Thomas Tuchyna, Sir Charles Gairdner Group: The expansion of Sir Charles Gairdner Hospital Cancer Centre

Expansion of the Sir Charles Gairdner Hospital Cancer Centre

Delivering a Healthy WA

Thomas Tuchyna Project Director

Stage I Stage II

December 9, 2013 Slide 2

Overview

• Infrastructure development

• Organisational changes

• Operational workflow

• Adolescent and Young Adult facilities (AYA)

• CyberKnife

• Oncology Information Management System (OIMS)

Key stages / features


Schedule of Accommodation (SoA) – • The Business Case SoA (July 2007) modified as per list below:

1. Clinic Suites – Increased from 16 to 27 + (10) 2. Addition of Registrar’s office / workstations 3. Additional 6th linac bunker 4. Addition of Solaris Care 5. Addition of Adolescent & Young Adult (AYA) facilities 6. Office Accommodation to be located elsewhere:

1. Senior Medical Staff / Admin / Allied Health 2. Treatment Planning 3. Medical Physics 4. Research / Students

• Alterations approved 22nd August 2008

Building the Infrastructure Background and Key Challenges

Approx 90 staff, requiring 1,300m2


Cancer Centre Stage II Distribution of Floor Space

Total Floor Space = 7,782 m2

Staff in Stage II 210 Staff elsewhere 90 (SCGH)

– Senior Medical Staff offices (MOnc, ROnc, Haem, Pall Care) – Medical Support (Clerks,

Admin Assist) – Radiation Therapy Treatment

Planning – Medical Physics – Research Staff and Students – Administration


Site Location:

Aerial image of QEII Medical Centre (SCGH): late 2009


Site Location:

Aerial image of QEII Medical Centre (SCGH): late 2009

CC Stage I

1,095 m2

CC Stage II 7,782 m2


Cancer Centre Stage I


Cancer Centre Stage II


Works Progress • Demolition • Excavation & tension pile works • Concrete structure • Service installation

Tension pile works.

Photo: Fri 10th Sept 2010


Construction Progress

December 9, 2013 Slide 11 Photo: Fri. 5th Nov 2010.

Detailed basement excavation and compaction works.

Installation of plywood sheets and waterproof membrane to basement.

Installation of fire tank walls to basement.

Installation of tension / compression piles.

Construction Progress




Day Ward (Med Onc & Haem)



CLINICAL TRIALS – Workstations Medical Oncology 14 Radiation Oncology 13 Haematology 8 Company Monitor’s Rooms 3 Registrars x16

SHARED AREA & CLERICAL Reception Registration Typists Workstations File Store & Preparation Switch Operator Cancer Registry Meeting/Conference Room Staff Room

SOLARIS CARE Therapy Room 4 Counselling 1 Drop in Centre 1 Resource Room 1 Office 2

CLINIC SUITE Standard 25 Large 3 ENT 2 Stretcher 2 Consult Rooms Total 32

Original Consult Rooms CCII Consult Rooms (combined) Med Onc*: 9 27 Clinic Haem: 4 5 Allied Health Rad Onc: 11 5 RO Treat Review TOTAL: 24 TOTAL: 37 Consult Rooms in CCII

*Note: Med Onc had a dual purpose office/consult room arrangement. Haem & Rad Onc had separate offices and consult rooms.



Radiation Oncology Treatment Linac Bed Hold Dressing Room

6 2 2

Radiation Oncology Treatment Preparation Simulation Area Consult Rooms 7

Radiation Oncology Mould Room Engineering Area Brachytherapy

Day Ward Med. Onc. Haem.

