4NHS

NHS Improvement

Oncology Patients Admitted as Emergencies– Baseline Audit and Testing of Two Modelsof Care at the Royal Berkshire HospitalIntroductionThe project was developed in response to a call forapplications as testing sites from the Cancer ServicesCollaborative Improvement Partnership.

The overall aim of this national scheme is to improve theexperience of in-patient care for oncology patients, reduceoverall length of stay and improve in-patient pathways.

The successful application from the Royal BerkshireHospital proposed a baseline audit to assess the length ofstay for patients admitted as an emergency and to alsoassess the length of time from admission to review by anoncology doctor. Within the baseline a comparison wasmade with haematology patients as haematologists at theRoyal Berkshire operate a ‘haematologist of the week’system whereby a consultant is freed from cliniccommitments in order to carry out daily ward-rounds andreview patients admitted as emergencies.

It was postulated that oncology patients admitted asemergencies were under the care of the ‘on take’ medicalteams and there were frequently delays in oncologistsbeing informed that their patients were in the Trust,despite the fact that these patients were undergoing activeoncological programmes of care. It was also postulatedthat these delays could result in extended in-patient stays.

Following the baseline audit two models of delivering careto cancer patients admitted as emergencies were testedand audited over periods of one week (including oneweekend)

• Model 1 – a consultant ‘oncologist of the week’ wouldassess patients with oncological problems as close aspossible to their admission to the Trust and wouldrelinquish clinic commitments in order to do this.

• Model 2 – the Nurse Consultant, together with anoncology Clinical Nurse Specialist would triageemergency admissions and provide a ‘signposting’ serviceto oncology teams and other health care professionals

Neither of these models included any ‘out-of-hours’ orweekend cover and were subjected to continuous audit.

Baseline Audit Findings10 patients admitted as emergencies

3 haematology patients

7 oncology patients

5 in hours (9-5)

5 out of hours

Presenting Problem

Diagnosis

Time from admission to being seen byoncologistAverage time forHaematology = 23hrs (range 12 to 46)Average Time forOncology = 41hrs (range 1 to 72)

Cancer Inpatients Case Studies

winningprinciplesAssessment

prior toadmission

Definedinpatient

pathways

Encourage selfmanagement

Daily decisionmaking

31

2

Oncology Patients Admitted as Emergencies – Baseline Audit and Testing of Two Models ofCare at the Royal Berkshire Hospital

Length of Stay – BaselineAverage LOS Haematology = 88 hrs (range 72 to 120hrs)Average LOS Oncology = 185 hrs (range 72 to 360 hrs)

Key Features of the Data• Both the waiting time to be seen by specialist team and

length of stay longer in oncology. It is likely that awarenessthat the patient has been admitted is an important factor.

• Only one patient able to be admitted to bed ononcology/haematology ward – patient with shortest wait.90% of patients were outliers. It is likely that the location ofthe patients is important in obtaining a specialist review.

• High proportion of breast cancer patients with neutropaenicsepsis (3) and lung patients with increased shortness of breath(2)

• Shorter length of stay than HES data – due to acute nature ofthis sample with 6 patients being admitted with neutropaenicsepsis.

Model 1 Testing Findings – Oncologist of the Week

11 patients admitted as emergency

6 ‘in hours’ (9 to 5) and 5 ‘out of hours’

4 patients subsequently found not to have an oncologicalreason for admission

Additional workload in reviewing patients already seen andthose on the oncology ward (15 other reviews across the week)

Presenting Problem

Diagnosis

Time from admission to being seen byoncologist – Model 1Average time in baseline = 41hrs (range 1 to 72)Average time forModel 1 = 9.5 hrs (range1.5 to 30)

Length of Stay – Model 1Average LOS baseline = 185 hrs (range 72 to 360 hrs)Average LOSModel 1 = 203 hrs (range 26 to 336)

Key Features of Data from Model 1• Much less acute sample of patients than in

baseline. No admissions with neutropaenicsepsis. Two deaths in this sample, thislikely to have increased length of stay.

• Time to oncology review dramaticallydecreased by 75% from baseline.

• No overall reduction in length of stay frombaseline. This likely to reflect patient grouprather than care received

• Large additional workload (15 additionalconsultations) for consultant in reviewingpatients already seen (as these had notbeen taken over by oncology) andreviewing sick patients on oncology ward.

Model 2 Testing Findings – NurseConsultant Plus CNS

10 patients admitted as emergency

7 in hours and 3 out of hours.

