Lessons learnt from establishing an Acute Oncology service Dr. Pauline Leonard MD FRCP Consultant Medical Oncologist Whittington Health Over next 45 minutes….. • Lessons learnt from: – setting up a new service – embedding a new service – challenging traditional working practises • Share the positive gains for an AOS • Highlight the dynamics of an Acute Oncology Service 1
Rumsfeld principles... • Known knowns – NCAG 2009 – NCEPOD 2008 – National Patient safety alerts oral chemo • Known unknowns – Scale of the problem for each Trust/network – Impact on current Oncology services • Unknown unknowns – Impact of doing things differently • Both positive and negative A key recommendation from NCAG report 2009 • Development of an Acute Oncology Service – Management of patients who develop severe complications following chemo or as a consequence of their cancer – Management of patients who present as emergencies with previously undiagnosed cancer • AOS brings together expertise from oncology disciplines, emergency medicine, and general medicine and general surgery 2
What is an Acute Oncology Team? • Emergency care medical & nursing staff • Acute Medical on-take medical team • Oncologist • Palliative Care • Clinical Nurse specialists • Chemotherapy nurses AOS brings together expertise from oncology disciplines, emergency medicine , and general medicine and general surgery What is unscheduled care? • Unscheduled or urgent care is care for those whose treatment is not planned in advance • Examples in cancer – Toxicity from treatment • Diarrhoea • Febrile neutropenia – Symptoms from disease • Pain • Metastatic cord compression – Patient with a previously undiagnosed cancer – Medical and surgical emergencies not directly related to the underlying cancer 3
From the Patient perspective • Accessing appropriate and skilled help when unwell – Telephone advice – Emergency services • Delays in recognising complications of treatment or disease progression – Timely antibiotics in febrile neutropenia – Missed opportunities for intervention to prevent paraplegia in malignant spinal cord compression (MSCC) • Poor experience of care – Waiting in busy Emergency departments – Wrong person sharing results Professional issues • Limited access to clinical information on patient – Especially out of hours – Sometimes patients and their families unaware of prognosis • Lack of specialist skills – To recognise chemotherapy toxicities • Ceilings of care not clear – ITU or EOLC • Organisational issues – Pathways of care • Education opportunities • Challenging current culture 4
Lesson 1: Have a clear vision for an approach • Be clear on what an Acute Oncology service is – Working with those who deliver acute care to our patients • Be accessible • Share expertise • Provide updated protocols • Very clear on what is was not – Oncologists in ED • Clerking patients • Carrying our interventional procedures • Communicate experience from previous working practices – Able to portray a “better experience” – Attuned to current gaps Lesson 2: Define the role of Oncologist in AOS • Sharing expertise in managing Oncological emergencies irrespective of tumour type – Sub-specialisation has eroded confidence in generic skills • Advisory capacity in how best to proceed in patients who present with a new suspected cancer – Where case does not fit into recognised established pathways – Individualised treatment plans incorporating PS & co- morbidities 5
Be clear on what an Acute Oncology Service is not? • Seeing patients with a past history of a resected cancer and now present with atrial fibrillation • Seeing patients with a vague history and signs e.g. fatigue and anaemia with no clear clinical or radiological evidence of malignancy • Acute Oncology should not supersede excellent diagnostic services but play a greater part in further management when malignancy suspected on radiology Lesson 3: Engage “key stakeholders” with your vision • Set aside first 6 weeks after my appointment to meet all key staff from ED & AAU • Spent day with Outreach critical care team to understand local landscape and issues • Ensured I listened to feedback – What was currently not good enough – What needed fixing • Stayed flexible around personal views – My usual response is to solve – Aim to deliver the shortfall 6
What did the acute clinicians want? • Ready access to information on patients – Chemo regimen given – Treatment intention • Patients to be better informed • Admitted patients to be prioritised to Mercers Ward • Approachable & accessible Oncology input • Updated pathways on managing oncological emergencies Next steps • Engaged with IM&T – Setting up referral systems – Setting up Rapid alert systems • Discussed with Bed Managers – Prioritising all admissions for patients with cancer to a designated medical ward • Dr Leonard responsible for in-patient care • Started a programme of Education – ED Nurses – Junior doctors & Medical Consultants 7
Used in house systems to bolt – on referral systems • Engaged with IM&T – To set up referral systems using existing software • E.g. order comms Sunquest ICE – To set up Rapid alert systems • To alert staff when known cancer patients – on chemo present to ED – With known bone mets present with back pain, weak legs • Possible to use in house resources – Used ACCESS database with PAS & Business Objects 8
9
Understand workforce available • Scope existing expert personnel – May already be doing the role without knowing it – May have been waiting for a leader • Biggest investment required is TIME – Starting a new service on top of a busy timetable not do-able • Sabbatical for 6 months versus a new appointment – Advantages of having someone senior to engage Lesson 4: Data is King 10
Understand your local Oncology Landscape • Cancer unit with a population 440,000 – Within 3 miles of UCLH & RFH • 583 new cancer diagnoses in 2008 at Whittington – Majority referred via OPA – 9.9% self-referred via ED • Number of emergency medical admissions per day – 30 (25-33) large seasonal variation – 1-2 patients with cancer per day Data to understand the usual pathway King et al BMJ Qual Saf 2011;20:718-724 Process mapping the patient pathway for medical presentations 59% self referral Delay awaiting Delay awaiting Delay procedure report awaiting MDT Refer for MDT Cancer endoscopy/ review Radiology report confirmed Refer to A&E Admit biopsy for imaging suggests cancer on oncology tissue And histology diagnosis histology 1.6 days 41% GP referral 9 days 34 medical patients presented via ED 2008 and found to have a new cancer diagnosis Median Los 19 days Blood tests 42 Number of tests 3 47% referred to palliative care 26% Oncology 60% upper GI/HPB 11
Recommend
More recommend
