Acute Oncology The National Picture 1 Philippa Jones Acute - - PDF document

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Acute Oncology The National Picture 1 Philippa Jones Acute - - PDF document

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16/07/2014 Acute Oncology The National Picture 1 Philippa Jones Acute Oncology Forum Lead Macmillan Associate Acute Oncology Nurse Advisor United Kingdom Acute Oncology Nursing Society 2 1 16/07/2014 Acute Oncology People with cancer

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Acute Oncology

The National Picture

1

Philippa Jones Acute Oncology Forum Lead Macmillan Associate Acute Oncology Nurse Advisor United Kingdom Acute Oncology Nursing Society

2

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Acute Oncology

People with cancer often develop new and acute problems which require an urgent response, either as a consequence of their cancer illness or the treatment itself.

3

Professor Sir Mike Richards (Royal College of Physicians 2012)

National Drivers

4

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NPSA and NCEPOD

Patients suffering from acute oncology emergencies not recognised, or appropriate treatment delayed by;

 Primary care teams  Ambulance personnel  Emergency care teams  Oncology teams  and Patients themselves

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Emergency care

 NCEPOD 49% having room for improvement and 8%

receiving less than satisfactory care.

 NCAG- There were 273,000 emergency admissions

with a diagnosis of cancer in 2006/7.

 This is roughly equivalent to 750 emergency

admissions each day across England.

 A typical Trust may have five emergency

admissions with cancer per day

6

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The National Chemotherapy Action Group (NCAG), guided partly by reports from NCEPOD and NPSA and from previous cancer peer review results, recommended that a more systematic approach should be taken to dealing with cancer-related emergencies. These recommendations have been embodied in the concept

  • f the 'Acute Oncology Service'.

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Acute Oncology Services

 Acute oncology services are being implemented at all acute trusts

that accept unplanned and emergency cancer admissions.

 They centre on a team consisting of one or more nurse specialists

  • r nurse practitioners with dedicated availability Monday to Friday

and from one or more oncologist.

 These professionals interface with acute teams, specialist

palliative care and others to improve the coordination of care with earlier access to the relevant specialist advice.

 They also have key roles in education and audit. 8

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  • Acute Oncology Nurse –

Who are Acute Oncology Patients?

Two Patient Groups :

1.

Patients with potentially acute complications of their cancer treatment.*

2.

Patients potentially suffering from certain emergencies caused by the disease process itself whether the primary site is known, unknown or presumed

* non-surgical treatment

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Key Features of an Acute Oncology Service:

 Early review by an oncologist or acute oncology nurse specialist

(within 24 hours)

 24/7 access to telephone advice from an oncologist  Fast track clinic access from A&E or MAU  Access to information on individual patients across the Trust  Protocols for the management of oncological emergencies and

referral pathways from A&E and acute admissions unit

 Specific pathways for the investigation and treatment of malignant

spinal cord compression

 Early management of MUO/CUP patients

11 Key Features of an Acute Oncology Service:

 Early review by an oncologist or acute oncology nurse specialist

(within 24 hours)

 24/7 access to telephone advice from an oncologist  Fast track clinic access from A&E or MAU  Access to information on individual patients across the Trust  Protocols for the management of oncological emergencies and

referral pathways from A&E and acute admissions unit

 Specific pathways for the investigation and treatment of malignant

spinal cord compression

 Early management of MUO/CUP patients

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 Where are we now?  What’s out there to help at the moment?  How can we promote a culture of Acute Oncology and

support each other?

 How can we influence change?

UK Picture

Trusts throughout the UK are developing specialist acute oncology advice and assessment services in response to concerns raised in 2008 by the NCEPOD report.

 Scotland……… a number of acute oncology projects and the

development of a national helpline service.

 Northern Ireland….aspects such as the adoption of UKONS

triage tool.

 Wales…………. Acute oncology projects led by the cancer

networks and UKONS triage tool.

 England……….National uptake guided by the Peer Review

measures.

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Internationally

UK leading the way!

 Hong Kong  Australia  Canada  New Zealand  Malta  Ireland  Saudi Arabia

Is it worth it?

 Admission avoidance  Decreased Length of stay  Reduced investigations/intervention

My favourites:

 Improvement in quality and safety  Increased patient satisfaction  Increased professional satisfaction

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Love it or loathe it

Peer Review

Loathe It?