3

Oncology Patients Admitted as Emergencies – Baseline Audit and Testing of Two Models ofCare at the Royal Berkshire Hospital

Presenting Problem

Diagnosis

Time from Admission to First seen by Service and Oncologist

Average time in baseline = 41hrs (range 1 to 72)Average time in phase 1 = 9.5 hrs (range1.5 to 30)Average time in phase 2

(Nurse Consultant/CNS) = 13 (range 1 to 34)Average time in phase 2 (Oncologist) = 22 (range 6 to 36)

Length of stay – Model 2Average LOS baseline = 185 hrs (range 72 to 360 hrs)Average LOS phase 1 = 203 hrs (range 26 to 336)Average LOS phase 2 = 183 hrs (range 24 to 360)

Key Features of data from Model 2• More balanced sample in terms of acuity.

One patient with newly diagnosed brainmetastases, one patient who wastransferred to hospice. Two patients withpossible neutropaenic sepsis.

• Very little additional workload other thanseeing patients for assessment (3 otherconsultations for reviewing patients seenon admission)

Report On Audit Of Prototype OfOncologist Of The Week at The RoyalBerkshire Foundation Trust (May 2008)

In late 2007 an audit was carried out toexplore the effect of introducing of an‘Oncologist of The Week’ system on thewaiting times emergency oncology patientsexperienced before obtaining a specialistreview, and also any effect on the overalllength of stay for this patient group. The‘oncologist of the week’ system was basedon the system employed within the RBFT bythe haematology consultant body whereby aconsultant was relieved of clinic duties for aweek and reviewed all admissions and wardpatients (including outliers).

In this audit it was demonstrated that the‘oncologist of the week’ system diddrastically reduce the time patients waitedfor an oncology review but did not appearto reduce the overall length of stay. As thebaseline group in the original audit wasunusually acute it was decided to repeat theaudit. Each audit period was carried outover one week (week-days only). Theoncologist of the week data only haspatients admitted over three week days dueto a days lost to a bank holiday and to otherconsultant commitments. The results areshown below.

Audit May 2008 – Baseline – 11 patients1) Presenting Condition

4

Oncology Patients Admitted as Emergencies – Baseline Audit and Testing of Two Models ofCare at the Royal Berkshire Hospital

2) Diagnosis

3) Length of wait to review Average wait = 48.1 hrs

4) Length of stay (LoS)Average LOS = 177.5

‘Oncologist of the Week’ 1) Presenting condition – 11 patients

2) Diagnosis

3) Length of wait to reviewAverage = 14.5 hrs

4) Length of Stay (LoS)Average LoS = 151 hrs

Key Features of The DataThe baseline and the sample of patientsseen by the ‘oncologist of the Week’ wouldappear to be better balanced in terms ofacuity than in the original audit with threepatients in each group being admitted withpossible sepsis. There would appear to be areasonable spread of patients across thetumour groups although, unusually therewere no patients with lung cancer ormesothelioma admitted in the ‘oncologist’group.

The average length of stay in the group seenby the ‘oncologist of the week’ had aconsiderably shorter length of stay thanthose in the baseline group.

Combined dataIf the data from both baseline audit weeksand both ‘oncologist of the week’ auditweeks the results can be seen below.

1) BaselinePatients = 17

Wait to review = 45.3 hrs

Average LoS = 180 hrs

5

Oncology Patients Admitted as Emergencies – Baseline Audit and Testing of Two Models ofCare at the Royal Berkshire Hospital

2) Oncologist of the WeekPatients =22

Wait to review =12hrs

Average LoS = 177

Other IssuesDuring this audit the oncology consultant saw a higher numberof patients per day than on previous audits, this can beillustrated by the fact that 11 patients were seen in 3 daysrather than 5.

The consultant performed an additional 15 reviews on patientswho had already been seen by the service, patients on the wardand reviews requested by other doctors.

The feedback from other clinicians was very positive, particularlynursing and medical staff in Accident and Emergency, theClinical Decision Unit and the short-stay admissions ward. Onemedical consultant, however believed that there was somerepetition of work-load between the Oncologist of the Day andthe ‘Physician of the Day’ covering CDU.

The computer was available in order to access cancer centrenotes system which increased efficiency.

DiscussionThere can be little doubt that the operation of an ‘Oncologist ofthe Week’ system does dramatically reduce the length of timepatients wait for oncology opinion when admitted as anemergency.

If this audit is taken in isolation it would suggest that therecould be a possible benefit from reducing Length of Stay froman early review by the Oncology teams caring for the patient.Even if the results from both audits are pooled there is still areduction in length of stay although this is much more modest. Ibelieve the main determining factor in the length of stay is thepresenting condition. The general impression from other healthcare professionals and from patients and carers is that theservice represents an improved service for patients admittedwith oncological problems.

The debate should now focus on

• Which group of clinicians should carry out this work and howshould it be resourced

• Is there a demonstrable improvement in quality other than apossible reduction in length of stay

• What is the patient experience?

Outstanding Further WorkPatient satisfaction/experience audit

Develop early warning system alongside the system

Authors

Mark FoulkesNurse Consultant/Trust Lead Cancer Nurse

Dr Jane BarrettConsultant Oncologist

Dr James GildersleveConsultant Oncologist