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Acute oncology service provisionLarge Cancer Centre
Dr Tim Perren & Dr Geoff HallSt James’s Institute of Oncology, Leeds
St James’s Institute of Oncology
• 350 beds – Oncology (Medical and Clinical) Pathology– Haematology Radiology (CT/MR/PET)– Gynae and Thoracic surgery Multi-storey car-park !
• Oncology – FY 2008/09– 7,500 new referrals– 34,000 follow-ups
• Radiotherapy - 12 linacs– 65,000 fractions– 5,000 patients
• Chemotherapy– 14,600 cycles– 3,280 patients
St James’s Institute of Oncology
• Oncology– 7-day wards x 3– 5-day IP treatment ward– 60 chair/bed chemo unit
• Medical staff– 18 SHOs, 2 staff grades
– 20+ SpRs
– Consultants - 16 medical oncology, 28 clinical oncology
Yorkshire Cancer NetworkLeeds Cancer Centre
Leeds 850,000
Bradford/Airedale 450,000
Huddersfield 400,000
York/Harrogate 450,000
Mid Yorkshire 550,000
TOTAL 2,700,000
Yorkshire Cancer NetworkLeeds Cancer Centre
Leeds Resident
Bradford/Airedale Mixed
Huddersfield Mixed
York/Harrogate Mixed
Mid Yorkshire Visiting
Leeds
York
Harrogate
Airedale
Bradford
Huddersfield
Halifax
Mid Yorkshire
Acute Oncology
The drivers for change
Cancer Reform Strategy – Dec 2007
• 12% of all hospital admissions
• 25% increase in last 8 years – 47% increase in acute admissions
• 25% increase in incidence next 15 years
• Maintain current costs– ↓ average admission duration by 35%
– OR ↓ acute admissions by 50%
• Cancer Action Team and Aptium Oncology– Ambulatory care model
– 1/3 of admissions can be avoided
– 1/3 of admissions can be shorter
http://tinyurl.com/CRS2007
Acute oncology service
• Complications of treatment– NCEPOD
– NCAG
• Complications of cancer– NICE - Malignant spinal cord compression
• Undiagnosed cancer– NICE – Unknown Primary
http://tinyurl.com/NCEPOD2008
Acute oncology service
• Complications of treatment– NCEPOD
– NCAG
• Complications of cancer– NICE - Malignant spinal cord compression
• Undiagnosed cancer– NICE – Unknown Primary
http://tinyurl.com/NCAG2009
Acute oncology service
• Complications of treatment– NCEPOD
– NCAG
• Complications of cancer– NICE - Malignant spinal cord compression
• Undiagnosed cancer– NICE – Unknown Primary
http://tinyurl.com/MSSC2008
Acute oncology service
• Complications of treatment– NCEPOD
– NCAG
• Complications of cancer– NICE - Malignant spinal cord compression
• Undiagnosed cancer– NICE – Unknown Primary
http://tinyurl.com/CUP2010
Transforming In-patient Care for Cancer Patients
http://tinyurl.com/TIPCCP10
Acute Oncology - Leeds
Before 2010
Acute oncology – LeedsBefore 2010
• Do not use A&E or General Physicians/Surgeons
• Encourage direct contact by patient or GP
– Emergency contact numbers to all (especially those on treatment)
– Direct contact (to last clinical contact area)
– Calls taken by nursing staff and discussed with Drs when required
• Stratify patients by time from treatment
– All patients within 6 weeks of treatment
– 6 weeks to 6 months – discussion / admit to NSO
– > 6 months only if unambiguous evidence of cancer
Acute oncology – LeedsBefore 2010
• Options available
– Review in site-specific clinic within 7 days (Rare)
– Assessed on 4-bed assessment unit and discharged or admitted
– Admitted direct to NSO bed-base
– Admitted to NSO via A&E (managed by NSO)
Acute oncology – LeedsBefore 2010
• Managed by
– On-call team medical oncology - SHO, SpR & Consultant• Consultant review if requested by SpR
– Managed by site-specific team next working day
– Reviewed at next consultant ward round (x 2 / week)
– Discharge planning of variable quality
• SOPs
– Neutropenic sepsis
– Spinal cord compression
– Hypercalcaemia
– Specific chemotherapy complications
Acute admissions dashboard2006 to 2010
Acute admissions – 2008 to presentAdmissions per day
Acute admissions – 2008 / 2009Admissions per day
Acute admissions – 2008 / 2009Time of day
Acute Oncology - Leeds
The new world
Oncology Admissions Unit
• 2 key components