Chairs Beds Rooms Apheresis

24 10 3 4 1 1 3

Total Treatment Spaces 46

PHARMACY Dispensing Cashier CleanRoom 4 Preparation

Med Onc

Haem

LINAC 2

LINAC 1

LINAC 3

Acacia Banksia Tuart

Bed Hold x2

Dressing Dressing

CT x2

Consult

Trt Review

Mould Room

ROBES

BRACHY


• Key Issues / Lessons Learned

– Well defined project scope – Tender process & Builder engagement – Contingencies (scope, time, $’s) – Cashflow (Builder’s claims) – IT – A separate (largely subcontracted) entity – Stability of working groups – Staff engagement – Separation of building from service – Building defect management

Infrastructure developments

Assumption Check: • A comprehensive centre for patients • Building capacity increased activity / staffing ≠


Overview





• CyberKnife



• Medical Oncology 38.5 FTE

• Haematology 24.3 FTE

• Radiation Oncology 169.5 FTE

• Palliative Care 5.0 FTE

• Allied Health 6.5 FTE

• Pharmacy 11.0 FTE

• Cancer Registry 4.5 FTE

• Solaris Care 7.0 FTE

• AYA 4.5 FTE

TOTAL 270.8 FTE

Staff Profile


24.3FTE

Haematology – Organisational Structure


Medical Oncology – Organisational Structure

38.5FTE Clerks / Admin had 3

distinct reporting lines

December 9, 2013 Slide 22 169.5FTE

Radiation Oncology – Organisational Structure


Cancer Centre – Organisational Structure (Work in Progress)

245 FTE not inclusive of: • Pharmacy / Palliative Care • Allied Health / Solaris Care • AYA


• Key Issues / Lessons Learned – Stable Leadership – HR processes (creating / abolishing positions) – Other recruiting within WA Health (e.g. FSH) – Staff engagement – Change management – Time

Assumption Check: Focus on the horizon while managing the present

Organisational Change


Overview



• Clinical transition



• CyberKnife



Projected Patient flows in key clinical areas

New Patients Follow-up A n n u a l visits

Daily visits

Clinic Area Rad Onc 2,581 26,261 Med Onc 3,172 17,040 Haem 643 8,362 Pall Care 194 419

Total 58,672 235 D a y W a r d Treatment

Med Onc 11,395 46

Treatment Haem 7,406 30 Total 18,801 68

R a d i a t i o n Oncology

Treatment Planning 4,693 19

Treatment 48,659 203 Treatment Review 9,419 38

Total 62,771 259 Total Annual Patient Visits 140,245 569

Estimated new cases for the Cancer Centre projected to be around 4,000 in 2011 for Chemotherapy and Radiation Therapy at SCGH.


Average AM Daily Patients: 121 Average PM Daily Patients: 30


Clinic Session Mapping

December 9, 2013 Slide 29 Average AM Daily Patients: 22 Average PM Daily Patients: 9







Overview

Average AM Daily Patients: 110 Average PM Daily Patients: 30 Outcome to date:

Essentially no change to clinic workload or distribution, for significantly increased clinic congestion on days (sessions) where majority of specialists hold busy clinics.


Daily cancellation 10-15 patients (~30%).

Daily cancellation 3-6 patients (~15%).

Relocation / Transition


• Clinic Organisation

– Common Vision – Patient Centered, not specialty based – Overlapping of busy clinics – Overlapping of ‘quiet’ clinics – Scheduled appointment timeslots – Common processes (DNA, Medical Record movement, billing,

re-bookings …) – Common tools TOPAS vs. others

• Day Ward Treatment

– Treatment Same Day (am) vs Treatment Other Day – Med Onc Day Ward treatments Medically led – Haem Day Ward treatments Nurse led

Assumption Check: Participation and adherence to common vision

Operational Workflow - Key Issues / Lessons Learned


Overview





• CyberKnife



AYA Background • A partnership between Sony Health, CanTeen & DoHA • $3M for additional 400m2 to be added to the Cancer Centre • For cancer patients aged 15-24 years • Spaces

– Group recreation room – Interview – Shard office – Consulting room – Treatment bays

