Referral guide for acute oncology emergencies 1 st Edition v 1.0 London Cancer March 2013 To be used in conjunction with London Cancer clinical guidelines for acute oncology emergencies; A Guide to Acute Oncology Emergencies 1 st edition October 2012. London Cancer Acute Oncology Referral Guidelines v1.0 240313 1
Foreword In April 2011, NHS London published an outline specification for an integrated cancer system (ICS) for the capital to deliver seamless cancer care. The North Central London & West Essex (NCLWE) Cancer Network and North East London (NEL) Cancer Network merged to become the London Cancer ICS. Dr Adrian Tookman and Dr Ekaterini Boleti were appointed in July 2012 as Co-Chairs of the Acute Oncology Expert Reference Group (AOS ERG) for London Cancer. The AOS ERG was rapidly established, and the first meeting was held on 27 th September 2012. Since that time the Expert Reference Group has been working to align Acute Oncology across London Cancer, bringing together services across the North East and North Central London and West Essex. This Referral Guide has been developed from that originally published by the North East London Network Acute Oncology Group to provide a resource for health care professionals in primary and secondary care about services across the whole of the Integrated Cancer System. Contents 1 Summary... 3 2 Full Referral Guidelines... 4 2.1 Introduction... 4 2.2 Background... 4 2.3 Acute Oncology Service Provision in London Cancer... 5 2.4 Acute Oncology contacts in London Cancer... 7 2.5 Acute Oncology Clinical Guidelines... 10 3 Appendix 1 Acute Oncology Reference Guide... 10 London Cancer Acute Oncology Referral Guidelines v1.0 240313 2
1 Summary Acute Oncology encompasses the management of: Patients with acute complications from their cancer diagnosis Patients with acute complications from their cancer treatments Patients who present as an emergency with a suspected but undiagnosed cancer. Acute Oncology Services exist at each of the acute trusts in the London Cancer Integrated Cancer System. The majority of these currently function in hours, Monday to Friday 9-5. Full details are available in Table 1. Access to acute oncology In hours The Acute Oncology team at your local should be used by primary care as the point of contact for this group of acutely unwell patients. In most trusts, admission will still be via A&E but contact with the Acute Oncology team can expedite and optimise management. Tumour-specific specialist oncology teams who are managing the treatment and care of patients are still available for advice where this is felt to be more appropriate and/or the situation is not acute. Out of hours If you are clear on the need for acute care and admission, then patients should be sent to your local A&E. If you would like specialist oncological advice on management, then all s offer 24/7 access for healthcare professionals to advice from a consultant oncologist. At all times Metastatic Spinal Cord Compression (MSCC) coordinators (see Table 2) should be contacted regarding any patients suspicious for MSCC. Each acute oncology team is equipped to deal appropriately with the following conditions, as well as any other cases where an urgent oncology assessment is needed: Conditions caused by the systemic treatment of cancer Conditions arising as a result of radiotherapy Conditions caused directly by malignant disease and presenting as an urgent acute problem Neutropenic sepsis Acute skin reactions Uncontrolled pain Uncontrolled nausea and vomiting Uncontrolled nausea and vomiting Pleural effusion. Pericardial effusion. Extravasation injury (not Uncontrolled diarrhoea Lymphangitiscarcinomatosa. provided at Homerton Hospital) Acute hypersensitivity reactions including anaphylactic shock Complications associated with venous access devices Uncontrolled diarrhoea Uncontrolled mucositis Hypomagnesaemia Uncontrolled mucositis Acute radiation pneumonitis Acute cerebral/other CNS, oedema London Cancer Acute Oncology Referral Guidelines v1.0 240313 3 Superior mediastinal obstruction syndrome, including superior vena caval obstruction. Abdominal ascites. Hypercalcaemia Spinal cord compression including MSCC + Cerebral space occupying lesion(s) A two page summary of this information, including all contact details, is available in Appendix 1