 Time consuming  Prescriptive  Directed at process and not outcomes

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Love It?

 Describes the structure/framework of a service - development  A framework for review – monitoring  A benchmarking tool – comparison  Evidence  Education

How reliable is the process?

 Can we be trusted to self assess?  Can we be rely on our trust/network colleagues to

assess us?

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Immediate Risks And Serious Concerns

Services with IRs (SA/IV) Services with IRs (PR) % services with IRs Services with SCs (SA/IV) Services with SCs (PR) % services with SC AO MDT 2011-12 15 N/A 8 % 50 N/A 27 % 2012-13 31 17 % 127 69 % Specialist AO/MDT 2011-12 N/A 3 N/A 21% 2012-13 1 8 % 6 50% Generic AO 2011- 12 15 N/A 8% 54 N/A 28% 2012-13 31 16% 132 68% AO In- Patient MDT 2011-12 15 N/A 8 % 52 N/A 27% 2012-13 30 16% 132 69%

Acute Oncology Immediate Risks

 There are still many non-functioning and totally non-compliant Acute

Oncology Services without sufficient planning to address this.

 There is a lack of staffing.  There are problems across the board regarding the core members of the

MDTs.

 Lack of appropriate training.  Lack of access to an oncologist within 24hrs of presentation.  Lack of a fully functioning electronic flagging system.  Lack of administration support.  1 hour Antibiotic pathway in A&E not being observed.

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Acute oncology immediate risks

MSCC pathways are not sufficiently robust and in some instances have no formal documented pathway at all, resulting in patients not being discussed by appropriate clinical teams which has high levels of risk for this group of patients.

Neutropenic sepsis pathways not being reviewed or audited and so remain unclear as to whether safe and effective care is being provided for these patients.

Lack of engagement with A&E departments.

Lack of engagement from Oncologists regarding the setup of the Acute

  • ncology service

No CUP (Cancer of Unknown Primary) service.

Mismanagement and patient safety issues regarding there being two sets of notes (Main medical and Oncology) for patients receiving treatment which may not be available to A&E department.

Acute Oncology Good Practice

  • Co-ordination and leadership role of the AOS nurse.
  • Trust-wide engagement from clinicians and nurses.
  • Raising the profile of the acute oncology service within

trusts and externally.

  • The use of patient group directives for nurses and placing
  • f sepsis trolleys in appropriate areas to improve time to

first dose of antibiotics.

  • Innovative and comprehensive training methods with the

development of e-learning packages.

  • Web based systems for well-developed policies and

protocols with a variety of promotional screensavers.

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Peer Review Is Here To Stay New Measures this year reinforced the role of the network groups in the development and review of acute

  • ncology services.

Outcomes

Lives of people affected by cancer will be improved through using the AOS Service by:

  • Reduction in length of stay
  • Reduction in emergency admissions
  • Timely and appropriate management of patients with potential

neutropenic sepsis

  • Timely review and assessment by members of the Acute Oncology

service

  • Reduction in unnecessary clinical investigations
  • Reduction in waiting times
  • Increase in patient satisfaction
  • Reduction in complaints
  • Reduction in avoidable deaths within 30 days of systemic anti-cancer

therapy (NCEPOD 2009)

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Forward

 Do you have defined outcome measures for your

service?

 Would it be better to have nationally agreed outcome

measures?

 Could you improve your Peer review?

National Group

Evidence

 Annual Peer Review against the measures for Acute Oncology  Patient satisfaction Survey results  Use of the Acute Oncology Services monitoring and outcome

measures for Acute Oncology

 This data and information will be presented regularly in an agreed

format at an agreed governance group meeting and any concerns regarding existing quality or concerns about maintaining quality will be escalated appropriately.

 The Acute Oncology Team will produce an annual report utilising the

information listed above to evaluate the efficiency and quality of the service.

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Data collection

Why do we want/need to collect data

 Demonstrate outcomes and effectiveness  Demonstrate financial aspects of service  Demonstrate need for service expansion or

improvement

 Demonstrate service demands  Highlight common problems  Evidence of practice - good and bad

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Data collection

 National outcome measures enabling us to compare

and not

 Local value – how are we doing ?  National value – how are we all doing ?  Do we have a problem or do we all have a problem -------

  • How can we fix it?

Data is crucial & powerful ?

