Acute Oncology Services Regional Chemo Service Review 30 th September 2009

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Background and Context Changing Cancer Paradigm New Models of Treatment Delivery NI Chemotherapy Service Standards (Nov 06) Adverse Incidents in NI Recent NPSA Oral Chemotherapy Alerts NCEPOD: for better for worse, (Nov 08) NCAG (National Chemotherapy Advisory Group) (Aug 09) NICaN Chemotherapy Service Review (Jan 09-Dec 10)

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Acute Oncology Services (AOSs) AOSs encompasses : The management of patients who develop severe complications following chemotherapy The management of patients who develop severe complications as a consequence of their previously diagnosed cancer The management of patients who present as emergencies with previously undiagnosed cancer

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Acute Oncology Services Acute oncology necessarily involves clinicians working in emergency departments and in acute medicine, as well as in oncology and related disciplines

Baseline Assessment Issues of relevance to this group

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Background Increasing demand, scarce resource, service pressure Baseline Assessment April - Aug 2009 Stakeholder interviews n=430 Positive, concerns, issues 4 working groups established New Models of chemo delivery Workforce Development Capacity Planning Acute Oncology Services*

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Current organisational model Hub and spoke model / CCentre and CUnits Centre based site specific oncs visit units weekly Registrars travel out to units to support clinics Variation in staff grade support at units Resident hematologists at centre and units Common cancers treated at units CC acts as unit for local catchment area plus regional service for complex cancers Appointments governed by CC Patient Notes leave CC and immediately return following visit

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival 5 locations: Chemo assessment clinics Chemotherapy administration Review clinics Chemotherapy preparation and dispensing suite (pharmacy) Chemo competent nurses ?

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival NI A/E Departments

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Components of chemo service Service configuration Workforce configuration Leadership arrangement Governance arrangements Data and information technology Effective communication systems & processes Commissioning arrangement

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Underpinning principles for commissioning chemo services (NCAG, 2009) Patients who might benefit from chemo are able to access quality services Treatments which are delivered are appropriate to a patients condition Services are delivered safely Services are convenient for patients Patient experience is good Services represent good value for money

Delivery & treatment environment Pt, carer information, education Urgent assessment, management of complications End of treatment record and care plan Access & referral Assessment, decision to treat, consent Prescribing & Dispensing

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Current AE realities All patients are priorities with competing interests not just oncology Only default mechanism is go to A/E / can’t close its doors Palliative care pts arriving, deaths in Dept, GP don’t want to take that responsibility, nobody wants to make decisions on these pts, location Patients arrive even when bed available in cancer unit

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Unsuitable Environment A/E worse place for these patients unless require resus Inappropriate environment, waiting on trolleys for 12 hours, beside drunks, ? infection MAU 150% bed occupancy in 24hrs – infection control

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Poor Clinical Information Flow Information poor, comes ad-hoc, no notes, no documentation, no access to COIS ? Regime, CTs and drug interactions Poor communication, no updates or information sharing No alert cards, pts forget to say on chemo Tx intent unclear, ? Status, short decision making time Difficulty in contacting Oncologist

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Strained professional relationships AE only get negative feedback and complaints Little sense of team work across departmental boundaries Dealing with “their” patients

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival A/E staff not expert in oncology Yet dealing with increasingly complex cancer patients Training an issue, no liaison with Oncology service, never approached, don’t know their names, no updates on what they are doing A/E staff not expert in oncology issues, inappropriately investigated, sometimes inappropriately/over treated Yet commonly bearer of bad news Concerns among non Oncology consultants in peripheral hospitals pts admitted with post chemo complications who they feel ill equipped to manage and who they are unable to transfer to oncology units

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Lacking pathways & ownership Neutropenic sepsis is easy, complications of cancer is the problem In cancer unit, patients are treated by visiting Cons with provision that we pick up the problem, no continuity, no holistic care Orphan patients – where should they go? Major issues with ownership / orphan patients Cancer centre only for treatment – where should others go? Difficulty in getting patients with recurrence back into system Admitted to wards with infections, junior staff with no oncology expertise, don’t get to see Oncologist

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Unrealistic Expectations Patients and professionals have unrealistic expectations of A/E Because CC next door to A/E next they expect admission Helpline raises expectations

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival AE Under-resourced NCEPOD, difficulties in meeting door to needle times A/E Departments remain open but not adequately resourced Cancer charity funding, vast amount work given by acute care but AE don’t receive any funding

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Suggestions for improvement Baseline Assessment

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Suggestions for improvement Complications serious but can be rare - should be kept in one area of expertise, need agreement on high dependency acute ward, skilled, knowledgeable staff Pt should have USB passport / smart card Need obvious alert card Permanent alert on patients notes on chemo A4 explicit careplan / care pathway - Direction of travel Robust pathway to Specialist Oncologist

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Suggestions for improvement Need for robust communication / information systems Need shared care model Prompt referrals for opinions should go to registrar, not F2 Continued care, shouldn’t just be about delivering care, at least see patient and say nothing more we can do Regional neutropenic sepsis audit in NI Regional audit, ”emergency presentations of onc pts”

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival Underpinning principles for commissioning chemo services (NCAG, 2009) Patients who might benefit from chemo are able to access quality services Treatments which are delivered are appropriate to a patients condition Services are delivered safely Services are convenient for patients Patient experience is good Services represent good value for money