2 Full Referral Guidelines 2.1 Introduction Acute Oncology encompasses the management of patients who develop complications from their cancer diagnosis or present with complications from their cancer treatments, as well as the management of patients who present as an emergency with an undiagnosed cancer. The Acute Oncology Service (AOS) brings together the skills and expertise of staff working in A&E, general medicine, oncology and palliative care, with the aim of ensuring the cancer patient/ suspected cancer patient who is admitted as an emergency is assessed promptly and referred to the most appropriate team. These acute oncology referral guidelines have been developed to assist primary care health care professionals and GPs whose patients may present or call with acute oncology symptoms following treatment for their cancer or as a direct result of the disease itself. The purpose of these AOS referral guidelines is to provide primary care clinicians and hospitals/ services outside London Cancer with: The contact details of the acute oncology teams in each of the local hospitals. The contact point for the 24 hour on call oncology telephone service (for healthcare professionals only) Guidance on where to refer those patients who present with Acute Oncology complications. These guidelines have been developed from those originally produced by the North East London Cancer Network Acute Oncology Board (NAOG) and should be used in conjunction with the London Cancer Guide to Acute Oncology Emergencies 1 st edition, which provides detail of the guidelines for clinical management of acute oncology emergencies. 2.2 Background The recent reports from National Confidential Enquiry into Patient Outcomes and Death 2008 (NCEPOD) and the National Chemotherapy Advisory group report 2009 (NCAG) have highlighted the urgent need for reform in the way we manage patients with cancer who present in the emergency setting. It recognises in-patient cancer care accounts for around 50% of all Cancer expenditure and that in-patient cancer care accounts for 12% of all acute in-patient bed stays. In-patient admissions for cancer have risen by 25% over the past eight years, which mostly are related to emergency admissions. It is estimated that an average hospital will have 5 cancer patients admitted to A&E every day. The NCAG report recommends that trusts should have a systematic approach for dealing with cancer-related emergencies, embodied in the concept of the Acute Oncology Service. Acute Oncology services, broadly, are intended to cater for patients potentially suffering from acute complications of cancer treatment, with the focus on non-surgical treatment (with acute post-operative emergencies managed in line with existing surgical care pathways) London Cancer Acute Oncology Referral Guidelines v1.0 240313 4
patients potentially suffering from certain emergencies caused by the disease process itself, whether the primary site is known, unknown or presumed. 1 2.3 Acute Oncology Service Provision in London Cancer The London Cancer ICS covers a wide geographical area and several acute s, as shown in figure 1. Fig 1: Map of the London Cancer Area Acute Oncology Services exist at each of the acute trusts in the network: Barking Havering and Redbridge University Hospitals NHS s o Queens Hospital, Romford o King George Hospital Barts Health NHS o St Bartholomew s Hospital o The Royal London o Whipps Cross Hospital o Newham Hospital 1 National Cancer Action Team Manual for Cancer Services: Acute Oncology Including Metastatic Spinal Cord Compression Measures Version 1.0 London Cancer Acute Oncology Referral Guidelines v1.0 240313 5
Homerton University Hospital Foundation NHS Barnet and Chase Farm Hospitals NHS o Barnet Hospital o Chase Farm Hospital North Middlesex University Hospital NHS Royal Free London NHS Foundation University College London Hospital NHS Foundation Whittington Health Princess Alexandra Hospital Each acute oncology team is equipped to deal appropriately with the following conditions: Conditions caused by the systemic treatment of cancer Neutropenic sepsis Uncontrolled nausea and vomiting Extravasation injury (not provided at Homerton Hospital) Acute hypersensitivity reactions including anaphylactic shock Complications associated with venous access devices Uncontrolled diarrhoea Uncontrolled mucositis Hypomagnesaemia Conditions arising as a result of radiotherapy Acute skin reactions Uncontrolled nausea and vomiting Uncontrolled diarrhoea Uncontrolled mucositis Acute radiation pneumonitis Acute cerebral/other CNS, oedema Conditions caused directly by malignant disease and presenting as an urgent acute problem Uncontrolled pain Pleural effusion. Pericardial effusion. Lymphangitiscarcinomatosa. Superior