What's out there to help

 A number a basic access data bases developed locally

and available for sharing

 Assessment tools and log sheets for data collection  Somerset Data Base –working on an Acute Oncology

Module to cover Acute Oncology ,MSCC and MUO/CUP.

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  • Many of us are looking to build upon existing

developments and utilise existing good practice.

  • There is also recognition that the standardisation
  • f training and patient management in the acute

setting is a sensible strategy to support safe, high quality care.

  • And it also saves valuable time and energy!

The future

  • To offer a group voice and collective opinion on matters relating to

Acute Oncology Nursing.

  • To provide support and guidance by connecting acute oncology nurses

across the UK.

  • To promote and facilitate the sharing of good practice.
  • To work together as a forum to develop guidelines, practical tools and

pathways to aid in the implementation of first class acute oncology services.

  • To provide a resource for the health community by gathering a pool of

expertise all can access.

  • To support education and showcase excellent practice through

workshops, study days etc.

  • To support multi agency project working with professional
  • rganisations such as the Macmillan Cancer Support and the Royal

Colleges.

Acute Oncology Forums

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Existing forums

  • There are a number of regional forum in

existence

  • UKONS launched a national group in November

2013- Now has 600+ on the distribution list

  • National Multi Disciplinary directory – currently

being collected to support the work of the National Group.

Developments to date.

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24 Hour Helpline Assessment 37

Progress

  • A tool that will determine “the patient’s level of risk” and prioritise

the level of urgency indicated by the presenting symptoms and will aid in identifying potential emergency situations

  • Uptake continues at a pace in both the NHS and Private sector in

the UK and internationally 160 trusts known (please look at the map).

  • The Pilot of the Paediatric version developed in partnership with the

RCN is almost complete, evaluation is underway.

  • Review and update in 2014 – expand scope.
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Primary Care Triage Services

 Shropshire care coordination and GP out of hours

  • service. Macmillan funded pilot.

 DH funded pilot in Scotland with NHS24.

Very positive results to date.

A Primary Care version

A Primary Care version has been developed in collaboration with Macmillan GP’s and Nursing forum. It is now available as a PDF or hard copy. Really well received by the Primary Care Teams.

