Over next 45 minutes.. Lessons learnt from: setting up a new - - PDF document

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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

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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

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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

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From the Patient perspective

• Accessing appropriate and skilled help when

unwell

– Telephone advice – Emergency services

• Delays in recognising complications of treatment
• r 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

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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

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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

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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

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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

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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

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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 41% GP referral A&E Radiology report suggests cancer Refer for endoscopy/ biopsy for tissue diagnosis Cancer confirmed

• n

histology Refer to

• ncology

Admit 9 days MDT review imaging And histology 1.6 days Delay awaiting procedure Delay awaiting report Delay awaiting MDT

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

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12 Relative one year survival: by cancer type

Malignant registrations, South West 2007, excluding multiples and DCOs EUROCARE Relative Survival 95% CIs Relative Survival 95% CIs Relative Survival 95% CIs Relative Survival Acute leukaemia

39.7

(28.1 - 51)

39.4

(32.9 - 45.8)

40.4

(29 - 51.5) Bladder

78.3

(74.6 - 81.5)

34.0

(27.3 - 40.8)

79.2

(73.2 - 84)

85.3

Brain & CNS

68.4

(60.1 - 75.4)

34.0

(29.1 - 38.9)

60.6

(53.6 - 66.8)

39.1

Breast

97.7

(96.8 - 98.4)

50.8

(44.4 - 56.9)

98.2

(97.5 - 98.8)

95

Colorectal

84.5

(82.7 - 86.2)

48.4

(45.2 - 51.5)

79.5

(76.9 - 81.9)

74.7

Kidney

81.1

(76.8 - 84.7)

24.0

(18.4 - 30)

72.4

(66.1 - 77.7)

74.7

Lung

39.8

(37.4 - 42.3)

8.9

7.6 - 10.3)

32.4

(29.1 - 35.7)

36.1

Multiple myeloma

83.6

(76.8 - 88.5)

53.1

(46.5 - 59.2)

73.0

(63.7 - 80.3)

70.5

Non-Hodgkin's lymphoma

86.6

(83.2 - 89.3)

43.7

(38.1 - 49.1)

80.9

(76 - 84.9)

73.1

Oesophagus

43.8

(38.9 - 48.6)

22.4

(16.7 - 28.7)

45.5

(39.5 - 51.4)

36.3

Other

81.1

(79.8 - 82.4)

27.2

(25.2 - 29.2)

77.8

(76.1 - 79.5) Ovary

83.4

(79.1 - 86.9)

38.8

(32.4 - 45.1)

72.1

(64.7 - 78.3)

70.7

Pancreas

21.0

(16.6 - 25.9)

6.0

(4.1 - 8.6)

22.3

(16.8 - 28.4)

19.2

Prostate

98.0

(97 - 98.7)

48.2

(43.6 - 52.7)

98.3

(96.9 - 99.1)

92.2

Stomach

49.1

(43.1 - 54.8)

17.7

(13.3 - 22.8)

47.6

(41 - 54)

44.1

Other route Emergency GP/OP referral (+TWW) Cancer type

All cancer Routes to Diagnosis: by cancer type

All malignant registrations South West 2007 excluding C44 and multiples

Routes to Diagnosis

GP/OP referral Two Week Wait Emergency presentation Other outpatient Screen detected Inpatient elective DCO Unknown Total Number of patients Acute leukaemia 17% 3% 61% 12% 0% 4% 0% 4% 100% 380 Bladder 22% 36% 18% 13% 0% 6% 1% 5% 100% 1,167 Brain & CNS 18% 2% 49% 20% 0% 5% 0% 5% 100% 740 Breast 8% 40% 5% 5% 28% 2% 0% 13% 100% 5,646 Cervix 21% 17% 12% 8% 23% 3% 1% 15% 100% 308 Chronic leukaemia 26% 6% 45% 13% 0% 4% 1% 4% 100% 629 Colorectal 19% 29% 24% 12% 0% 8% 0% 7% 100% 4,515 Kidney 22% 26% 23% 16% 0% 5% 0% 8% 100% 928 Larynx 35% 34% 8% 14% 0% 5% 0% 3% 100% 216 Lung 15% 26% 38% 10% 0% 4% 1% 7% 100% 3,893 Melanoma 23% 39% 4% 8% 0% 5% 0% 22% 100% 1,686 Multiple myeloma 20% 14% 44% 13% 0% 4% 1% 5% 100% 606 Non-Hodgkin's lymphoma 25% 22% 25% 13% 0% 6% 1% 9% 100% 1,349 Oesophagus 15% 32% 21% 14% 0% 13% 0% 4% 100% 912 Oral 32% 27% 5% 14% 0% 4% 1% 17% 100% 458 Ovary 20% 29% 28% 11% 0% 3% 1% 8% 100% 853 Pancreas 13% 20% 45% 10% 0% 5% 1% 7% 100% 917 Prostate 26% 28% 11% 11% 0% 7% 0% 16% 100% 4,865 Stomach 14% 24% 31% 13% 0% 11% 1% 6% 100% 801 tbc (other) 21% 18% 34% 12% 0% 4% 1% 9% 100% 4,323 Testis 14% 47% 9% 15% 0% 4% 0% 11% 100% 259 Uterus 28% 36% 8% 12% 0% 5% 0% 12% 100% 918 Total 19% 28% 22% 11% 5% 5% 1% 10% 100% 36,369

