st james’s institute of oncology, leeds · •elsewhere within ltht (and beyond) –rapa...

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



– NCAG



http://tinyurl.com/NCAG2009



– NCAG



http://tinyurl.com/MSSC2008



– NCAG



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


• 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)


• 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)


• Beyond LTHT

– Local versions of PPM in all associated cancer units/DGH

– Synchronised across cancer network


• Beyond LTHT

Publisher


• 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

st james’s institute of oncology, leeds · •elsewhere within ltht (and beyond) –rapa...

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