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P 37.5ºC OR 6ºC
  • r
– – T – Pt’ ’ significantly decreased No significant intake ’ (S ee specific toxicity) drink plenty of fluids. Use ficulty If your patient scores RED or AMBER for any toxicity you should contact the 24 Hour Helpline immediately for a full triage assessment. ONCOLOGY/HAEMATOLOGY RISK ASSESSMENT TOOL FOR PRIMARY HEALTH CARE PROFESSIONALS INSTRUCTIONS FOR USE Anorexia What was their weight before? What is appetite like? Any contributory factors e.g. dehydration, diarrhoea, vomiting, mucositis, and nausea? Bleeding Is it a new problem? Is it continuous? What amount? Where from? Is the patient on anticoagulants? Bruising Is it a new problem? Is it local/generalised? Is there any trauma involved? Chest Pain Onset? What makes it worse? Radiation? Any cardiac history? Constipation How long since bowels opened? What is normal? Does the patient have any abdominal pain/vomiting? Has the patient taken any medication? Consider obstruction and/or perforation Diarrhoea Consider infection! How many days has this occurred for? How many times in a 24 hour period? Does the patient have any abdominal pain/discomfort? For how long? Has the patient taken any medication? N.B If taking CAPECITABINE (Xeloda) chemotherapy please ask patient to discontinue treatment until they have had helpline review. Dyspnoea/Shortness of breath Is it a new symptom? Is dyspnoea worsening? What can the patient do? (alteration in Performance status) Consider SVCO/Anaemia/Pulmonary ebolism Extravasation - drug leakage around infusion site or along infusion pathway Has the patient got pain, soreness or ulceration around or along the infusion pathway/injection site/central venous catheter ? Fatigue How many days has this occurred for? Any other associated symptoms? Fever Patients who are at risk of immunosuppression who have an abnormal temperature should be referred to the helpline for assessment Fever and/or generally unwell and recieved systemic anti- cancer therapy (chemotherapy oral or I.V.) within the last 6 weeks or disease related immunosuppression If temperature is 37.5 C or above or below 36 C or generally unwell - Contact telephone helpline for URGENT Assessment - Risk of neutropenic sepsis ALERT - Patients on steroids/analgesics or dehydrated may not present with pyrexia but may still have infection (if in doubt phone for advice) TOXICITY None Loss of appetite without alteration in eating habits Mild, self limited controlled by conservative measures Petechia/bruising, localised Mild - no bowel movement in last 24 hours Advise - Dietary advice, supportive medication Increase to 2-3 bowel movements a day or over pre-treatment movements Intravenous therapy Certain chemotherapy drugs can cause long term severe tissue damage if extravasation (leakage) occurs. Chemotherapy extravasation requires urgent specialist review and management. Increased fatigue but not altering normal activities Advise - Rest accompanied with intermittent mild activity n/a Moderate or causing activities > 37.5 C - 38 C Severe loss of ability to perform some activities Bedridden or disabling No new symptoms Increase to 4-6 episodes a day or nocturnal movement/ moderate cramping Dyspnoea on exertion Dyspnoea at normal level of activity Dyspnoea at rest or requiring ventilatory support Increase to 7-9 episodes a day or incontinence Severe cramping Increase to > 10 episodes a day or grossly bloody diarrhoea or need for parenteral support Moderate - no bowel movement in last 48 hours Severe - no bowel movement in last 72 hours. Consider bowel obstruction and/or perforation. Life threatening sepsis Consider bowel obstruction and/or perforation. Arrange URGENT A&E attendance for medical assessment A number of chemotherapy drugs are cardio toxic urgent assessment is essential. Moderate petechia/purpura Generalised bruising Generalised petechia/purpura Generalised bruising Uncontrolable haemorrhage - Arrange URGENT A&E attendance for medical assessment Oral intake altered without malnutrition Oral intake altered in weight loss/malnutrition Life threatening complications e.g collapse None None None None None None None Normal > 38 C - 40 C > 40 C It is important that the effects of treatment are
  • f lower level amber toxicites is recognised.
Risk assessment process There are a number of questions to ask and information that will need to be collected to make sure that the correct advice is given. Step 1. The user moves methodically down the triage assessment tool, asking appropriate questions. e.g. do you have any nausea? If NO move
  • n.
If YES use the questions provided to help you grade the problem and note either amber
  • r red and initiate action according to step 2.
Step 2. Red and/or Amber: If your patient scores RED or Amber for any toxicity you should contact the 24 Hour Helpline immediately for a full triage assessment unless URGENT referral to A&E is advised. Patients may require urgent assessment in a suitable clinical area that provides access to investigation and treatment facilities. The helpline team will arrange assessment and/or further monitoring for the patient. Green:- If your patient scores green in all toxicities they should be reassured that the problem at present does not give cause for concern but they should be vigilant and if the situation gets worse or does not improve they should call the Helpline immediately. The UKONS 24 Hour Triage Tool is a widely utilised recognised tool that is used to a perform risk assessment for patients who have : Received systemic anti-cancer therapy including chemotherapy in the previous 6-8 weeks Radiotherapy Disease related immunosuppressuon It is a simple reliable evidence based process that grades the toxicities according to the advises action accordingly.

UKONS Primary Care Guidelines

generic guidelines supported by Macmillan. Will be available as a pocket tool for order on the Macmillan web-site with the facility to add trust contact details.

Developed by UKONS and The Macmillan GP Team Approved by: Greater Midlands Cancer Network. Midlands Acute Oncology Nurses Forum. Electronic version and App in development.

Patient versions

 North of England Cancer Network –Patient held

Chemotherapy record ( Lilly diary)

 Cancer Emergency Response Tool ,an app for patients

  • Dr. Richard Osborne ,Dorset Cancer Centre
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CERT APP is now live in iTunes, you can download it below. https://itunes.apple.com/gb/app/cancer-emergency-response/id711709486?mt=8&ign- mpt=uo%3D2

Initial assessment and management.

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Initial Management Guidelines

 UKONS- generic initial

management guidelines.

 RAG rated assessment and guide

for early management.