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Examples of CUP pathways which ensure early triage to specific tumour MDT

Cancer New ED diagnoses Total Dec – Feb Percentage of diagnoses by ED (Dec – Feb) National figure for percentage of diagnoses by ED (06- 08)

Lung 9 24 38% 39% Pancreas 6 6 100% 50% Hepatobiliary + GB 3 5 60% 48% NHL 3 7 43% 27% Myeloma 3 4 75% 37%

MUO 3 5 60% 37%

Gynae 3 11 27% 15% Colorectal 2 14 14% 26% CNS 2 2 100% 62% AML 2 2 100% 54% Bone sarcoma 1 1 100% 25% H&N- Oropharynx 1 1 100% 9% Mesothelioma 1 1 100% 36% Oesophagus 1 1 100% 22% Stomach 1 2 50% 33% Prostate 1 20 5% 10%

Prospective audit of emergency admissions

• f cancer Dec 2012 – March 2013

Examples of CUP pathways which ensure early triage to specific tumour MDT

Cancer New ED diagnoses (RIP) Total Dec – Feb Percentage of diagnoses by ED (Dec – Feb) National figure for percentage of diagnoses by ED (06- 08)

Lung 9 24 38% 39% Pancreas 6 6 100% 50% Hepatobiliary + GB 3 (2) 5 60% 48% NHL 3 7 43% 27% Myeloma 3 4 75% 37% MUO 3 5 60% 37% Gynae 3 11 27% 15% Colorectal 2 (1) 14 14% 26% CNS 2 2 100% 62% AML 2 (1) 2 100% 54% Bone sarcoma 1 1 100% 25% H&N- Oropharynx 1 1 100% 9% Mesothelioma 1 1 100% 36% Oesophagus 1 1 100% 22% Stomach 1 2 50% 33% Prostate 1 20 5% 10%

Prospective audit of emergency admissions

• f cancer Dec 2012 – March 2013

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In-patient admissions during pilot

Acute Oncology admissions to Mercers ward July- Dec 2009

5 10 15 20 25 30 B r e a s t L u n g C R C U p p e r G I H e p B i l O v a r i a n C U P B l a d d e r B r a i n Cancer type Number of patients Other Treatment related Disease related

In-patient admissions to Mercers Ward 89 pts in 6 months - 78/89 = 88% disease related 7/89 = 8% treatment related 4/89 = 4% “other”

3 consecutive years audit data on unplanned admissions admitted under care of Dr Leonard

Year (June – December )

Type 2 – known cancer treatment toxicities Type 3 – known cancer progressive disease/symptom control

2009 (n=89) 8% (7) 88% (78) 2010 (n=42) 17% (7) 83% (35) 2011 (n=18) 17% (3) 83% (15) Total 17 (12%) 128 (88%)

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Admission secondary to treatment related toxicity e.g. febrile neutropenia Admission secondary to symptom related to disease e.g. bone pain, increasing ascites End of life care episode Admission caused by medical event e.g. PE, UTI, fast AF, TIA, chest infection etc Known cancer patients (Dr Leonard) If admitted to Mercers Dr Leonard will take

• ver care over

If admitted to Mercers Dr Leonard will take

• ver care over

If admitted to Mercers Dr Leonard will take

• ver care over

To remain under care of admitting physician – please inform Dr Leonard Known cancer patients (other Oncologist) If admitted to Mercers Dr Leonard will take

• ver care over

If admitted to Mercers Dr Leonard will take

• ver care over

To remain under care of admitting physician – please involve Palliative care team To remain under care of admitting physician – Dr Leonard & AOS happy to give advice re:ceiling of care if appropriate Previously undiagnosed Cancer patient To remain under care of admitting physician – please refer to Dr Leonard & AOS via ICE To remain under care of admitting physician – please involve Palliative care team To remain under care of admitting physician – Dr Leonard & AOS happy to give advice re:ceiling of care if appropriate