• WA Health to fund staff to support AYA – Cancer Nurses / Care Navigators – Clinical lead – Social worker – Psychologist – Data Manager


AYA Group Room


AYA Spaces

Total space just under 200m2


• Additional space • Building alterations • Consider the recurring cost • Long term investment into improvement of outcomes

for 15-24 year olds

AYA Key Issues / Lessons Learned


Overview





• CyberKnife



CyberKnife Worldwide

Worldwide 280 installed CyberKnife systems with over almost 200,000 treatments, 45,000 alone in 2012

Nearest CK s to Australia are in Thailand, HK, Taiwan, Vietnam

Europe 62 Installed

Asia Pacific 31 Installed

Japan 24 Installed

America 152 Installed

South America 6 Installed

Middle East 5 Installed


Radiosurgery: The idea to use single high ablative radiation dose to kill tumor cells without operating on the patient Dr. Lars Leksell, 1907–1986, Neurosurgeon, Sweden

• 1949 First Radiosurgery Treatment in Sweden (Protons)

Problem in the past same as today: Treatment precision

• 1968 GammaKnife (Fixed Part-Invasive Frame as Reference) • 1980 Linear Accelerator for Radiosurgery (patient position is controlled before treatment, not during treatment)

History of Radiosurgery

Images: Elekta SE


CyberKnife Robotic Radiosurgery

Miniature Linear Accelerator

Robo2c Arm

X-‐Ray Detectors

X-‐Ray Tubes

Imagings-‐ system

Radia2on-‐ system Mo2on compensa2on

with Marker-‐Correla2on

Targe2ng through image registra2on

LED-‐Camera

Synchrony™


”The system adapts to the patient”

Linear Accelerator guidance through robotic arm

• Fully automated beam targeting through image registration

• Real time compensation of tumor motion

• Resulting in excellent treatment precision (< 1mm), high local tumor control, minimal side effects, reduced treatment time, for selected tumors ANYWHERE in the body!

CyberKnife Robotic Radiosurgery

Beam Target

CK Inventors: Prof. John Adler, Prof. Achim Schweikard


Primary or combined therapy for selected tumors or as an option for recurrent tumors after failure of other treatments

Intracranial and Spine (not all listed) • Malignant Brain Tumors, Uveal Melanomas (Eye Tumors) • Benign Tumors (Meningiomas, Acoustic Neuromas) • Spinal and Bone Tumors

Functional Radiosurgery (not all listed) • Arterial-Venous Malformations, Trigeminal Neuralgia

Extracranial (not all listed) • Low & Intermediate Risk Prostate Tumors • Inoperable Lung and Liver Tumors • Breast • In selected cases Renal & Pancreatic Tumors • Lymph Nodes

CyberKnife Treatment Indications


Study / Study Site(s)

Treatment No. of patients

Risk groups

Follow-up Efficacy Acute grade toxicity Late grade toxicity

Katz, et al. 2010 [3] Winthrop University Hospiral, Mineola, NY USA

PROSTATE 35 – 36.25 Gy in 5 fx

304 Low, intermediate, high

35 Gy: Median, 30 months (range 26 – 37 months) 36.25 Gy: Median, 17 months (range, 8 – 27 months)

Free from biochemical failure 35 Gy cohort: 100% 36.25 Gy cohort: 98.5%


Study / Study site(s)


Tumour characteristics

Follow-up

Efficacy Acute toxicity Late toxicity

van der Voort van Zyp, et al. 2010 [11] Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands

45 – 60 Gy in 3 – 6 fx One to five fiducial placement

39 T1-2N0M0 NSCLC

Median, 17 months (range, 6 – 31 months)

Overall survival at 12 months: 75% Overall survival at 24 months: 62% Local control at 12 months: 97% Local control at 24 months: 97%

Nuyttens, et al. 2012 [12] Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands

45 – 60 in 5 – 6 fx

56 (58 lesions)

