thomas tuchyna, sir charles gairdner group: the expansion of sir charles gairdner hospital cancer...
DESCRIPTION
Thomas Tuchyna, Senior Project Director, Sir Charles Gairdner Group delivered this presentation at the 2013 Cancer Centres Symposium in Australia. The annual event explores current opportunities and challenges surrounding cancer centre policy, funding, operations, innovations and development. For more information about the annual event, please visit the conference website: http://www.informa.com.au/cancercentressymposiumTRANSCRIPT
Expansion of the Sir Charles Gairdner Hospital Cancer Centre
Delivering a Healthy WA
Thomas Tuchyna Project Director
Stage I Stage II
December 9, 2013 Slide 2
Overview
• Infrastructure development
• Organisational changes
• Operational workflow
• Adolescent and Young Adult facilities (AYA)
• CyberKnife
• Oncology Information Management System (OIMS)
Key stages / features
December 9, 2013 Slide 3
Schedule of Accommodation (SoA) – • The Business Case SoA (July 2007) modified as per list below:
1. Clinic Suites – Increased from 16 to 27 + (10) 2. Addition of Registrar’s office / workstations 3. Additional 6th linac bunker 4. Addition of Solaris Care 5. Addition of Adolescent & Young Adult (AYA) facilities 6. Office Accommodation to be located elsewhere:
1. Senior Medical Staff / Admin / Allied Health 2. Treatment Planning 3. Medical Physics 4. Research / Students
• Alterations approved 22nd August 2008
Building the Infrastructure Background and Key Challenges
Approx 90 staff, requiring 1,300m2
December 9, 2013 Slide 4
Cancer Centre Stage II Distribution of Floor Space
Total Floor Space = 7,782 m2
Staff in Stage II 210 Staff elsewhere 90 (SCGH)
– Senior Medical Staff offices (MOnc, ROnc, Haem, Pall Care) – Medical Support (Clerks,
Admin Assist) – Radiation Therapy Treatment
Planning – Medical Physics – Research Staff and Students – Administration
December 9, 2013 Slide 5
Site Location:
Aerial image of QEII Medical Centre (SCGH): late 2009
December 9, 2013 Slide 6
Site Location:
Aerial image of QEII Medical Centre (SCGH): late 2009
CC Stage I
1,095 m2
CC Stage II 7,782 m2
December 9, 2013 Slide 7
Cancer Centre Stage I
December 9, 2013 Slide 8
Cancer Centre Stage II
December 9, 2013 Slide 9
Works Progress • Demolition • Excavation & tension pile works • Concrete structure • Service installation
Tension pile works.
Photo: Fri 10th Sept 2010
December 9, 2013 Slide 10
Construction Progress
December 9, 2013 Slide 11 Photo: Fri. 5th Nov 2010.
Detailed basement excavation and compaction works.
Installation of plywood sheets and waterproof membrane to basement.
Installation of fire tank walls to basement.
Installation of tension / compression piles.
Construction Progress
December 9, 2013 Slide 12
December 9, 2013 Slide 13
December 9, 2013 Slide 14
Day Ward (Med Onc & Haem)
December 9, 2013 Slide 15
Cancer Centre Stage II
CLINICAL TRIALS – Workstations Medical Oncology 14 Radiation Oncology 13 Haematology 8 Company Monitor’s Rooms 3 Registrars x16
SHARED AREA & CLERICAL Reception Registration Typists Workstations File Store & Preparation Switch Operator Cancer Registry Meeting/Conference Room Staff Room
SOLARIS CARE Therapy Room 4 Counselling 1 Drop in Centre 1 Resource Room 1 Office 2
CLINIC SUITE Standard 25 Large 3 ENT 2 Stretcher 2 Consult Rooms Total 32
Original Consult Rooms CCII Consult Rooms (combined) Med Onc*: 9 27 Clinic Haem: 4 5 Allied Health Rad Onc: 11 5 RO Treat Review TOTAL: 24 TOTAL: 37 Consult Rooms in CCII
*Note: Med Onc had a dual purpose office/consult room arrangement. Haem & Rad Onc had separate offices and consult rooms.
December 9, 2013 Slide 16
Cancer Centre Stage II
Radiation Oncology Treatment Linac Bed Hold Dressing Room
6 2 2
Radiation Oncology Treatment Preparation Simulation Area Consult Rooms 7
Radiation Oncology Mould Room Engineering Area Brachytherapy
Day Ward Med. Onc. Haem.