The Acute Oncology service and admissions to Mercers ward Lesson 5: Embedding the service

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Reach all health care professionals

• A study or induction day is not enough

– High turnover of staff – All levels needed to be engaged

• Consultants are territorial and set in their ways
• Repetitive & consistent

– Grand rounds – FY1/2 teaching…core trainee…ST… – At the bedside

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Introducing new pathways of care

The Gatekeepers are the Radiologists

• Referral direct from Cons

Radiologist – 35 yr old female

• 6m history back pain &

lethargy

– GP referred for CT on basis of abnormal CXR – Called on day of CT to explain – Within 24 hrs mediastinoscopy – Within 4 working days diagnosis

• HD

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MR WM 71yrs Non-smoker Hx RUQ pain 06.1.12 GP rang for advice – liver mets on US 10.1.12 Seen by PL Fast track OPA (4/7) PS 1 Keen for all interventions understood treatment plan and intention 17.1.12 CT results & diagnostic plan (11/7) 18.1.12 EBUS UCLH (12/7) MDT presentation on 20.1.12 (14/7) 27.1.12 EBUS results & 1st day treatment (21/7) 1.2.12 Lung MDT presentation (26/7)

Compare & contrast Fast track v Best 2WW

• MR WM 71yrs Non-smoker Hx RUQ pain
• 06.1.12 GP rang for advice – liver mets on US
• 10.1.12 Seen by PL Fast track OPA

(4/7)

• PS 1 Keen for all interventions understood

treatment plan and intention

• 17.1.12 CT results & diagnostic plan

(11/7)

• 18.1.12 EBUS UCLH

(12/7)

• 20.1.12 Unkown Primary MDT presentation

(21/7)

• 27.1.12 EBUS results & 1st day treatment

(21/7)

• 1.2.12 Lung MDT presentation

(26/7)

• MR WM 71yrs Non-smoker Hx RUQ pain
• 06.1.12 GP sends 2WW - liver mets on US
• 20.1.12 Seen by Gastro team

(14/7)

• PS 1 Keen for all interventions understood

treatment plan and intention

• 27.1.12 CT results & discussion at unknown

primary MDT (21/7) Outcome refer Lung MDT

• 1.2..12 MDT discussion - outcome refer EBUS

UCLH (26/7)

• 8.2.12 EBUS UCLH

(33/7)

• 15.2.12 MDT presentation

(40/7)

• 21.2.12 PL Onco clinic & 1st day treatment

(46/7)

P a t i e n t e x p e r i e n c e

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Traditional pathway – same outcome

• 89 yrs female
• Short history fatigue, nausea &

reduced appetite

• 28.6.12 GP U/S

– Peritoneal cake – CT done same day

• 29.6.12 MUO MDT (D2)

– PL rang GP to offer fast-track OPA for assessment on 3.7.12 (D6) – Informed by GP for PP

• Saw HPB surgeon - biopsy
• 20.7.12 Meets PL (D23)

– PS 2 – Doesn’t want chemo – GFR 29 mls/min – Dex & community Pall care

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Early AOS can improve experience of care-celebration

• f generic skills
• 28 yrs female 6m history back pain
• Abnormal x-ray reported & orthopaedic team

alerted

• MRI pelvis & CT Thorax/Abdo done
• AOS involved
• 5.1.13 Seen at RNOH
• 18.1.13 Sarcoma MDT
• 25.1.13 Prof Whelan – no chemo
• 3.4.13 RIP

Liver metastases only

• How do we manage

this case?

• determine fitness
• PS
• renal & liver function
• assess symptoms
• explore wishes
• Biopsy if chemo appropriate

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Why do clinicians over investigate?

Fear of missing the treatable? Unwillingness that CUP is advanced disease? Do something is easier than having an honest discussion about poor prognosis? Belief that histological diagnosis a stronger determinant than prognosis determined by PS/co-morbidities

Metastatic Spinal cord compression

• 59yrs female
• Short history of weakness

& loss of sensation right hand with pain in neck

• Contacted directly by MRI

26.2.10

• Vertebral collapse C7,

T1,T2 & T3 with impending cord compression

• Organised by phone

urgent RT & team approach

– Patient transferred UCLH 27.2.10 and treated – Post RT biopsy

• Metastatic breast ca

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75% of all presentations of MSCC are from Breast, Lung & Prostate

5-10% will be myeloma or lymphoma

Total number of AOS admissions – proportion referred via ICE (blue) April 2011- October 2012

