acute oncology: local issues for district general hospitals · local issues for district general...
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Acute Oncology:
local issues for District General
Hospitals
Chris Bradley
Bradford Teaching Hospitals23 March 2010
Provision of oncology service in district hospitals
Chemotherapy
Integration with MDTs
Advanced cancer/links to palliative care
“Acute Cancer Service”
Optimising care of all cancer patients admitted acutely
Evolution of Yorkshire model
Resident non-surgical oncology
Network population 2.6 million
History of devolved oncology services
9 district general hospitals
Several large population centres outside Leeds ca. 500k
Natural alliances between neighbouring hospitals
Subsequent mergers into larger Trusts
York – Harrogate
5 Oncologists
18 bed ward
Bradford/Airedale
6 Oncologists
21 bed ward
Hudderfield/
Calderdale
4 Oncologists
22 bed ward
Mid-Yorkshire
No resident
oncologists
(2.9 wte visiting)
10 years later…
Integrated oncology services
Critical mass of consultants/specialist nurses
Site specialised service – 2-3 consultants/site
Day case chemotherapy in both hospitals
Dedicated inpatient ward on one site
SpR/SHO level support
Mature service well integrated with MDTs
Settled structure of chemotherapy services
Acute pathway for chemotherapy complications well developed Patients, GPs, A&E well informed and make direct contact
What about cancer patients not
under care of oncology?
“Expert oncological assessment within
24 hours?”
What is a cancer patient?
Elderly medicine admission
78 year old woman
Breast cancer 2008
Surgery
Radiotherapy
Anastrazole
Breathless
AF
Hypoxic and raised D-dimers
But also…
Scan showed lung and
pleural metastases
Referred to
Breast surgery
Medical oncology
Seen same day
Discussed at MDT
within 48h
What is appropriate acute care?
What if:
Metastatic disease was primary problem?
New breast lump as incidental finding?
No evidence of new cancer related problem?
What sort of cancer patients are
admitted acutely to hospital?
Retrospective audit of all acute admissions over 7 day
period in September 2009
Cross referenced with Trust cancer database
Included all patients discussed at MDT/with a cancer
diagnosis in the preceding 12 months
Also all patients coded as a new cancer diagnosis during
this admission
Acute cancer admissions
0
1
2
3
4
30-39 40-49 50-59 60-69 70-79 80-89
oncology
haematology
other
8
421
2
21 1
0ncology
elderly medicine
general medicine
thoracic
medicine
haematology
general surgery
urology
gynaecology
Acute Cancer admissions
21 admissions
Notes available on 17 6 oncology
2 haematology
3 known to oncology and reviewed on ward
6 others 89 yr old - squamous Ca skin
82 yr old - Ca ureter and CVA
47 yr old - urgent colonoscopy for Ca colon
59 yr old - transferred back after surgery for MSCC from prostate Ca
52 yr old - abdo abscess after anterior resection for stage A colon Ca
63 yr old - Ca vulva
Acute cancer admissions
4 patients with new/suspected cancer
87 year old woman – dementia/general deterioration – CLL
on blood film
73 year old man with DVT and lymphadenopathy/prostatic
mass on scans – metastatic prostate cancer
67 year old man with abdo pain and uncontrolled
hypertension – renal cancer on CT
67 year old man with abdo pain – R ureteric stone/bladder
wall thickening. Subsequent OP cystoscopy – bladder cancer
Integrated primary care/palliative
care record Electronic patient record
Used by 95% GPs across Bradford/Airedale
Out of hours service across SHA
12 palliative care services across Yorkshire
Available in A&E, MAU
Patient’s current treatment plan available in summary care record
Eventually link to PPM?
What sort of Acute Cancer Service do
we need?
Depends on starting point
Different models for different situations
Address existing local deficiencies
Recognise expertise of all members of MDTs
Use existing pathways and systems
Cost efficiency in selection of Acute
Cancer Service Model?
“Difficult decisions”
Common sense approach
If limited local oncology – get more
If already adequate - invest in
good links with specialist teams
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