 Available for local adaptation.  Meets peer review requirements

(As well as not instead of trust toxicity prevention and management policies)

Generic management guidelines for chemotherapy toxicities (see specific algorithms for management of each toxicity) Grade 1 (Green) Grade 2 (Amber) Grade 3 (Red) Grade 4 (Red) Mild Moderate Severe Life threatening

Also consider factors which lower threshold for inpatient admission: Symptoms needing urgent admission – temperature, chest pain, bleeding? Might be neutropenic? More than one Grade 2 toxicity? Poor historian/ difficult to assess on phone? Compliance of patient / ability to understand and follow instructions Grade 2 toxicity not settling despite maximal outpatient efforts? Becoming weak/dehydrated? NB Neutropenic sepsis needs urgent admission and immediate iv broad spectrum antibiotics/fluids.
  • Do not get GP out first.
  • Do not wait for FBC before
giving antibiotics.
  • See specific guideline for
further detail. ACTION: Grade 1 See specific toxicity guidelines Advise patient to phone back if getting worse Document call and advice given ACTION: Grade 2 See specific toxicity guidelines Assess for admission if two grade 2 toxicities or toxicity not settling despite initial advice Advise patient to phone back if getting worse Phone/review patient within 24 hours to ensure settling Document call and advice given ACTION: Grade 3 and 4 Admit for assessment, investigation and parenteral management. See specific toxicity guidelines and sections on management of inpatients with chemotherapy toxicities on page 3 If not needing admission, ensure FBC, U+E checked, good oral intake and daily contact with patient until improving, with low threshold for admission. Document call and advice given and inform specialist team NB – rapid deterioration possible. Chemotherapy toxicities are reversible but need aggressive management Please ensure that your Acute Oncology Team are informed of the patients admission as soon as possible

UNPLANNED ADMISSION LOG SHEET

√ Standardised Assessment Process Evidence Based Assessment Tool

Check List/aid memoir Audit Tool Record Keeping Evidence of practice Training and education Communication tool

Midlands Acute Oncology Nurses Forum

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Midlands Acute Oncology Nurses Forum

Ma Macmilla cmillan Learn rn Zone

Macmillan are kindly supporting a Special Interest Group for the Midlands Acute Oncology Nurses Forum on Learn Zone. This provides a forum discussion facility and a document library allowing us to share good practice and seek opinion and/or advice. This is not restricted to nurses working within the Midlands you are all welcome to join and make use of this facility.

Accessing the Acute Oncology Special Interest Group on Learn Zone - Go to : http://learnzone.org.uk/

  • In the green bar click on ‘special interest groups’
  • It will ask you to enrol-click ‘continue ‘
  • You will need to either log in or create an account.
  • It will then list the special interest groups, select:

Midlands Acute Oncology Nurses Forum For first time access the password is ---MidA0N ( the 0 is a zero)

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A web based Generic Acute Oncology Induction Training Programme. Developed by Acute Oncology Nurses and Macmillan using the East Midlands Cancer Network template. Due to be launched end of 2013 Forum members are working alongside Macmillan to complete an online Acute Oncology Induction Training Programme.

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In the pipeline

  • MSCC patient information
  • MSCC Care and management plan

The message is getting through!

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National Developments

National working party linked to Chemotherapy Reference Group (CRG):-

 England - National Acute Oncology Service Specification  National Outcome Measures  Review of current service provision- what's out there? is

it working?

 Are the PEER review measures appropriate?  How do we take the service forward

The message

 Avoid repetition.  Don’t work in isolation.  Don’t keep good things to yourself  Lets work together, join forces.  Standardise and share  Support each other

Nationally – contribute and collaborate.

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Remember

 AOS brings together expertise from

  • ncology disciplines, emergency

medicine, palliative care, general medicine, general surgery and the community

Why do we need to succeed?

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 Patient contacted chemotherapy helpline –

symptoms described in line with spinal cord

  • compression. Advised to ring 999 for assessment in
  • ED. Patient contacted help line again 3 days later –

condition worse – had attended ED as directed previously but was discharged after a 5 hour wait. Patient now immobile. Patient was later admitted to ward and treated for MSCC.

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 Patient receiving chemotherapy with a history of

neutropaenic sepsis following each previous cycle of

  • treatment. Telephoned A&E for advice as she had a

raised temperature. She was advised to take regular paracetamol and to report if temperature of 38.00c whilst

  • n paracetamol. Patient presented at chemotherapy

clinic, unwell, pyrexia 38.00c and neutrophils 0.1x10x9/L. Immediate admission for treatment of neutropaenic sepsis.

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 The patient was discharged post chemotherapy

with recovering blood counts. The Clinical Nurse Specialist contacted the patient and gave them aftercare advice and the emergency contact number. When the patient became pyrexial 380c he followed CNS advice and contacted the Helpline number/Ward. The person who took the call told him to take some paracetamol.

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Any questions ? Thank you

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philippajones@nhs.net