ACUTE ONCOLOGY SERVICE MODELS Dr Judith Carser Consultant in medical oncology Southern Health & Social Care Trust

Overview AO workload projections AO models in England Merseyside & Cheshire experience and workload analysis Clinical case examples

Projected AO workload 2006/07 - 273,000 unplanned cancer admissions = 750 admissions per day in England1 Equates to 5 cancer admissions per trust per day on average 2008/09 average LoS varied for cancer related admissions between 5.1-10.1 days - potential saving of 566,000 bed days if every region had the same LoS as average in the best performing regions 2 One day snapshot at combined cancer centre/acute hospital trust reported 19% of all in patients had a cancer diagnosis3 Average Los for those admitted to oncology was shorter than for those admitted to general medicine3 1NCEPOD report 2008 2National Audit Office.DoH:Delivering the Cancer Reform Strategy 2010 3Acute Oncology Service: assessing the need and its implications. Clin Oncol 2011 Mansour D et al

AO models in UK Core principles of AO promote education, awareness and early access to specialist oncology advice Number and type of AO admissions variable and will reflect local service configuration AO models should be configured to best meet local needs and integrate with existing services whilst identifying areas for development Acute district general hospital vs. integrated cancer centre vs. stand alone tertiary oncology service

Model I – comprehensive cancer centre Yorkshire Cancer Network – 2.6 million, 8000 new patient episodes/yr. Non-surgical oncology –St James Institute of oncology – local services for Leeds and tertiary referral centre for region. Acute services on site Six additional hospital trusts providing cancer unit services with mix of resident and visiting oncologists AOS developed independently in each cancer unit by the resident oncology team In Cancer centre – assessment unit staffed by ANPs and junior doctors. Model requires 20PAs of consultant time to provide a 5 day service – equivalent to 2 FTEs

Model II – An acute cancer unit model, Whittington Health Stand alone consultant medical oncologist, specialty doctor in oncology, haematology consultant and 2 oncology CNS, admin support Dedicated medical ward for oncology-related admissions with medical oncologist responsible for inpatient care – admission guidelines Daily AOT review offered of appropriate patients in outlying medical wards / MAU Electronic referral pathways – inbuilt audit trail and data gathering capacity. Electronic alerts for chemotherapy patients / fast track MUO clinics / weekly CUP MDT / radiology flags

Model III – stand alone cancer centre Merseyside and Cheshire Cancer network – population 2.3 million, 10,000 new patient episodes/yr. Tertiary stand alone Cancer Centre – no acute services on site. Local cancer services for Wirral Nine satellite chemotherapy clinics, one satellite radiotherapy unit AOS developed in all 7 acute trusts in 2010 (excluding IoM) to complement existing service in St Helens and Knowsley NHS Trust ANP-led Acute oncology assessment ward, CCC established 2013

Location of AOS within acute trusts Merseyside & Cheshire Key: CCC – The Clatterbridge Cancer Centre NHS FT WTH – Wirral University Hospitals NHS FT UHA – University Hospital Aintree NHS FT SORM – Southport & Ormskirk NHS Trust RLUH – Royal Liverpool & Broadgreen NHS Trust W&H – Warrington & Halton NHS Trust SHK – St Helen’s and Knowsley NHS FT COC – Countess of Chester NHS Trust

Model III – acute oncology services Local AOS with visiting oncologists (at least 2 per unit), 5PAs of consultant support provided per week. The AOS oncologists provide at least one site specialised service at the same trust At least 1 WTE acute oncology CNS, 0.6-1.0 WTE admin support No inpatient oncology beds, no acute trust employed oncology nurses AO service available mon-fri 9am – 5pm to review patients as necessary and within one working day of referral Local AO and CUP MDTs Central 24hour chemotherapy triage at Cancer Centre

Average LOS days (range) Comparison of projected (2005-6 data) vs. actual workload of AOS throughout network (2010-11) NatCanSAT commissioned to provide analysis of potential annual AO workload – HES, chemotherapy, radiotherapy data, Cancer Registry Projected potential workload = 3,924 patients, overall average LoS 12.8 days Type of admission Average LOS days (range) 1.new cancers (17%) 11 (7.5-16.1) 2.complications of cancer treatments (40%) 9.1 (5.7-14.1) 3.complications of cancer (43%) 17.3 (10.2-23.5)