– Oncology Assessment Unit – 4 beds 24/7• All patients will be assessed prior to admission• Reviewed/triaged within 30 minutes• Point of care testing for FBC• Commence antibiotics within 60 minutes• A&E targets to apply i.e. moved to Admissions Ward within 4 hours
– Oncology Acute Admissions Ward – 24 beds 24/7• Reviewed within 12-24 hours of admission by on-call team• Handed ASAP to site-specific team• Daily consultant review (site specific team OR acute team)• Transferred to site-specific ward if admission > 3 days• All patients to have projected date of discharge FROM ADMISSION
Proposed Changes
• Acute oncology team – MedOnc and ClinOnc
– 2 SHOs, 2 SpRs, 2 consultants (1 in 14)
– 3rd Clinical Oncology consultant – Radiotherapy (1 in 14)
– Clinical Bed co-ordinator (Band 6) to co-ordinate admissions
– 2 Band-5 Nurse Practitioners (SHO conversions)
– 2 CNS posts to support Unknown Primary Service
– Increase training and competencies of all nursing staff
Proposed Changes
• Oncology Admissions Unit
– Central point of contact for all acute contact with patients
– Co-ordinate all acute activity• Malignant spinal cord compression
• Metastatic cancer unknown primary – Review inpatients if required within 24 hours
– Arrange appropriate OP review within 2 weeks
– Responsible for defining pathways for management of acute problems
Proposed Changes
• Acute oncology team – MedOnc and ClinOnc
– Daily 08:30 acute ward round• Review all acute admissions within previous 24 hours• Clear management plan for all patients• Projected discharge date proposed for all patients, at all times
– Transfer to site-specific team• Daily review on Acute Ward• Transfer to site-specific ward if admission > 3 days
– SpR and Consultant supernumerary to other commitments• ~ 4h additional DCC work /day to deliver new model – 0.5 PAs
Oncology admissions – Known patients
• Elsewhere within LTHT (and beyond)
– RAPA (Recurring Admission Patient Alert) via PPM
– PPM – Comprehensive EPR / Database on all cancer patients in LTHT• Demographics, admissions, OPAs
• Chemotherapy, radiotherapy, clinical trials
• MDT, diagnosis, key workers
– Acute admission event notified by email/SMS to• Acute Oncology Co-ordinator
• Key worker and Consultant
• Principal investigator / Research nurse (SAE alerts)
Oncology admissions – Known patients
• Beyond LTHT
– Local versions of PPM in all associated cancer units/DGH
– Synchronised across cancer network
Oncology admissions – Known patients
• Beyond LTHT
Publisher
Oncology admissions – Known patients
• Beyond LTHT
– Local versions of PPM in all associated cancer units/DGH
– Synchronised across cancer network
– Allows RAPA across organisations• Chemotherapy in Leeds (especially within clinical trial)
• Acute admission to General Physicians in Pontefract
– Acute admission event notified by email/SMS to• Acute Oncology Co-ordinator
• Key worker and Consultant
• Principal investigator / Research nurse (SAE alerts)
Cancer – Unknown Primary
• The biggest challenge in LTHT– Eight hospital sites
– More than 2000 beds
http://tinyurl.com/CUP2010
Cancer – Unknown Primary
• Known malignancy – (RAPA to appropriate team)
• New diagnosis– Act as signpost correct MDT
– Guide investigation
– Engage appropriate clinical team
– CUP CNS and Acute Consultanthttp://tinyurl.com/CUP2010
So how much will all of this cost ?Can it be cost-neutral ?
Oncology admissions unit £ 0
Clinical Bed co-ordinator (Band 6) £ 40,000
2 x Band 6 Nurse Practitioners £ 80,000
2 x SHOs -£ 90,000
2 x CNSs (1 Band 7, 1 Band 6) £ 85,000
Consultant PAs (20) £ 240,000
RAPA £ 0
TOTAL £ 355,000
So how much will all of this cost ?Can it be cost-neutral ?
• Whittington Hospital – Dr Pauline Leonard– http://tinyurl.com/ycqmkh9
– Single handed oncologist, 538 cancer diagnoses
– Discussions underway with PCT to fund service
– “Invest to save”
I think I would rather organise acute oncology at
a large cancer centre
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