastases and no known primary site of origin (cancers of unknown origin) The emphasis of the Acute Oncology Service is non-surgical management since guidelines and care pathways concerning acute post-operative emergencies are normally well established and would supercede any others. The noticeable exception to this is the initial surgical management of patients presenting with Metastatic Spinal Cord Compression (M.S.C.C) Cancer patients may also present to emergency departments with problems that are considered to be unrelated to their cancer and which are a manifestation of co-morbidity. In general these presentations will not be referred to the Acute Oncology team although it might be appropriate to seek their advice if the patient is on current treatment or there is uncertainty as to whether the presenting problem is a consequence of the cancer and/or its treatment. Advantages of an Acute Oncology service For Staff Cancer management is becoming increasingly complex. All staff that sees these acute patients needs to have prompt access to up to date clinical information about a patients cancer, treatment details, aims and prognosis. There should also be easy access to specialist oncology advice, both during the working day and outside of working hours for members of the Acute Oncology team including non-surgical oncologists who may be sited at the Cancer Centre. For Patients The aim of Acute Oncology is to improve both the safety and quality of care: Safer cancer treatments with side effects managed promptly and correctly 68

69 Management of cancer problems co-ordination of expertise in emergency care, non-surgical oncology, haemato-oncology and palliative care More efficient pathway management with fewer, potentially avoidable admissions, unnecessary tests and investigations and shorter lengths of stay Greater confidence for patients and carers in teams that have access to up to date clinical information, who understand the concept of acute oncology and who communicate effectively with each other Locality Training Requirements Each locality within the Network should provide induction training to inform all relevant health care professionals according to the Acute Oncology Cancer Peer Review Measures (2011) 2 and how to access them. There should be a local plan to ensure that it is given to all new starters to organisations and particularly to all staff working on Medical admissions units, A&E and junior doctors. It is important that the information should contain locally specific information. It is expected that this training will be individual to each locality and will be delivered locally due to an understanding of their geographical location and processes. All organisations will have different emergency access configurations so requiring this approach. In addition to this, training is provided by South Yorkshire Programme Education in cancer care, around oncology issues and this can also be accessed from other areas. Any local training in the use of the acute oncology service is expected to apply to Consultant Oncologists and to the hospital acute oncology assessment rota staff in all the hospitals who take part in such a rota (Measure11-3Y-403) It should also be part of the training for the staff who take part in the Consultant oncologist 24/7 on call rota and the 24/7 chemotherapy advice service rota should be trained in the use of an acute oncology service if that hospital provides such a service. (Measure 11-3Y-305) It also expected that the training should include an assessment process which ascertains the treatment intent and addresses Palliative and End of life issues The education policy should be developed in conjunction with existing policies already developed by NTCN for example 2 National Cancer Peer Review Programme Manual for Cancer Services: Acute Oncology - Including Metastatic Spinal Cord Compression Measures Version 1.0 April

70 Guidelines/Microsoft%20Word%20-%20chemo%20ed%20v3.pdf There is a requirement that the training should include at least the following 5. A description of the network configuration of the acute oncology service and where they are based in each of the localities 6. The roles and responsibilities and relevant contact points of key personnel in oncology services by locality and network wide including The Network Acute Oncology Group The Hospital Acute Oncology teams, The Acute Oncology Assessment service, The 24/7chemotherapy patient advice service How to fast track referral to out patient clinics How to access the consultant on call service How to access the MSCC co coordinators How to access the MSCC clinical advisors 3. An awareness and understanding of the acute oncology referral guidelines and how individual patients should be managed 4 The protocols and pathways associated with the acute oncology service 5. Contain locally specific information 6. Confirmation of completion of this training as part of induction should be kept and regularly updated. 70

71 1. A description of the network configuration of the acute oncology service and where they are based in each of the localities NTCN Acute Oncology Service Hospice Palliative care beds Chesterfield Royal A+E Haem beds OP Chemo Acute medical beds Hospice Palliative care beds Northern General A & E Palliative Care Unit Acute Medical Beds No OP Chemo STHFT Hospice Palliative care beds Royal Hallamshire No A+E No Acute Medicine beds Haem beds OP Chemo Weston Park Hospital No A+E No Acute medicine beds Hospice Palliative care beds Barnsley A+E Acute medical beds OP Chemo (Onc) Haem Beds Rotherham A+E OP Chemo Haem beds Acute medical beds Bassetlaw A & E No OP chemo Doncaster Haem beds OP Chemo (Haem + Onc) A & E Hospice Palliative care beds 71

