Transcript ACE presentation CUP SSG 4 Nov

ACE project closure:
results
Dr Paola Di Nardo
ACE project
• January to June 2015
• Aimed to develop the Acute Oncology and Cancer of
Unknown Primary Service
• Target population: all patients suspected to have cancer,
but for whom it is currently unclear which cancer
pathway they should be referred to
• Bristol CCG lead commissioner, but strongly supported
by South Glos and North Somerset CCGs
ACE project: key aims
• Improve patient outcomes and experience for those patients
in whom cancer is suspected but the specific cancer site is
unknown
• To improve the time from referral to symptom management,
diagnosis and care plan for those patients with suspected
cancer for which the specific cancer site is yet unknown
• To improve patient outcomes through planned referrals to a
single service rather than “bouncing” them around the system
or having to be diagnosed in an emergency setting
• To reduce the number of unnecessary investigations
undertaken on patients whose care plan will not change
irrespective of more accurate diagnosis
• To develop the services with strong patient and carer input to
ensure it is best meeting the needs of this patient population.
ACE project: key strands
• CUP Urgent Referral Pathway - Development and commissioning of a single
approach across BNSSG for urgent referrals with evidence of cancer where there are
no signs/symptoms to suggest the location of the primary cancer (CUP);
• Vague Symptoms Pathway Proposal- Clarification of the unmet need for
patients with vague symptoms where cancer may be a differential diagnosis amongst
other serious diseases and development of a service proposal for how this could be
resolved locally;
• Acute Oncology Service Specification - Refining and formalising of Acute
Oncology Services across all three BNSSG providers, including support for patients
with toxicity issues and formalising this in a single service specification for inclusion
in provider contracts.
Project Closure: CUP Urgent Referral
Pathway /1
…To improve the time from referral to symptom management, diagnosis and
care plan for those patients with suspected cancer for which the specific cancer
site is yet unknown…
• CUP Urgent Referral Pathway
• Two pilot approaches available: UHBristol’s 2WW CUP Referral and
WAHT’s Urgent CUP Referral.
• Need to meet national requirements for 2WW: patients were being seen
without appropriate diagnostics being done first. This actually created
delays
• Small numbers being referred through this route: questionable need to
commission 3 separate clinics by 3 separate providers across BNSSG.
Project Closure: CUP Urgent Referral
Pathway /2
• “…The providers already have a robust pathway for treating patients where
the specific cancer site is unknown and it is recommended that the 2ww
process for these patients is downgraded to accept urgent referrals
instead. This would allow for appropriate diagnostics/tests to be
implemented prior to consultation. This process is already in place in
WAHT and allows for more informed and accurate consultation with
patients upon receipt of diagnostic/test results. UHBristol would also like to
adopt this process. “
• Recommendation to the BNSSG cancer board to remove the 2ww for these
patients:
▫ ensure robust process to ensure patients do not slip through the net and once
cancer is diagnosed, patients can be appropriately upgraded..
Phase 2: CUP
• CUP Urgent Referral Pathway
• With the BNSSG agreement to adopt the proposed approach to the
CUP Urgent Referral Pathway there would be minimal project
management support required
• Providers should be able to take this forward within the own
organisations
• The pathway can be captured and included in an appendix to the
Acute Oncology Service Specification and progress in delivery of the
service can then be managed through normal contract monitoring
routes.
Project Closure: Vague Symptoms
Pathway Proposal
• Clarification of the unmet need for patients with vague symptoms
where cancer may be a differential diagnosis amongst other serious
diseases
• Development of a service proposal for how this could be resolved
locally
• CCGs to consider how to resource the recommendation from the
pathway redesign for a service to accept the patients requiring a
broader clinical review
Project Closure: Vague Symptoms
Pathway Proposal/2
Project Closure: Vague Symptoms
Pathway Proposal/3
• Patients with clusters of vague symptoms where there is no specific diagnostic
identified cancer but there is still a reasonable suspicion. Not easy access to diagnosis
and appropriate secondary care management in a timely way.
• A number of services were spoken to regarding potential siting of the broad
experience clinician but no specific existing service met the needs of this group of
patients, these included:
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CALS (complex adult liason service) which was felt would not be appropriate for these
patients;
patients with unidentified medical symptoms – this clinic was purely for psychology patients
and again not appropriate;
Rapid access diagnostic service at UHBristol – this was felt to be focused much more on same
day urgent care and not appropriate for this pathway.
Project Closure: Vague Symptoms
Pathway Proposal/4
• If an existing service cannot have its referral criteria extended, initial
thoughts for how the provision of broad experience clinician appointments
could be developed are:
▫ Creation of an MDT that includes GP with special interest, Geriatrician,
Medical Consultant and Medical Oncologist;
▫ Use of a HOT Clinic approach to ensure that urgent access is available
whenever required;
▫ Development of an advice and guidance option to allow GPs to discuss
the patient in a timely manner to avoid unnecessary emergency
admissions.
Project Closure: Vague Symptoms
Pathway Proposal/5
• However, whilst repeatedly seeking evidence of the numbers of patients
that fit the hypothesis and trying to find cases to understand more about
this cohort of patients, the project group has been unable to identify who
these patients are.
• It is recommended that prior to further work on pathway design,
commissioning and implementation, a new approach is agreed
for identifying this patient cohort and information is collected on
the age range and symptom clusters that this cohort are
presenting with in primary care
• It is recommended that once a patient cohort has been identified
prior to being formally commissioned this pathway is tested with
GP Referral Management Service Leads, potential future clinic
speciality leads, patients and carers and further refined.