Chairs Beds Rooms Apheresis
24 10 3 4 1 1 3
Total Treatment Spaces 46
PHARMACY Dispensing Cashier CleanRoom 4 Preparation
Med Onc
Haem
LINAC 2
LINAC 1
LINAC 3
Acacia Banksia Tuart
Bed Hold x2
Dressing Dressing
CT x2
Consult
Trt Review
Mould Room
ROBES
BRACHY
December 9, 2013 Slide 17
• Key Issues / Lessons Learned
– Well defined project scope – Tender process & Builder engagement – Contingencies (scope, time, $’s) – Cashflow (Builder’s claims) – IT – A separate (largely subcontracted) entity – Stability of working groups – Staff engagement – Separation of building from service – Building defect management
Infrastructure developments
Assumption Check: • A comprehensive centre for patients • Building capacity increased activity / staffing ≠
December 9, 2013 Slide 18
Overview
• Infrastructure development
• Organisational changes
• Operational workflow
• Adolescent and Young Adult facilities (AYA)
• CyberKnife
• Oncology Information Management System (OIMS)
December 9, 2013 Slide 19
• Medical Oncology 38.5 FTE
• Haematology 24.3 FTE
• Radiation Oncology 169.5 FTE
• Palliative Care 5.0 FTE
• Allied Health 6.5 FTE
• Pharmacy 11.0 FTE
• Cancer Registry 4.5 FTE
• Solaris Care 7.0 FTE
• AYA 4.5 FTE
TOTAL 270.8 FTE
Staff Profile
December 9, 2013 Slide 20
24.3FTE
Haematology – Organisational Structure
December 9, 2013 Slide 21
Medical Oncology – Organisational Structure
38.5FTE Clerks / Admin had 3
distinct reporting lines
December 9, 2013 Slide 22 169.5FTE
Radiation Oncology – Organisational Structure
December 9, 2013 Slide 23
Cancer Centre – Organisational Structure (Work in Progress)
245 FTE not inclusive of: • Pharmacy / Palliative Care • Allied Health / Solaris Care • AYA
December 9, 2013 Slide 24
• Key Issues / Lessons Learned – Stable Leadership – HR processes (creating / abolishing positions) – Other recruiting within WA Health (e.g. FSH) – Staff engagement – Change management – Time
Assumption Check: Focus on the horizon while managing the present
Organisational Change
December 9, 2013 Slide 25
Overview
• Infrastructure development
• Organisational changes
• Clinical transition
• Operational workflow
• Adolescent and Young Adult facilities (AYA)
• CyberKnife
• Oncology Information Management System (OIMS)
December 9, 2013 Slide 26
Projected Patient flows in key clinical areas
New Patients Follow-up A n n u a l visits
Daily visits
Clinic Area Rad Onc 2,581 26,261 Med Onc 3,172 17,040 Haem 643 8,362 Pall Care 194 419
Total 58,672 235 D a y W a r d Treatment
Med Onc 11,395 46
Treatment Haem 7,406 30 Total 18,801 68
R a d i a t i o n Oncology
Treatment Planning 4,693 19
Treatment 48,659 203 Treatment Review 9,419 38
Total 62,771 259 Total Annual Patient Visits 140,245 569
Estimated new cases for the Cancer Centre projected to be around 4,000 in 2011 for Chemotherapy and Radiation Therapy at SCGH.
December 9, 2013 Slide 27
Average AM Daily Patients: 121 Average PM Daily Patients: 30
December 9, 2013 Slide 28
Clinic Session Mapping
December 9, 2013 Slide 29 Average AM Daily Patients: 22 Average PM Daily Patients: 9
Average AM Daily Patients: 25 Average PM Daily Patients: 13
December 9, 2013 Slide 30 Average AM Daily Patients: 46 Average PM Daily Patients: 8
Average AM Daily Patients: 51 Average PM Daily Patients: 8
December 9, 2013 Slide 31 Average AM Daily Patients: 43 Average PM Daily Patients: 15
Average AM Daily Patients: 46 Average PM Daily Patients: 14
December 9, 2013 Slide 32
Overview
Average AM Daily Patients: 110 Average PM Daily Patients: 30 Outcome to date:
Essentially no change to clinic workload or distribution, for significantly increased clinic congestion on days (sessions) where majority of specialists hold busy clinics.
December 9, 2013 Slide 33
Daily cancellation 10-15 patients (~30%).
Daily cancellation 3-6 patients (~15%).