mediastinal obstruction syndrome, including superior vena caval obstruction. Abdominal ascites. Hypercalcaemia Spinal cord compression including MSCC + Cerebral space occupying lesion(s) In addition to those conditions specified above, all acute oncology services will also ensure appropriate review of any other cases where A&E or acute medical staff decide an urgent oncology assessment is needed. Which should you contact? For patients presenting with likely complications as a result of their cancer diagnosis or cancer treatment: o If the patient is acutely unwell they should be directed to their nearest, local for emergency management. Please note this may not be the at which the patient s care is being managed. London Cancer Acute Oncology Referral Guidelines v1.0 240313 6
o If you would like to alert the local acute oncology team to the presentation of an acutely unwell cancer patient, then please do so using the contact numbers below. This may help expedite care and management. o If you would like further advice on a specific patient already diagnosed and under the management of a certain specialty team, then please contact that specialty team directly. Out of hours, please use the contact numbers below to contact the oncology team at that. For patients presenting with acute symptoms which are suspicious of an undiagnosed cancer: o If the patient is acutely unwell they should be directed to their local A&E department. o If you would like further advice on a specific patient, then please contact your local acute oncology service using the contact numbers below. As above, you may wish to alert the team to the presentation of the patient even if no specific advice is required. This may help expedite care and management. For patients in the palliative care/ end of life care stages of their disease: o If the patient is acutely unwell they should be directed to their local A&E department, unless there is a clear end of life plan in place in which case this should be followed as appropriate. o If you would like further advice on a specific patient, then please contact the local community palliative care team or hospice. 2.4 Acute Oncology contacts in London Cancer Many trusts have specific acute oncology teams which are operational during standard working hours, Monday to Friday 9-5pm. However all s also provide access to 24 hour acute oncology advice for healthcare professionals. Contact details for both of these are provided in table 1 below. Table 2 gives contact details for local metastatic spinal cord compression (MSCC) coordinators who should be alerted to cases suspicious of MSCC. Table 1: Acute Oncology services and 24 hour advice services Acute Oncology Service 24 hour advice for healthcare professionals Barking Havering and Redbridge University Hospitals NHS s King George s Hospital Queen s Romford Mon-Fri 9am-5pm: 01708 435000 ext 6804 24/7 Oncology on call rota via Tel: 01708 435 000 Barts Health NHS Barts Cancer Centre At all times: Oncology on call rota Royal London Hospital At all times: Barts Oncology on call rota 24/7 Barts Cancer Centre Oncology on call rota London Cancer Acute Oncology Referral Guidelines v1.0 240313 7
Newham University Hospital Mon-Fri 9am-5pm: AOS nurse contact 07956 358 077 Whipps Cross Mon-Fri 8am-4pm: AOS nursing team via 020 8539 5522 bleep 476 Homerton University Hospital Foundation NHS Barnet and Chase Farm Hospitals NHS Barnet General Hospital At all times: Oncology on call rota (Barts Health) Mon-Fri 9am-5pm: 07852 428 667 Chase Farm Hospital Mon-Fri 9am-5pm: 07852428667 North Middlesex University Hospital NHS Royal Free London NHS Foundation University College London Hospital NHS Foundation Mon-Fri 9am-5pm: 07436 036 512 Mon-Fri 9am-5pm: Acute Oncology CNS on 020 7794 0500 Bleep 2237 Mon-Fri 9am-5pm: Acute Oncology Specialty Doctor on 08451555 000 Bleep 2070, or mobile 07789980371 Whittington Health Mon-Fri 9am-5pm: 020 7272 3070 blp 3392 Princess Alexandra Hospital Mon-Fri 9am-7pm: Dr Gordon Read 07969 762 597 or Dr Joud Abduljawad or Dr Maria Tenuta via 24/7 Barts Cancer Centre Oncology on call rota 24/7 Oncology on call rota (Barts Health) Out of hours: UCLH Consultant oncologist on call via Tel: 0845 1555 000 Out of hours: NMH Consultant oncologist on call via Tel: 0208 887 2000 Out of hours: oncology consultant on call, via Tel: 0208 887 2000 24/7 Clinical or Medical Oncology consultant on call via Tel: 020 7794 0500 24/7 Consultant oncologist on call via Tel: 0845 1555 000 or 020 3456 7890 [Additional 24/7 advice available from * ONCOLOGY senior nurse: 07947 959 020 * HAEMATOLOGY senior nurse: 07852 220 900] 24/7 Consultant oncologist on call at UCLH via Tel: 0845 1555 000 or 020 3456 7890 Out of hours: As for NMUH consultant oncologist on call via Tel: 0208 887 2000 London Cancer Acute Oncology Referral Guidelines v1.0 240313 8