Early stage NSCLC; solitary metastases


Local control at 24 months: 85% for BED > 100 Gy 60% for BED =< 100 Gy

LUNG


LIVER

Study / Study site(s)


Tumour characteristics

Follow-up Efficacy Complications (% patients)

Kress, et al. 2012 [26] Georgetown University Hospital, Washington, DC USA

16 – 50 Gy in 1 – 5 fx

52 (85 lesions)

Liver metastases (n=72), primary tumour (n=13)

Median, 11.3 months (range, 1 – 67 months)

Overall survival at 12 months: 50.8% Local control at 12 months (of the 40 patients in radiographic follow-up): 74.8% Median time to failure (of 40 the patients in radiographic follow-up): 35.5 months

Acute grade 3 - 4 toxicity: 11.5% Including: Bilirubin elevation (grade 3, n=4; grade 4, n=1), AST elevation (grade 3, n=1), acalculous cholecystitis (grade 3, n=1), alkaline phosphatise (grade 3, n=1). The authors mentioned that grade 1 – 2 toxicities were common, but did not report the number of cases

Goodman, et al. 2010 [27] Memorial Sloan-Kettering Cancer Center, New York, NY USA; Stanford University, Stanford, CA USA

18 – 30 Gy in 1 fx

26 (40 lesions)

Liver metastases, primary tumours


Of the 25 patients with 38 lesions in radiographic follow-up: Local control: 47% of lesions Overall survival at 12 months treated for primary tumours: 71.4% Overall survival at 24 months treated for primary tumours: 53.6% Overall survival at 12 months treated for metastases: 61.8% Overall survival at 24 months treated for metastases: 49.4% Probability of local failure by 12 months: 23%

Late toxicity data was not available for one patient (n=25). Of the four reported Grade 2 toxicities, two were gastrointestinal and two were musculoskeletal.


SCGH Current Status • Core Clinical team selected

– (x3 Rad Oncs) – (x3 Radiation Therapists) – (x3 Medical Physicists) – (x2 Engineers)

• Training underway

• Machine Shipment underway – Due to late Dec early Jan

• Installation starts – 12th Jan

• Clinical operations start – 24th March

SCGH investigating to join three large multi centre clinical trials and or to initiate local clinical trails


Overview





• CyberKnife



Common Oncology Information Management System (OIMS)

Rad Onc

Haem

Med Onc

Pharmacy

The case for a common Oncology Information System • At present, key cancer services have stand alone information systems

(some reasonably well developed, some rather inadequate). • All key cancer services are a part of the Cancer Centre and use parts of

the same floor plan / accommodation. • Current information flow, particularly between clinicians and clerical staff

limits clinical care • There are areas of significant overlap in both processes and need to

access common information. e.g.

• 50% OF RAD ONC PATIENTS HAVE A COMBINED RAD ONC / MED ONC TREATMENT AND HENCE NEED ACCESS TO COMMON PATIENT INFORMATION

• HAEMTOLOGY PROCESSES OVERLAP WITH MEDICAL ONCOLOGY PROCESSES

• PHARMACY PROCESSES AND INFORMATION REQUIREMENTS ARE INTERTWINED WITH MEDICAL ONCOLOGY & HAEMATOLOGY TREATMENTS

Distribution of Floor Space in CCII

Total CCII Floor Space = 7,782 m2

A formal Tender an OIMS is underway, with vendor responses received last week and the evaluation process about to begin. Aim to award during 2nd Quarter of 2014, with

implementation to be concluded by late 2015/early 2016


Areas remaining to be resolved

• Clinic & Treatment scheduling

• Organisational re-structure

• Accommodation for those not in the Cancer Centre

• Common tool set - OIMS

• IT – HIN Infrastructure

Thankyou

Health & Medicine

Thomas Tuchyna, Sir Charles Gairdner Group: The expansion of Sir Charles Gairdner Hospital Cancer Centre