Relocation / Transition
December 9, 2013 Slide 34
• Clinic Organisation
– Common Vision – Patient Centered, not specialty based – Overlapping of busy clinics – Overlapping of ‘quiet’ clinics – Scheduled appointment timeslots – Common processes (DNA, Medical Record movement, billing,
re-bookings …) – Common tools TOPAS vs. others
• Day Ward Treatment
– Treatment Same Day (am) vs Treatment Other Day – Med Onc Day Ward treatments Medically led – Haem Day Ward treatments Nurse led
Assumption Check: Participation and adherence to common vision
Operational Workflow - Key Issues / Lessons Learned
December 9, 2013 Slide 35
Overview
• Infrastructure development
• Organisational changes
• Operational workflow
• Adolescent and Young Adult facilities (AYA)
• CyberKnife
• Oncology Information Management System (OIMS)
December 9, 2013 Slide 36
AYA Background • A partnership between Sony Health, CanTeen & DoHA • $3M for additional 400m2 to be added to the Cancer Centre • For cancer patients aged 15-24 years • Spaces
– Group recreation room – Interview – Shard office – Consulting room – Treatment bays
• WA Health to fund staff to support AYA – Cancer Nurses / Care Navigators – Clinical lead – Social worker – Psychologist – Data Manager
December 9, 2013 Slide 37
AYA Group Room
December 9, 2013 Slide 38
AYA Spaces
Total space just under 200m2
December 9, 2013 Slide 39
• Additional space • Building alterations • Consider the recurring cost • Long term investment into improvement of outcomes
for 15-24 year olds
AYA Key Issues / Lessons Learned
December 9, 2013 Slide 40
Overview
• Infrastructure development
• Organisational changes
• Operational workflow
• Adolescent and Young Adult facilities (AYA)
• CyberKnife
• Oncology Information Management System (OIMS)
December 9, 2013 Slide 41
CyberKnife Worldwide
Worldwide 280 installed CyberKnife systems with over almost 200,000 treatments, 45,000 alone in 2012
Nearest CK s to Australia are in Thailand, HK, Taiwan, Vietnam
Europe 62 Installed
Asia Pacific 31 Installed
Japan 24 Installed
America 152 Installed
South America 6 Installed
Middle East 5 Installed
December 9, 2013 Slide 42
Radiosurgery: The idea to use single high ablative radiation dose to kill tumor cells without operating on the patient Dr. Lars Leksell, 1907–1986, Neurosurgeon, Sweden
• 1949 First Radiosurgery Treatment in Sweden (Protons)
Problem in the past same as today: Treatment precision
• 1968 GammaKnife (Fixed Part-Invasive Frame as Reference) • 1980 Linear Accelerator for Radiosurgery (patient position is controlled before treatment, not during treatment)
History of Radiosurgery
Images: Elekta SE
December 9, 2013 Slide 43
CyberKnife Robotic Radiosurgery
Miniature Linear Accelerator
Robo2c Arm
X-‐Ray Detectors
X-‐Ray Tubes
Imagings-‐ system
Radia2on-‐ system Mo2on compensa2on
with Marker-‐Correla2on
Targe2ng through image registra2on
LED-‐Camera
Synchrony™
December 9, 2013 Slide 44
”The system adapts to the patient”
Linear Accelerator guidance through robotic arm
• Fully automated beam targeting through image registration
• Real time compensation of tumor motion
• Resulting in excellent treatment precision (< 1mm), high local tumor control, minimal side effects, reduced treatment time, for selected tumors ANYWHERE in the body!
CyberKnife Robotic Radiosurgery
Beam Target
CK Inventors: Prof. John Adler, Prof. Achim Schweikard
December 9, 2013 Slide 45
Primary or combined therapy for selected tumors or as an option for recurrent tumors after failure of other treatments
Intracranial and Spine (not all listed) • Malignant Brain Tumors, Uveal Melanomas (Eye Tumors) • Benign Tumors (Meningiomas, Acoustic Neuromas) • Spinal and Bone Tumors
Functional Radiosurgery (not all listed) • Arterial-Venous Malformations, Trigeminal Neuralgia
Extracranial (not all listed) • Low & Intermediate Risk Prostate Tumors • Inoperable Lung and Liver Tumors • Breast • In selected cases Renal & Pancreatic Tumors • Lymph Nodes
CyberKnife Treatment Indications
December 9, 2013 Slide 46
Study / Study Site(s)
Treatment No. of patients
Risk groups
Follow-up Efficacy Acute grade toxicity Late grade toxicity
Katz, et al. 2010 [3] Winthrop University Hospiral, Mineola, NY USA
PROSTATE 35 – 36.25 Gy in 5 fx
304 Low, intermediate, high
35 Gy: Median, 30 months (range 26 – 37 months) 36.25 Gy: Median, 17 months (range, 8 – 27 months)
Free from biochemical failure 35 Gy cohort: 100% 36.25 Gy cohort: 98.5%