Phase 2: Vague Symptoms Pathway
• Identify the patient cohort for progression of this pathway
• Before moving forwards with this project future resourcing for this element
of the project needs to be decided by BNSSG Cancer Working Group.
• Potential options for proceeding are:
▫ Capture information from inappropriate referrals to CUP Urgent Referral
Pathway and review this in 1 years’ time when there is critical mass of
information..
▫ Do a retrospective audit on the referrals that were moved from the original MDT
through 2WW pathways to another MDT,.
▫ Request example patient cases from GP practices based on the outline pathway
described above to test if the types of patients identified by practices and consider
the trends around symptom clusters and patient demographics.
Project Closure: Acute Oncology/1
• Aims and objectives of service
• The aim of an Acute Oncology Service is to improve the care of patients
presenting at secondary care services with cancer-related emergencies.
• Provide a model of care that will deliver improved patient outcomes
▫ in line with National Chemotherapy Advisory Group (NCAG) Guidelines,
▫ to exceed where possible the National Peer Review Standards for Acute Oncology.
• On this basis, the aim of the overall service is to provide rapid specialist
clinical input into the care of patients who are acutely unwell as a result of:
▫ Complications relating to chemotherapy/radiotherapy treatment
▫ Disease progression
▫ Suspected but unconfirmed malignancy
Project Closure: Acute Oncology/2
• Acute Oncology service offered by each of the 3 providers for several
years
• The current service specification did not reflect everything that the
service currently offered and had not built in developments to the
service for the future
• Therefore, the Service Specification has been updated by the
identified clinical leads within the project team. It identifies future
service developments which require further scoping/resourcing.
Project Closure: Acute Oncology/3
• Local defined outcomes
• It is anticipated that the following outcomes will result from the
implementation of an Acute Oncology Service:
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Improved patient experience of services
Improved patient outcomes
Reduction in emergency admissions
Reduced length of stay for Acute Oncology patients
Reduction in unnecessary diagnostic tests
Reduction in non-beneficial curative treatment when palliative care would be
more appropriate
• An increase in the number of patients with suspected neutropenic sepsis receiving
antibiotics within 1 hour of contacting the hospital
• An increase in the proportion of patients with suspected malignant spinal cord
compression receiving appropriate investigation and treatment within nationally
agreed timeframes
Project Closure: Acute Oncology/4
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National measures:
An Acute Oncology Team for each acute hospital
Protocols for the treatment of Acute Oncology presentations
Patients to be seen within 24 hours (1 working day) by the AO team
▫ at least one designated consultant assessment session each day, Mon–Fri
▫ at least two designated nurse triage sessions each day, Mon–Fri
24/7 Telephone Advice Line for known cancer patients currently on treatment
Rapid access to fast track outpatient clinic appointments
Patient flagging system
AO training for A&E, medical admissions unit and acute medical staff
Policies and protocols
‘1 hour to antibiotics’ pathway for patients with neutropenic sepsis
Audits of the treatment of neutropenic sepsis and MSCC
Project Closure: Acute Oncology/5
• Future Acute Oncology Service initiatives (as agreed by BNSSG Cancer project board
who will designate teams to take plans forwards)
• Direct patient access to acute oncology services for those with known malignancy (off
treatment) with complications of cancer, for example:
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Ascites
Pain
symptoms of progressive disease
blood transfusions
• Daily urgent access clinics for patients with suspected cancer of unknown primary
requiring urgent investigations
• Increasing move to community based assessment and management of patients with
acute oncology presentations via:
▫ primary care
▫ chemotherapy satellite units
▫ community nursing and palliative care services
Phase 2: Acute Oncology
• Implementation should be managed by a cross-provider working
group consisting of the key stakeholders from each provider
• Once contracts and the BNSSG Cancer Working Group have signed
off the service specification, any additional resources required to
implement this should be negotiated through contracting routes.
• Progress on delivery of this element of the project can be overseen
through contract management meetings, exception reporting shared
with BNSSG Cancer Working Group through provider members to
the group.
Phase 2: ACE National Requirements
• Cross-provider team to ensure commitment for national
requirements is continually met
• GP clinical leadership linked to the group – it’s recommended that a
GP lead from BNSSG Cancer Working Group is identified to work
with the cross-provider project team to continue this work.
Evaluation of changes
• PROMs: patient outcome measure to be agreed upon to allow
comparison with other projects
▫ Patient Activation Measure (PAM) to be considered and developed into clinical
practice
• Basic data collection:
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length of time from initial visit to GP to diagnosis
length of time into appropriate alternative service
the number of patients accessing the service
the number of diagnostic tests undertaken by the service – split by tests before
and after referral to the service
▫ performance status of the patients referred to the service
▫ impact of PS and tests on the management approach
▫ time to agree a management approach with the patient
Evaluation of changes/2
• Baseline work –retrospective data collection on a percentage of
patients who have accessed the service in the last 12 months
• Patient and carer experience –very short pre/post patient and carer
experience survey (no more than 5 questions).
▫ Work is being done by the national cluster team to develop something
that could be used, based on a number of cancer PES questions.
• Referrer experience survey – very short referrer survey sent with
each feedback letter/email
• Use of peer review scores to see the impact that the changes to the
service have had over time.
Questions?