Dr Judith Carser

Consultant in medical oncology

Southern Health & Social Care Trust

Dr Judith Carser

Consultant in medical oncology

Southern Health & Social Care Trust

ACUTE ONCOLOGY SERVICE MODELS

OverviewOverview

AO workload projections

AO models in England

Merseyside & Cheshire experience and workload analysis

Clinical case examples

Projected AO workloadProjected AO workload 2006/07 - 273,000 unplanned cancer admissions = 750 admissions per day in

England1

Equates to 5 cancer admissions per trust per day on average

2008/09 average LoS varied for cancer related admissions between 5.1-10.1 days - potential saving of 566,000 bed days if every region had the same LoS as average in the best performing regions 2

One day snapshot at combined cancer centre/acute hospital trust reported 19% of all in patients had a cancer diagnosis3

Average Los for those admitted to oncology was shorter than for those admitted to general medicine3

1NCEPOD report 20082National Audit Office.DoH:Delivering the Cancer Reform Strategy 20103Acute Oncology Service: assessing the need and its implications. Clin Oncol 2011 Mansour D et al

AO models in UKAO models in UK

Core principles of AO promote education, awareness and early access to specialist oncology advice

Number and type of AO admissions variable and will reflect local service configuration

AO models should be configured to best meet local needs and integrate with existing services whilst identifying areas for development

Acute district general hospital vs. integrated cancer centre vs. stand alone tertiary oncology service

Model I – comprehensive cancer centreModel I – comprehensive cancer centre Yorkshire Cancer Network – 2.6 million, 8000 new patient episodes/yr.

Non-surgical oncology –St James Institute of oncology – local services for Leeds and tertiary referral centre for region. Acute services on site

Six additional hospital trusts providing cancer unit services with mix of resident and visiting oncologists

AOS developed independently in each cancer unit by the resident oncology team

In Cancer centre – assessment unit staffed by ANPs and junior doctors. Model requires 20PAs of consultant time to provide a 5 day service – equivalent to 2 FTEs

Model II – An acute cancer unit model, Whittington HealthModel II – An acute cancer unit model, Whittington Health

Stand alone consultant medical oncologist, specialty doctor in oncology, haematology consultant and 2 oncology CNS, admin support

Dedicated medical ward for oncology-related admissions with medical oncologist responsible for inpatient care – admission guidelines

Daily AOT review offered of appropriate patients in outlying medical wards / MAU

Electronic referral pathways – inbuilt audit trail and data gathering capacity.

Electronic alerts for chemotherapy patients / fast track MUO clinics / weekly CUP MDT / radiology flags

Model III – stand alone cancer centreModel III – stand alone cancer centre Merseyside and Cheshire Cancer network – population 2.3 million,

10,000 new patient episodes/yr.

Tertiary stand alone Cancer Centre – no acute services on site. Local cancer services for Wirral

Nine satellite chemotherapy clinics, one satellite radiotherapy unit

AOS developed in all 7 acute trusts in 2010 (excluding IoM) to complement existing service in St Helens and Knowsley NHS Trust

ANP-led Acute oncology assessment ward, CCC established 2013

Location of AOS within acute trusts Merseyside & CheshireLocation of AOS within acute trusts Merseyside & Cheshire

sss

UHA

SORM

RLUH

SHK

W&H

COC

WTH

CCC

Key:

CCC – The Clatterbridge Cancer Centre NHS FTWTH – Wirral University Hospitals NHS FT UHA – University Hospital Aintree NHS FTSORM – Southport & Ormskirk NHS TrustRLUH – Royal Liverpool & Broadgreen NHS TrustW&H – Warrington & Halton NHS TrustSHK – St Helen’s and Knowsley NHS FTCOC – Countess of Chester NHS Trust

Model III – acute oncology servicesModel III – acute oncology services Local AOS with visiting oncologists (at least 2 per unit), 5PAs of consultant support

provided per week. The AOS oncologists provide at least one site specialised service at the same trust

At least 1 WTE acute oncology CNS, 0.6-1.0 WTE admin support

No inpatient oncology beds, no acute trust employed oncology nurses

AO service available mon-fri 9am – 5pm to review patients as necessary and within one working day of referral

Local AO and CUP MDTs

Central 24hour chemotherapy triage at Cancer Centre

Comparison of projected (2005-6 data) vs. actual workload of AOS throughout network (2010-11)

-NatCanSAT commissioned to provide analysis of potential annual AO workload – HES, chemotherapy, radiotherapy data, Cancer Registry

Projected potential workload = 3,924 patients, overall average LoS 12.8 days

Type of admission Average LOS days (range)

1.new cancers (17%) 11 (7.5-16.1)

2.complications of cancer treatments (40%) 9.1 (5.7-14.1)

3.complications of cancer (43%) 17.3 (10.2-23.5)

Network AO workload 2010-11Network AO workload 2010-11

Actual workload = 3,031 new referrals to 7 teams (incomplete 12 months for 3 teams)

Average Los reduced by 3 days from 12.8 to 9.7 days representing saving of over 9,000 bed days

Impact of AO interventionImpact of AO intervention

Type of intervention

Major • Managing new cancers (including MU0)