December 9, 2013 Slide 47
Study / Study site(s)
Treatment No. of patients
Tumour characteristics
Follow-up
Efficacy Acute toxicity Late toxicity
van der Voort van Zyp, et al. 2010 [11] Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
45 – 60 Gy in 3 – 6 fx One to five fiducial placement
39 T1-2N0M0 NSCLC
Median, 17 months (range, 6 – 31 months)
Overall survival at 12 months: 75% Overall survival at 24 months: 62% Local control at 12 months: 97% Local control at 24 months: 97%
Nuyttens, et al. 2012 [12] Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
45 – 60 in 5 – 6 fx
56 (58 lesions)
Early stage NSCLC; solitary metastases
Median, 23 months (range, 1 – 54 months)
Local control at 24 months: 85% for BED > 100 Gy 60% for BED =< 100 Gy
LUNG
December 9, 2013 Slide 48
LIVER
Study / Study site(s)
Treatment No. of patients
Tumour characteristics
Follow-up Efficacy Complications (% patients)
Kress, et al. 2012 [26] Georgetown University Hospital, Washington, DC USA
16 – 50 Gy in 1 – 5 fx
52 (85 lesions)
Liver metastases (n=72), primary tumour (n=13)
Median, 11.3 months (range, 1 – 67 months)
Overall survival at 12 months: 50.8% Local control at 12 months (of the 40 patients in radiographic follow-up): 74.8% Median time to failure (of 40 the patients in radiographic follow-up): 35.5 months
Acute grade 3 - 4 toxicity: 11.5% Including: Bilirubin elevation (grade 3, n=4; grade 4, n=1), AST elevation (grade 3, n=1), acalculous cholecystitis (grade 3, n=1), alkaline phosphatise (grade 3, n=1). The authors mentioned that grade 1 – 2 toxicities were common, but did not report the number of cases
Goodman, et al. 2010 [27] Memorial Sloan-Kettering Cancer Center, New York, NY USA; Stanford University, Stanford, CA USA
18 – 30 Gy in 1 fx
26 (40 lesions)
Liver metastases, primary tumours
Median, 17 months (range, 2 – 55 months)
Of the 25 patients with 38 lesions in radiographic follow-up: Local control: 47% of lesions Overall survival at 12 months treated for primary tumours: 71.4% Overall survival at 24 months treated for primary tumours: 53.6% Overall survival at 12 months treated for metastases: 61.8% Overall survival at 24 months treated for metastases: 49.4% Probability of local failure by 12 months: 23%
Late toxicity data was not available for one patient (n=25). Of the four reported Grade 2 toxicities, two were gastrointestinal and two were musculoskeletal.
December 9, 2013 Slide 49
SCGH Current Status • Core Clinical team selected
– (x3 Rad Oncs) – (x3 Radiation Therapists) – (x3 Medical Physicists) – (x2 Engineers)
• Training underway
• Machine Shipment underway – Due to late Dec early Jan
• Installation starts – 12th Jan
• Clinical operations start – 24th March
SCGH investigating to join three large multi centre clinical trials and or to initiate local clinical trails
December 9, 2013 Slide 50
Overview
• Infrastructure development
• Organisational changes
• Operational workflow
• Adolescent and Young Adult facilities (AYA)
• CyberKnife
• Oncology Information Management System (OIMS)
December 9, 2013 Slide 51
Common Oncology Information Management System (OIMS)
Rad Onc
Haem
Med Onc
Pharmacy
The case for a common Oncology Information System • At present, key cancer services have stand alone information systems
(some reasonably well developed, some rather inadequate). • All key cancer services are a part of the Cancer Centre and use parts of
the same floor plan / accommodation. • Current information flow, particularly between clinicians and clerical staff
limits clinical care • There are areas of significant overlap in both processes and need to
access common information. e.g.
• 50% OF RAD ONC PATIENTS HAVE A COMBINED RAD ONC / MED ONC TREATMENT AND HENCE NEED ACCESS TO COMMON PATIENT INFORMATION
• HAEMTOLOGY PROCESSES OVERLAP WITH MEDICAL ONCOLOGY PROCESSES
• PHARMACY PROCESSES AND INFORMATION REQUIREMENTS ARE INTERTWINED WITH MEDICAL ONCOLOGY & HAEMATOLOGY TREATMENTS
Distribution of Floor Space in CCII
Total CCII Floor Space = 7,782 m2
A formal Tender an OIMS is underway, with vendor responses received last week and the evaluation process about to begin. Aim to award during 2nd Quarter of 2014, with
implementation to be concluded by late 2015/early 2016
December 9, 2013 Slide 52
Areas remaining to be resolved
• Clinic & Treatment scheduling
• Organisational re-structure
• Accommodation for those not in the Cancer Centre
• Common tool set - OIMS
• IT – HIN Infrastructure
Thankyou