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