• Managing complications of chemo/radiotherapy

• Organising diagnostic tests• Cancelling or preventing

unnecessary tests• Symptom management• Preventing admission

Intermediate • Referral to other teams including cancer centre/other hospitals

• Psychological support• Communication to primary

oncologists/others

Minor • Supervising progress of inpatients

• Organising follow upn=1,403major vs. intermediate intervention, p<0.05; major vs. minor intervention p<0.05

Wirral experience - AOSWirral experience - AOSWirral experience - AOSWirral experience - AOS

Griffiths R et al Wirral University Hospitals NHS Foundation Trust

New cancer referrals– Royal Liverpool University Hospital AOS 2010-11

New cancer referrals– Royal Liverpool University Hospital AOS 2010-11

Seen by AOS 2010 - 2011

Number 135

Gender Malefemale

71 (53%)64 (47%)

Median age in yrs (range) 73 (37-92)

Final diagnosis

Malignancy undefined origin cCUP LungBreastUpper/lower GIUrologyGynaeOther

32 (24%) 18 (14%)40 (30%) 6 (4%)

14 (10%) 6 (4%) 7 (5%)12 (9%)

Median survival

Admission – death (95% CI)Discharge – death (95% CI)

61 days (48-74)37 days (20-54)

Deaths in hospital 27 (20%)

Systemic therapy Radiotherapy

22 (16%)12 (9%)

Impact of an AOS upon the management of Impact of an AOS upon the management of patients with MUO – Wirral University Hospital patients with MUO – Wirral University Hospital experienceexperience

Impact of an AOS upon the management of Impact of an AOS upon the management of patients with MUO – Wirral University Hospital patients with MUO – Wirral University Hospital experienceexperience

Mean LoS for patients admitted during the diagnostic phase

Mean number of investigations during the diagnostic phase

Griffiths RW. et al, abstract NCRI 2012 Wirral University Hospitals NHS Foundation trust

p=0.114

Comparison of historical and AO cohort Comparison of historical and AO cohort at Wirral University Hospitalat Wirral University HospitalComparison of historical and AO cohort Comparison of historical and AO cohort at Wirral University Hospitalat Wirral University Hospital

Proportion of patients dying without a clear decision on management

Average time from referral until definitive treatment decision

Griffiths RW et al abstract NCRI 2012 Wirral University Hospitals NHS Foundation Trust

Local agreementsLocal agreements

Each acute Trust responsible for developing their own AOS which best meets local needs including geographical location, demographics, specialist service provisions

Ongoing engagement between acute trust and tertiary Cancer Centre

Local AO and CUP MDTs

Local AO steering groups

Local teaching and staff education

Local policies and procedures for referrals and patient alerts

Network agreementsNetwork agreements

Required to meet National Cancer Peer Review measures for both carcinoma unknown primary and acute oncology including:AO induction packsNetwork treatment and disease related complications protocol bookAO and CUP clinical network groupsSpecialist regional CUP MDTNetwork agreed pathways for MUO, brain metastasesAO e-learning module supported by University of LiverpoolNetwork audits e.g. MSCC, neutropenic sepsisAgreed oncology registrations for all AO patientsNetwork agreed minimum data set

Clinical scenariosClinical scenarios Patient 1: 54-year-old woman with breast cancer is undergoing

adjuvant chemotherapy and develops nausea and dizziness. The patient has a temperature of 38ºC and phones the chemotherapy helpline for advice

Patient 2: 72-year-old man presents to ED generally unwell with abdominal pain, nausea and weight loss. CT scan reveals multiple liver metastases but no obvious primary cancer

Patient 3: 61-year-old woman with metastatic lung cancer presents with increasing pain. Patient had been due to attend cancer centre for radiotherapy but admitted acutely to local hospital

SummarySummary There is proof that AOS works (and saves money!)

An evolving service which must adapt to local requirements

A successful AOS requires ‘buy-in’ and commitment from all

Should be developed alongside existing visiting oncology services to provide continuity of care / reduce time travelling for oncologists

Cancer unit oncologists vs. visiting oncologists with more time in unit

Team effort – service must be adequately staffed, resourced and supported if it is to succeed and develop

ReferencesReferences The National Confidential Enquiry into Patient Outcomes and Death. For better, or worse? NCEPOD,

2008

National Chemotherapy Advisory Group. Chemotherapy Services in England: ensuring quality and safety, 2009

Royal College of Physicians and Royal College of Radiologists. Cancer patients in crisis: responding to urgent needs, 2012

Towards saving a million bed days: reducing length of stay through an acute oncology model of care for inpatients diagnosed as having cancer, BMJ Qual Saf 2011: 20:718-724. King J et al.

What is the impact of a new acute oncology service in acute hospitals. Experience from the Clatterbridge Cancer Centre and Merseyside and Cheshire Cancer Network, Clinical Medicine 2013, Vol 13, No 6: 1-5. HL Neville-Webbe , JE Carser et al.

Acute oncology service: assessing the need and its implications.Clin Oncol (R Coll Radiol) 2011;23:168-173. Mansour D et al.