Table 2: Local MSCC coordinators for healthcare professionals to refer or access clinical advice MSCC Coordinator Service Contact Details Barking Havering and Redbridge University Hospitals NHS s King George s Hospital Queen s Romford Barts Health NHS Barts Cancer Centre At all times: 01708 435 0000 ext 6177 Royal London Hospital Newham University Hospital Whipps Cross At all times: On Call Radiotherapy registrar at Barts Cancer Centre 07786 118 349, or bleep via 0207377 7000 Homerton University Hospital Foundation NHS Barnet and Chase Farm Hospitals NHS At all times: On Call Radiotherapy registrar at Barts Cancer Centre 07786 118 349, or bleep via 0207377 7000 Barnet General Hospital Mon-Fri 9am-5pm: Acute oncology CNS 07432 637 195 Out of hours: Mount Vernon Hospital Oncology SpR on call 01438 314333 Chase Farm Hospital Mon-Fri 9am-5pm: Acute oncology CNS 07432 637 195 Out of hours: North Middlesex Hospital Oncology SpR on call 0208 8872000 North Middlesex University Hospital NHS Mon-Fri 9am-5pm: 07436 036 512 Out of hours: Oncology SpR on call via 0208 887 2000 Royal Free London NHS Foundation Mon-Fri 9am-5pm: Acute oncology CNS 020 7794 0500 Blp 2237 Out of hours: clinical oncologist consultant on call via University College London Hospital NHS Foundation Mon-Fri 9am-5pm: Acute Oncology Specialty Doctor on 0845 1555 000 Bleep 2070, or mobile 07789980371 Out of hours: On Call Clinical Oncology SpR via 0845 1555 000 Whittington Health Mon-Fri 9am-5pm: 020 7272 3070 blp 3392 Out of hours: Contact UCLH Consultant oncologist on call via Tel: 0845 1555 000 or 020 3456 7890 Princess Alexandra Hospital Mon-Fri 9am-7pm: Dr Gordon Read 07969 762 597 Out of hours: Contact the North Middlesex Hospital Oncology SpR on call via 0208 887 2000 London Cancer Acute Oncology Referral Guidelines v1.0 240313 9
2.5 Acute Oncology Clinical Guidelines For reference, guidelines for the following list of clinical presentations can be found in A Guide to Acute Oncology Emergencies 1 st edition on the Acute Oncology pages of the London Cancer web-site www.londoncancer.org. - Neutropenic Sepsis - Uncontrolled nausea and vomiting - Extravasation injury - Acute hypersensitivity reactions (including anaphylactic shock) - Complications associated with venous access devices - Uncontrolled diarrhoea - Uncontrolled mucositis - Hypomagnesaemia - Pleural effusion - Pericardial effusion - Superior mediastinal obstruction syndrome, including superior vena cava obstruction - Hypercalcaemia - Spinal cord compression including MSCC - Cerebral space occupying lesion(s) - Acute skin reactions - Acute radiation pneumonitis These were approved at the October 2012 AOS ERG meeting, having been adopted from the old North East London Cancer Network as an interim measure. On publication of the UKONS guidelines, expected in 2013, these will be reviewed and revised. Please not that these guidelines are provided for reference; it is not the expectation that primary care or colleagues working in the community should manage these clinical presentations without the input of specialist acute oncology services. 3 Appendix 1 Acute Oncology Reference Guide The following 2 pages summarise these referral guidelines and can be used as a one sheet printable reference guide. London Cancer Acute Oncology Referral Guidelines v1.0 240313 10
ACUTE ONCOLOGY SERVICES in LONDON CANCER Acute Oncology encompasses the management of: Patients with acute complications from their cancer diagnosis Patients with acute complications from their cancer treatments Patients who present as an emergency with a suspected but undiagnosed cancer. Acute Oncology Services exist at each of the acute trusts in the London Cancer Integrated Cancer System. The majority of these currently function in hours, Monday to Friday 9-5. Full details are available in Table 1. Table 1: Acute Oncology services and 24 hour advice services Acute Oncology Service 24 hour advice for healthcare professionals Barking Havering and Redbridge University Hospitals NHS s King George s Hospital Mon-Fri 9am-5pm: 01708 435000 ext 6804 Queen s Romford Barts Health NHS Barts Cancer Centre At all times: Oncology on call rota Royal London Hospital At all