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ED alerts April 2011- March 2012

• 1171 alerts
• 651/1171

– (55%) admitted – Cf 2009/10 68.9% – Cf 2010/11 64%

Cancer type Numbers admitted CRC 153 Lung 138 Breast 114 Prostate 46 Oesophageal 35 Gastric 12 Bladder 8 Ovarian 6 Pancreatic 6 Melanoma 4

Example of Rapid alert changing management

• 40 yrs male
• Completed neoadjuvant

chemo for synchronous sigmoid & liver CRC

• 4 weeks post hepatic

resection

• Presented ED with

headache over weekend

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Updated algorithim NICE 2012

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27 Summary of patients who presented with FN in a 6 month period in 2011

Patient ED Arrival time ED Triage time Medical assessment time

Time Tazocin given Time gentamicin given 60 min pathway time met

1 12.51 13.01 14.05 14.45 14.45 Y 2 13.59 13.59 14.20 16.00 23.00 N 3 01.40 01.40 02.45 Cipro 03.00 03.00 N Need to ensure antibiotics to be given by ED team in resus

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Collaborating with other teams

Patient Specific Protocols

• Individualised
• Consent
• Involve the patient and

the entire treatment team

• LAS Letterhead
• Medical Director’s

signature London Ambulance Service NHS Trust

56

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Headline data from pilot

• Pilot ran from 1.1.12 – 31.12.12
• 175 patients treated with chemo
• 63 assessed as high risk

– 18/63 (29%) admitted via ED – 14/18 were on chemotherapy – 6/14 (55%) confirmed FN – (3.4% of all patients treated) – 10/14 on chemo Ca Breast ( 7/10 FEC-T - curative) – 3/14 Lung – 1/14 Neoadjuvant GOJ Small proportion of all treated – door to needle time improved with PSP

Results Pilot 24/7 telephone helpline

• Pilot time

– 30th July – 21st October 2012

• 171 treatment episodes

– Rota with each participant taking a week Mon -Sun

• 64 calls ( 37% pts treated)

– 65% 09.00-17.00hrs Monday – Friday

• 42% 09.00-10.00hrs

– 21% Weekend – 14% 21.00-09.00hrs anytime

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Careful provision of care by teams who communicate well How do we communicate?

One point of referral for AOT (electronic system) All referrals triaged daily by Dr Leonard/Dr Mohamed & AOS CNS Refer to Palliative Care Refer to site specific CNS Dr Leonard, Dr Mohamed

• r

AOS CNS to review Refer to Haematology All suspected and/or confirmed cancer cases are discussed at site specific

• r malignancy unknown MDT

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The Whitt MUO referral pathway

Patient presents as an emergency with alarm symptoms or suspicious imaging Make a decision to admit or fast track to OPA assessment Communicate suspicion of cancer Needs admission Assess PS – 0-1 or >2 Measure renal & liver function Determine patient preferences for possible treatment interventions Good PS & fit and willing for further interventions refer site specific or MUO MDT – involve AOT to help tailor timely & appropriate investigations Poor or borderline PS/co- morbidities/patient or physician unsure refer AOS within 24hrs

• f suspicious scan

Refer MUO or site specific MDT for completeness Arrange discharge NO obvious primary site or unclear if fit for further intervention book to fast track AOS OPA within week Clear primary site refer site specialist team for OPA OPA review Good PS with good renal, haem & liver function & willing to undergo biopsy arrange biopsy of site which maximises staging information if unclear from imaging Refer MUO MDT

PS = Performance Status AOS = Acute Oncology Service AOT = Acute Oncology team MUO= Malignancy unknown origin OPA = out-patient appointment

What could be the benefits of embedding comprehensive AOS

• Improved patient experience
• Improved patient outcomes
• Equipping on-call teams with AOS training & updated protocols

to : – Achieve door to needle time of 60 minutes in patients with FN – Referral of appropriate patients for neurosurgical opinion in MSCC

• Up skilling all front-line staff to recognise the emergency and

manage appropriately – Lending expertise – Avoid duplication of resources

• Improve efficiency of services
• Timely assessment after admission from experienced

Oncologist can ensure the most appropriate in management is undertaken – More satisfied patients (and staff!!) – Reduced length of stay

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Overcoming challenges

• Engage and share vision

– Ensure all key stakeholders are involved

• Collect data

– Only way to challenge “perception”

• Listen

– To all feedback

• Reflect

– When things have not gone so well

• Stay responsive and dynamic

– Service needs change

• Ensure you have authority to deliver change