Network AO workload 2010-11 Actual workload = 3,031 new referrals to 7 teams (incomplete 12 months for 3 teams) Average Los reduced by 3 days from 12.8 to 9.7 days representing saving of over 9,000 bed days

Impact of AO intervention Type of intervention Major Managing new cancers (including MU0) Managing complications of chemo/radiotherapy Organising diagnostic tests Cancelling or preventing unnecessary tests Symptom management Preventing admission Intermediate Referral to other teams including cancer centre/other hospitals Psychological support Communication to primary oncologists/others Minor Supervising progress of inpatients Organising follow up % patients n=1,403 major vs. intermediate intervention, p<0.05; major vs. minor intervention p<0.05

Wirral experience - AOS Griffiths R et al Wirral University Hospitals NHS Foundation Trust

New cancer referrals– Royal Liverpool University Hospital AOS 2010-11 Seen by AOS 2010 - 2011 Number 135 Gender Male female 71 (53%) 64 (47%) Median age in yrs (range) 73 (37-92) Final diagnosis Malignancy undefined origin cCUP Lung Breast Upper/lower GI Urology Gynae Other 32 (24%) 18 (14%) 40 (30%) 6 (4%) 14 (10%) 7 (5%) 12 (9%) Median survival Admission – death (95% CI) Discharge – death (95% CI) 61 days (48-74) 37 days (20-54) Deaths in hospital 27 (20%) Systemic therapy Radiotherapy 22 (16%)

Impact of an AOS upon the management of patients with MUO – Wirral University Hospital experience Mean LoS for patients admitted during the diagnostic phase Mean number of investigations during the diagnostic phase Griffiths RW. et al, abstract NCRI 2012 Wirral University Hospitals NHS Foundation trust

Comparison of historical and AO cohort at Wirral University Hospital Proportion of patients dying without a clear decision on management Average time from referral until definitive treatment decision Griffiths RW et al abstract NCRI 2012 Wirral University Hospitals NHS Foundation Trust

Local agreements Each acute Trust responsible for developing their own AOS which best meets local needs including geographical location, demographics, specialist service provisions Ongoing engagement between acute trust and tertiary Cancer Centre Local AO and CUP MDTs Local AO steering groups Local teaching and staff education Local policies and procedures for referrals and patient alerts

Network agreements Required to meet National Cancer Peer Review measures for both carcinoma unknown primary and acute oncology including: AO induction packs Network treatment and disease related complications protocol book AO and CUP clinical network groups Specialist regional CUP MDT Network agreed pathways for MUO, brain metastases AO e-learning module supported by University of Liverpool Network audits e.g. MSCC, neutropenic sepsis Agreed oncology registrations for all AO patients Network agreed minimum data set

Clinical scenarios Patient 1: 54-year-old woman with breast cancer is undergoing adjuvant chemotherapy and develops nausea and dizziness. The patient has a temperature of 38ºC and phones the chemotherapy helpline for advice Patient 2: 72-year-old man presents to ED generally unwell with abdominal pain, nausea and weight loss. CT scan reveals multiple liver metastases but no obvious primary cancer Patient 3: 61-year-old woman with metastatic lung cancer presents with increasing pain. Patient had been due to attend cancer centre for radiotherapy but admitted acutely to local hospital

Summary There is proof that AOS works (and saves money!) An evolving service which must adapt to local requirements A successful AOS requires ‘buy-in’ and commitment from all Should be developed alongside existing visiting oncology services to provide continuity of care / reduce time travelling for oncologists Cancer unit oncologists vs. visiting oncologists with more time in unit Team effort – service must be adequately staffed, resourced and supported if it is to succeed and develop

References The National Confidential Enquiry into Patient Outcomes and Death. For better, or worse? NCEPOD, 2008 National Chemotherapy Advisory Group. Chemotherapy Services in England: ensuring quality and safety, 2009 Royal College of Physicians and Royal College of Radiologists. Cancer patients in crisis: responding to urgent needs, 2012 Towards saving a million bed days: reducing length of stay through an acute oncology model of care for inpatients diagnosed as having cancer, BMJ Qual Saf 2011: 20:718-724. King J et al. What is the impact of a new acute oncology service in acute hospitals. Experience from the Clatterbridge Cancer Centre and Merseyside and Cheshire Cancer Network, Clinical Medicine 2013, Vol 13, No 6: 1-5. HL Neville-Webbe , JE Carser et al. Acute oncology service: assessing the need and its implications.Clin Oncol (R Coll Radiol) 2011;23:168-173. Mansour D et al.