72 2. The roles and responsibilities and relevant contact points HOSPITALS PROVIDING ACUTE CARE IN NORTH TRENT CANCER NETWORK AND THE HOSPITAL ACUTE ONCOLOGY TEAMS CONTACT DETAILS ARE AVAILABLE LOCALLY FOR ALL SERVICES Designated Lead AOS Clinician/Team Hospital Host Organisation Referring PCT Population (not weighted) MSCC treated Dr Julian Humphrey Consultant in Emergency Medicine Barnsley District General Hospital Barnsley Hospital NHS Foundation Trust Barnsley Primary Care Trust 234,397 No Dr Mansur Reza Consultant in General Medicine Dr Joe Joseph Consultant Haematologist Dr Ahmed Arefin, Consultant Physician Dr Matthew Winter Consultant Medical Oncologist Dr Peter Kirkbride Consultant Clinical Oncologist Chesterfield Royal Hospital Doncaster Royal Infirmary and Bassetlaw Hospital Rotherham Hospital Sheffield Teaching Hospitals Chesterfield Royal Hospital NHS Foundation Trust Doncaster & Bassetlaw NHS Foundation Trust Rotherham Hospital NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust Derbyshire County Primary Care Trust Doncaster Primary Care Trust Bassetlaw Primary Care Trust Rotherham Primary Care Trust Sheffield Primary Care Trust 320, ,624 No No 106,691 No 243,151 No 550,513 Yes Surgery at NGH DXR WPH at 72

73 Network Acute Oncology Group The Network Acute Oncology Group is a subgroup of the Network Chemotherapy Strategy Group and reports into this group Details of the members and activities of the group are available in the Network Acute Oncology Group Constitution document and on the NTCN website. All localities from the Network are represented on this group and contact details should be available locally. In addition it is expected that the training should provide 3. Awareness and understanding of the acute oncology referral guidelines and how individual patients should be managed and the purpose of the Acute Oncology team. Acute Oncology Presentations Each Hospital will diagnose and treat with appropriate consultation with the cancer centre the following caused by the systemic treatment of cancer in line with NTCN agreed guidelines. Weston Park Hospital does not manage either Pleural or Pericardial effusions The current network policy is that the all patients receiving chemotherapy treatment for solid tumours contact Weston Park Hospital directly and are admitted to WPH for treatment. However, in view of the fact that some patients will present locally despite this, all units need to have processes in place to ensure that patients who present directly to them via A&E are promptly assessed and treated in discussion with WPH. When patients are stable they should then be transferred to WPH at the earliest opportunity. The following, as caused by systemic anti-cancer treatment: Neutropaenic sepsis Uncontrolled nausea and vomiting Extravasation injury Acute hypersensitivity reactions including anaphylactic shock Complications associated with venous access devices Uncontrolled diarrhoea Uncontrolled mucositis Hypomagnesaemia The following, as caused by radiotherapy: 73

74 Acute skin reactions Uncontrolled nausea and vomiting Uncontrolled diarrhoea Uncontrolled mucositis Acute radiation pneumonitis Acute cerebral/other CNS oedema The following, caused directly by malignant disease and presenting as an acute problem. This section may refer to patients with known malignant disease, whether they are picked up by the hospitals flagging system or not, or patients with previously unknown malignant disease: Pleural effusion Pericardial effusion Lymphangitis carcinomatosa Superior mediastinal obstruction syndrome, including superior vena cava obstruction Abdominal ascites Hypercalcaemia Spinal cord compression including M.S.C.C Cerebral space occupying lesion(s) Any other cases where the A&E staff and acute medical firm decide an urgent oncology assessment is needed. Assessing the Cancer Patient in the Emergency Department When a known cancer patient attends the emergency department an Acute Oncology Assessment Proforma should be completed. The documentation is designed to assist clinicians with the assessment and to help determine the need for admission (Appendix 1) This documentation maybe different in each locality but should take account of at least the following factors. Patient assessment Type of cancer and sites of disease 74

