Transcript AO in WELSH HOSP (1000 Lives Plus PB 05 03)

Acute Oncology in
Welsh Hospitals
Niladri Ghosal
Tom Crosby
Geraint Roberts
Matt Makin
Cancer Reform Strategy 2007
NCEPOD report 2008
The NCAG report 2009
Use of chemotherapy (and its
problems) are growing
60% increase in chemotherapy
between 2002-2006 (CRS)
The 4 Cancer Centres Audit
showed :
• Chemotherapy episodes doubled
in colorectal cancer
• Breast and ovarian chemo
increased by 40%
Availability of new
drugs and longer
durations
Pts having more
lines of chemo
Wider range of
cancer are
treated with
chemo
Increasing neoadjuvant and
adjuvant
indications
Safety of Patients receiving Systemic AntiCancer Treatment (SACT) was a concern
Confidential Enquiry into Patient Outcome and
Death (NCEPOD) report between June – July 2006
• 47,050 systemic anti-cancer treatments were
given
• 1044 (2%) died within 30 days. Of them:
• 35% received “Good” care
• 49% had “Room for Improvement”
• 8% received “Poor” care
Factors affecting patient safety
• Lack of specialist oncology input
• Lack of continuity of care
• Sub-optimal communication between admitting teams and oncologists
• Inadequate and late discharge planning compromising future
oncological interventions such as delay in chemotherapy cycles
• increased length of stay
• Unnecessary investigations and interventions
• Lack of “single point of contact” for oncological advice for medical and
nursing staff
• Lack of oncology specific training among junior doctors and nurses
The financial impact of Cancer and
SACT related illness are enormous
Approximately £4.35 billion was spent on cancer services in
2006/07, amounting to 5.2% of all NHS spending - DH
programme budgeting data at www.dh.gov.uk
Cancer Care is a major factor in Acute care:
273,000 emergency admissions a year with cancer (2006-07)
Acute care takes 25-50% of NHS cancer spend
12% of all acute beds used for ‘cancer care’
Increase of 30% over 10 years
Average DGH admissions ~5 pts a day with complications
of treatment
Average DGH admissions ~4 pts a week with cancer
unknown (or undiagnosed) primary
Framework of planning
and monitoring
chemotherapy services
NCAG report
advised on 3
key areas
Developing Acute
Oncology Services
The leadership,
information systems,
governance, monitoring,
and commissioning of
chemotherapy services.
• CUP services
• CUP MDTs
Education
• Streamlining
pathways,
• Governance
• Rolling audits
• MSCC pathway
management,
• Oncological emergencies,
• Chemotherapy complications
• Radiotherapy complications
• Other
oncological
problems
• Liaison service
• Providing specialist input in
day to day management
• Early discharge planning
• Co-ordinating care
• Continuity of care
Day 1 - admitted
PS-1 abdominal pain
Common Scenarios: Example 1
IF Acute oncology review
•Information
•Biopsy & urgent clinic
•Discharged
Day 2 & 3 - CT scan – liver
metatasis
Day 5 - Colonoscopy &
Day 6- Endoscopy & Bone
scan
Day 5-11
Await liver biopsy (bank holiday)
Day 14
Discussed at MDT- refer oncology
Day 15
Discharged – awaits clinic
appointment
Day 1
Admitted
PS-3 dementia
Common Scenarios: Example 2
Day 2 & 3 - CT scan & ascitic tap
IF Acute Oncology review
• PS = 3/4 Best supportive
care decision day 2
Day 5 - Diagnosis ovarian
cancer
Day 5-11
Await transfer ward ? for chemo
Day 11
Seen by oncologist
Not fit for chemo
Got diarrhoeamissed
consultant
review
Day 13
Palliative care planning
Day 26- Nursing home
NCAT anticipates:
• AOS would reduce the Length of Stay
(LOS) of Oncology In-patients by up to
1/3rd (but this will depend on existing
pathways)
• There will also be reduction in
unnecessary investigations
An Illustration of how AOS can solve some
of these issues in a peripheral DGH setting
AOS in Wrexham Maelor Hospital (WMH)
Summary of oncological activity in WMH and SSU
PARAMETER
QUANTITY
1. Total number of care episodes (chemotherapy cycles)
delivered in SSU per annum
5000
2. Number of care episodes per day
20 (approx)
3. Number of oncology admissions per year
300 (approx)
4. Number of new admissions per week
5-6
5. Length of stay (LOS) for oncology in-patients
7 days
6. Cost of oncology in-patient activity (@ £200 /day*)
£420,000
7. Projected savings of reducing mean LOS by 1 day
£60,000
Data obtained from direct observation of activity in 2011
* = data obtained from work carried out in Velindre Cancer Centre,Cardiff
Others
SAU
MAU
A&E
Home
GP
Hospice
Others
SAU
MAU
A&E
AOS 2012
Home
GP
Hospice
Prospectively collected data for AOS Wrexham March – December 2011
Died in same Admission
n
230
Mean LOS
8.2 days
7 days or less
148 (64%)
7 (4%)
14 days or less
192 (83%)
11 (5%)
>14 days
38 (17%)
9 (24%)
Different Models……
NCAG Proposals:
AOT would need minimum of:
1. Consultant Oncologist – 0.5 WTE
(on site commitment to AOS from two
oncologists)
2. Nurse Specialist for acute oncology
service
It is anticipated that the costs of recruitment
of extra staff could be offset by reductions in
inappropriate admissions and in lengths of
stay, as well as reduced investigations and
procedures performed.
The Liverpool Model: St Helens and Knowlsey NHS Trust
Adapted from Dr Ernie Marshall’s presentation
The Velindre Model: AOS at the “Hub”
Acute Oncology VCC- robust
‘Hub’ advise 24/7
– Consultant on-call
– Acute oncology SpR
– SHO
– Nurse led chemo-pager
– Palliative care CNS and
Consultant 24/7
Peripheral DGH Setting:
The Wrexham Model
Oncology service provided centrally
from the North Wales Cancer Centre
based in Glan Clwyd Hospital
The frontline service is resourced by:
0.25 WTE on-site consultant support
1.0 FTE Advanced Nurse Practitioner
0.8 FTE Speciality Doctor
The team closely links with the
Specialist Palliative Care service.
The on-site consultants also support the
AOT whenever needed.
The consultant support is due to
increase.
The Future
National body of AOS should be
developed to support
• Minimum data set
• Peer review the practice
• Ensure uniformity of service across
Wales.
Conclusion
1. AOS improves patient safety and saves NHS
resources by streamlining patient pathways, reducing
length of stay and reducing unnecessary
investigations
2. The chosen model of AOS must adapt to local needs
3. Closer collaboration among the Wales Hospitals to
develop the AOS must be encouraged