times: Barts Oncology on call rota Newham University Mon-Fri 9am-5pm: AOS nurse contact Hospital 07956 358 077 Whipps Cross Mon-Fri 8am-4pm: AOS nursing team via 020 8539 5522 bleep 476 Homerton University At all times: Hospital Foundation NHS Oncology on call rota (Barts Health) Tel: 07917 093 738 Barnet and Chase Farm Hospitals NHS Barnet General Mon-Fri 9am-5pm: 07852 428 667 Hospital 24/7 Oncology on call rota via Tel: 01708 435 000 24/7 Barts Cancer Centre Oncology on call rota 24/7 Oncology on call rota (Barts Health) Tel: 07917 093 738 Out of hours: UCLH Consultant oncologist on call via Tel: 0845 1555 000 Chase Farm Hospital Mon-Fri 9am-5pm: 07852428667 Out of hours: NMH Consultant oncologist on call via Tel: 0208 887 2000 North Middlesex University Hospital NHS Royal Free London NHS Foundation University College London Hospital NHS Foundation Whittington Health Princess Alexandra Hospital Mon-Fri 9am-5pm: 07436 036 512 Mon-Fri 9am-5pm: Acute Oncology CNS on 020 7794 0500 Bleep 2237 Mon-Fri 9am-5pm: Acute Oncology Specialty Doctor on 08451555 000 Bleep 2070, or mobile 07789980371 Mon-Fri 9am-5pm: 020 7272 3070 blp 3392 Mon-Fri 9am-7pm: Dr Gordon Read 07969 762 597 or Dr Joud Abduljawad or Dr Maria Tenuta via Out of hours: oncology consultant on call, via Tel: 0208 887 2000 24/7 Clinical or Medical Oncology consultant on call via Tel: 020 7794 0500 24/7 Consultant oncologist on call via Tel: 0845 1555 000 or 020 3456 7890 [Additional 24/7 advice available from * ONCOLOGY senior nurse: 07947 959 020 * HAEMATOLOGY senior nurse: 07852 220 900] 24/7 Consultant oncologist on call at UCLH via Tel: 0845 1555 000 or 020 3456 7890 Out of hours: As for NMUH consultant oncologist on call via Tel: 0208 887 2000 London Cancer Acute Oncology Referral Guidelines v1.0 240313 11
Access to acute oncology In hours The Acute Oncology team at your local should be used by primary care as the point of contact for this group of acutely unwell patients. In most trusts, admission will still be via A&E but contact with the Acute Oncology team can expedite and optimise management. Tumour-specific specialist oncology teams who are managing the treatment and care of patients are still available for advice where this is felt to be more appropriate and/or the situation is not acute. Out of hours If you are clear on the need for acute care and admission, then patients should be sent to your local A&E. If you would like specialist oncological advice on management, then all s offer 24/7 access for healthcare professionals to advice from a consultant oncologist. At all times Metastatic Spinal Cord Compression (MSCC) coordinators (see Table 2) should be contacted regarding any patients suspicious for MSCC. Table 2: Local MSCC coordinators for healthcare professionals to refer or access clinical advice MSCC Coordinator Service Contact Details Barking Havering and Redbridge University Hospitals NHS s King George s Hospital At all times: 01708 435 0000 ext 6177 Queen s Romford Barts Health NHS Barts Cancer Centre At all times: On Call Radiotherapy registrar at Barts Cancer Centre 07786 118 349, or bleep via 0207377 7000 Royal London Hospital Newham University Hospital Whipps Cross Homerton University Hospital Foundation NHS At all times: On Call Radiotherapy registrar at Barts Cancer Centre 07786 118 349, or bleep via 0207377 7000 Barnet and Chase Farm Hospitals NHS Barnet General Hospital Mon-Fri 9am-5pm: Acute oncology CNS 07432 637 195 Out of hours: Mount Vernon Hospital Oncology SpR on call 01438 314333 Chase Farm Hospital Mon-Fri 9am-5pm: Acute oncology CNS 07432 637 195 Out of hours: North Middlesex Hospital Oncology SpR on call 0208 8872000 North Middlesex University Hospital NHS Mon-Fri 9am-5pm: 07436 036 512 Out of hours: Oncology SpR on call via 0208 887 2000 Royal Free London NHS Foundation Mon-Fri 9am-5pm: Acute oncology CNS 020 7794 0500 Blp 2237 Out of hours: clinical oncologist consultant on call via University College London Hospital NHS Foundation Mon-Fri 9am-5pm: Acute Oncology Specialty Doctor on 0845 1555 000 Bleep 2070, or mobile 07789980371 Out of hours: On Call Clinical Oncology SpR via 0845 1555 000 Whittington Health Mon-Fri 9am-5pm: 020 7272 3070 blp 3392 Out of hours: Contact UCLH Consultant oncologist on call via Tel: 0845 1555 000 or 020 3456 7890 Princess Alexandra Hospital Mon-Fri 9am-7pm: Dr Gordon Read 07969 762 597 Out of hours: Contact the North Middlesex Hospital Oncology SpR on call via 0208 887 2000 London Cancer Acute Oncology Referral Guidelines v1.0 240313 12