75 Name of oncologist (haematologist) with overall management, hospital where seen for treatment/follow-up, key worker name Names contact details, hospital number Are they currently on chemotherapy/radiotherapy treatment or completed in the last 6 weeks Date of last treatment When last seen Current medication Prognosis and treatment intent Currently on treatment /not started Is the problem related to cancer treatment/infection/eol/unrelated to cancer Patients and carers understanding and expectations The Acute Oncology Team The Acute oncology team is not an MDT. This team s role is not intended to be one of dealing with the care of individual patients although individual members may be involved with Acute Oncology problems in the course of their everyday practice. The team is organisational, dealing with Acute Oncology policies, protocols and procedures. The team will have the designated responsibility from the hospital management to: Act as the coordinating body for matters relating to acute oncology between the hospitals directorates and departments and between the hospital and other hospitals in the Network. Ensure the implementation and compliance with the Acute Oncology Cancer Peer Review measures for the hospital Report to the N.A.O.G and the hospital management team Metastatic Spinal Cord Compression It is recommended that any training that is delivered should pay particular attention to raising awareness of Metastatic Spinal Cord Compression and understanding of the local pathways and appropriate referrals to the MSCC service based at the Northern General Hospital In Sheffield. This will require an understanding of:- 1. Metastatic Spinal Cord Compression: early signs and symptoms Contact MSCC co-ordinator urgently within 24 hours to discuss care of patients with cancer and any of the following symptoms suggestive of spinal metastases: Pain in the middle (thoracic) or upper (cervical) spine Progressive lower (lumbar) spinal pain Severe unremitting lower spinal pain 75

76 Spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing) Localised spinal tenderness Nocturnal spinal pain preventing sleep N.B Most patients who are felt to be particularly at risk of this condition occurring should have already been provided with appropriate information to raise the patients awareness of this risk. This information should include relevant local contact details as felt appropriate Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and to view them as an oncological emergency: This is for either Surgery or Radiotherapy Neurological symptoms including radicular pain, any limb weakness, difficulty walking, sensory loss or bladder and bowel dysfunction Neurological signs of spinal cord or corda equina compression. Referral forms and contact details for this condition are included in NTCN Constitution document and should be part of all organisations local information and training and are on NTCN website. Training for MSCC Co-ordinators. Measure 11-1E-107y Within North Trent we operate a system where Clinical advisors act as the coordinators for this emergency condition. The Clinical advisors are Consultant surgeons, Oncologists and Radiologists and have highly specialist knowledge of this condition. 4. The protocols associated with the acute oncology service Network oncology pathways have been developed and cover all the main tumour groups. These have been developed in conjunction with all localities but they may be produced in a slightly different format in each area. 76

77 In addition there are more comprehensive policies available via the NTCN website e.g. neutropaenic sepsis which has been developed across the network and links into the education and training process. Guidelines/Microsoft%20Word%20- %20Neutropenic%20Sepsis%20revised%202007%20minus%20answers%20r atified%202010%204.pdf Treatment protocols and guidelines for acute oncology presentations should be available electronically and hard copies will also be available prominently in clinical areas. These again should not detract from the need to seek specialist advice from the MDT members/oncologist/haematologist managing the patient s cancer. Within NTCN there is a requirement for all solid tumour patients being treated or having been treated with chemotherapy in the last 6 weeks and presenting with signs and/or symptoms of neutropenia to be treated and transferred to Weston Park Hospital. Assessing clinicians/health Care Professionals must liaise with the patients own oncologist or the oncologist on call at W.P.H for advice and to arrange the transfer. In the event that Weston Park Hospital does not have any beds available the transfer should be facilitated at the earliest opportunity Contact details included in Appendix 2 and available on NTCN website Fast track Access to OP Clinics The training should address the process of how to access Fast Track referrals for patients to attend the appropriate Outpatients clinics in their organisations. This will require an understanding of a locality Oncologist timetable and services/ specialities provided. Access to Advice and information Training should inform staff on how they can access the North Trent 24/7Chemotherapy Patient Advice service as per flyer Appendix 2 and in addition an awareness of The Consultant On Call service and how to access this Training Compliance There is a requirement for localities to keep written records of the training completion There is no specification as to how the training itself should be delivered and can be done in a variety of formats i.e. face to face, e learning. 77

78 In the future it is planned to develop an e-learning package in conjunction with East Midlands Cancer Network which may support and enhance this work Within North Trent Cancer Network, all organisations have developed their own individual training packages, which incorporate the above requirements. There is a requirement that localities will provide reassurance to the NAOG that this process is being undertaking on a regular basis and that a list on training completion is kept and updated locally. This will be a regular agenda item of the group. As an example of training already undertaken, the South Yorkshire Programmes for Education in cancer care have developed a programme to cover issues around Acute Oncology services and will continue to be delivered. Programme included in Appendix 3 78

79 Appendix 1 AOS Assessment Proforma 79