Dr Judith Carser

Consultant in medical oncology

April 2014

The Southern Health & Social Care Trust

Acute oncology experience

Overview

Acute oncology team

Pathways for oncology admission and referral to AOS

Workload and data collection

Service development

Northern Ireland Cancer Network • Population 1.8 million

• 11 acute hospitals with ED(3 have

part-time ED)

• Cancer Centre on BCH site (no

ED)

• North west Satellite radiotherapy

and chemotherapy centre due to

open 2015

• 5 cancer units – visiting

oncologists, one resident

oncologist CAH

• Approx. 5,000 new patient

episodes /year

Acute oncology service SHSCT

The AOS aims to provide access to specialist oncology advice and

assessment for patients presenting with acute cancer problems

It complements existing sources of specialist medical and clinical

oncology advice

The aim is to provide a single advice route available to all clinicians,

Monday to Friday.

The AO team

Consultant medical oncologist, full time SHSCT approx. 4 PAs AO /

week. Site specific interests lung/GU (September 2013)

Specialty doctor in oncology - full time (March 2013)

CNS – full time (current CNS seconded for 12 months to cover mat

leave) – post recurrently funded

Part-time admin support approx. 0.5WTE (November 2013)

Visiting oncologists – 2 breast (currently CO), 1 lung/GU (CO), 2 GI

(CO)

Cancer network

groups

Pathology

Radiology

Emergency

Department

Site specific

MDTs Specialist nurses

Education and

audit

PALLIATIVE

CARE

Haematology

Microbiology

ACUTE MEDICAL

ADMISSIONS

UNIT

ACUTE ONCOLOGY

SERVICE

Who do we see?

Patients presenting with acute complications of cancer. This includes:

– patients with known malignancy and

– patients with previously unknown malignancy

Patients presenting with acute complications of chemotherapy

Patients presenting with acute complications of radiotherapy

Patients with metastatic malignancy of undefined primary origin

ACUTE ONCOLOGY TEAM

REFERRAL FORM

Date of referral ________________________ Ward _______________________

Consultant agreed to referral Yes ( ) No ( )

Reason for admission ________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Reason for referral (tick applicable)

- receiving or within 6 weeks of systemic anti-cancer therapy or radiotherapy

- complications from a known cancer diagnosis

- previously undiagnosed cancer where primary site is uncertain at time of referral

All patients must be aware of referral to the oncology team

Contact bleep 1782 Mon-Fri 9am-5pm

Please leave completed referral form for collection

Patient addressograph / details

ED Mandeville unit

(within 6 weeks of chemo) GP

Acutely unwell cancer patient

unstable stable

Outcome of medical assessment

AO problem requiring

immediate oncology

input

Potential AO problem

requiring admission but

does not require

immediate oncology input

No AO problem and

no immediate

oncology input

required

Mon-Fri

Contact AO

team

Bleep 1782.

Contact AO

team Mon-Fri

9am-5pm

Inform treating

oncology team

and check for

existing

appointment

Out of hours

Registrar on

call, Cancer

Centre

Presentation

Assessment

Complications from a new cancer diagnosis

/ unknown primary cancer

Patients with site specific symptoms should be referred via

existing fast-track pathways

Malignancy of undefined origin (MUO) – ‘metastatic malignancy

defined on the basis of a limited number of tests, without an obvious

primary site before comprehensive investigation’

Patients meeting criteria for MUO may be referred to AOS to assess

fitness for oncological intervention providing:

1. suspicion of malignant diagnosis on cross-sectional imaging +/-

histology (referral encouraged before biopsy)

2. patient and family aware of likely cancer diagnosis and referral

How to Refer to the Acute

Oncology Service

Team available Mon-Fri 9am-5pm

Use referral forms available in all wards and departments

Please BLEEP the team to make them aware of referral 1782

Pathways available on intranet – directorates – acute – cancer

It may be appropriate to contact the relevant consultant team

directly in NICC if fast-track appointment / specific advice required

Raising the profile of AO Quarterly AO steering group meeting

AO now part of hospital grand rounds, junior doctor teaching in CAH

Ward based teaching at every opportunity – engaging trainees in

patients treatment plans

Link-nurses in each ward and ED

Input into monthly medical M+M

Input into site specific and palliative care MDT and service awareness

sessions with community teams

New referrals to AOS

Median age = 61years (range 29-82 years)

Pattern of referrals

22 patients referred on at least two separate admissions

55 of 120 referrals received now deceased as of 31st March 2014

(45% of referrals)

Excluding patients who were referred during more than one admission

– number of new patients seen = 100

44 of 100 new patients seen now deceased (as of 31st March 2014) –

44% of admissions

Of these 10 died in hospital = 22%

Numbers and reasons for

presentation

Average length of stay for cancer

inpatients referred to Acute

oncology

7

10.8

11.4

9.6

0 2 4 6 8 10 12

complications from cancer treatment

complications from cancer

new cancer diagnosis

All admissions

Mean length of stay (days)

Review of unit helpline calls

August 2012-2014

Purpose: to assess methods of referral and patient management via

chemotherapy helpline triage before / after development of AO team

To assess numbers of patients advised to attend ED /GP /

chemotherapy unit

To assess numbers of patients presenting in and out of hours

Method: All helpline triage records reviewed between August 2012 –

February 2013 (pre AOS) and April 2013 – October 2013 (post AOS)

(150 patients in each group) for patients where assessment was

advised

Results – place of assessment

Pre AOS Post AOS

Number and reason for ED

assessments

Pre AOS (n=53) Post AOS (n=21)

Rates of admission following ED

assessments

Pre introduction of AOS:

30 patients admitted via ED reflecting 20.4% of helpline calls

38% of those advised to attend ED were admitted

Post introduction of AOS:

23 patients admitted (including 6 via chemo unit) reflecting 15% of

helpline calls

53% of those advised to attend ED were admitted (65% of chemo unit

referrals, 38.5% out of hours)

Overall reflects more appropriate assessment of patients by specialist

oncology service, reduction in ED referrals and enhanced patient

experience

Challenges in developing a local AOS

Spreading the word

Identifying appropriate AO patients

Single oncologist – peer support, one CNS

Balance between advice and ‘ownership’

Development of nurse-led assessments to chemotherapy unit

Data collection and audit

Service development

The One Hour to Antibiotic Pathway

Fast Track Referrals in known oncology patients

Development / updating pathways e.g. NS, MSCC, MUO

Nurse-led assessments of unwell chemotherapy patients

Education, training & data collection

Integration with community / primary care

NETWORK

WIDE AOS