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

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

3. Projected AO workload
2006/ ,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 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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, 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

10. Average LOS days (range)
Comparison of projected ( data) vs. actual workload of AOS throughout network ( )
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 ( )
2.complications of cancer treatments (40%)
9.1 ( )
3.complications of cancer (43%)
17.3 ( )

11. Network AO workload
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

12. 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

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

14. New cancer referrals– Royal Liverpool University Hospital AOS 2010-11
Seen by AOS
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%)

15. 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 Wirral University Hospitals NHS Foundation trust

16. 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 Wirral University Hospitals NHS Foundation Trust

17. 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

18. 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

19. 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

20. 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

21. 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: 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: Mansour D et al.