Transcript Ambulatory Care at Macmillan Cancer Centre, University College

Ambulatory Care at
Macmillan Cancer Centre,
University College London
Hospital
October 2015
Diana Comerford RGN
Ambulatory Care Clinical Lead
University College London Hospitals
NHS Foundation Trust
What is Ambulatory Care (AC)?





An extension of inpatient services
Healthcare service without overnight hospital stay
Patients receive same treatment administered in
inpatient setting
Reside at Cotton Rooms (UCLH Hotel), other local hotel,
or at home
Patients attend AC daily for treatment or assessment,
located next to Chemo Day Care service
Brief History








Opened in 2005 with two side rooms and one
Band 6 and one Band 7 nurse, treating two
patients
2 blocked inpatient beds
ESHAP mainly, conservative treatment
Local hotel with installed panic alarms
Cost pressure until proven safe
£130 hotel stay vs £700 per night hospital stay
Consultant buy in
Slowly increased capacity with demand
AC at Present








6 chairs+6 side rooms, 15-22 patients daily
4 experienced haem/onc nurses
1 potentially blocked inpatient bed
All white cell regimes w. exception of 1st AML
cycle, or high risk relapse patients, sarcoma
regimes
LEAM/BEAM/Melphalan Autograft
Low Intensity Allograft
Remain in AC if clinically well
No capacity at times
AC Operational Management








Open from 0800-1900
Electronic appointment system (FileMaker Pro)
Patients assessed daily by nurses using NCI
CTC (2003) scoring system, obs., bloods, etc.
Nurse-Led service
Doctor review if required
Twice weekly ward round with Consultants
Patients/carers have 24hr access to AC mobile
number for advice
Panic alarm installed in hotel rooms
AC Operational Management




Hotel provides breakfast (+fridge, microwave in
common area, tea/coffee making facilities,
washer/dryer for clothes)
Food vouchers
One AC bed inpatient for emergencies
Aim for all admissions during AC operating hours
Length of Stay Sample
TREATMENTS
BEAM Auto (Start between Wed to Fri to avoid
melphalan at weekend)1,2
Protocol
Carmustine 300mg/m2 IV infusion on day -6
Cytarabine 200mg/m2 IV infusion BD on days -5 to 2 (8 doses in total - in 48ml CADD)
Etoposide 200mg/m2 IV infusion on days -5 to -2 (4
doses in total)
Melphalan 140mg/m2 IV infusion on day -1
LENGTH OF STAY
(Number of Nights for
Booking)
15+
DAILY LENGTH OF STAY PER DAY OF TREATMENT (Hours)
Day
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
7
8
9
Hours
8
2.5 2.5 2.5 2.5 1.5
8
1
1
1
1
1
1
1
1
1
CADD Pumps
Examples:
•
•
•
•
Cytarabine BD
Cisplatin
Foscarnet
IVH (mesna, sodium
bicarbonate)
AC Patient Eligibility Criteria
•
•
•
•
•
•
•
•
25 years old and above (TYA service available)
Patient Consent
Patient or Carer must speak English
Those with limited mobility must have a carer
Mobile phone
Thermometer (provided by us)
Compliant with care and medications
Have an address to be discharged to
AC at Home

Consultant agreement
Lives within 60 minute travel time
Carer available to drive patient
Live near local hospital (30-45 minutes)

Complexities of AC at Home



–
–
–
No parking
Missing ward rounds
Late night issues with infusion pumps
House Rules




Must pick up phone at all times
Take own medication and temperature
Call if unwell, temperature, uncontrolled
diarrhoea/nausea/vomiting
Show up on time
Why Use AC?



Patient freedom and independence
Sense of control
Earlier discharge compared to inpatients
–




(data available)
Privacy
Better food choices
Valuable family time
Financial savings
Safety Considerations




AC chat and sign
Who uses side rooms (allo/infectious patients)
Teaching of CADD pumps, spillage kits, CADD
record of infusion
Who cares for patients out-of-hours?
–
–
24 hour advice phone
Medical notes to ward
Total AC Hospital Transfers n =116
•
13 Out-of-hours transfers to hospital (11%)
•
More than one factor/patient contributing to transfer
•
5 major reasons for admission
- febrile neutropenia
- anxiety
- GI symptoms
- stem cell reaction
- multiple infusion requirements
N
s
ty
5
Reasons for Admission
4
O
th
er
6
lR
ea
ct
io
Dr
n
ug
Re
ac
t io
n
Ce
l
An
xie
35
St
em
eu
Ne
t
ut
In
fe
Ex
ct
io
tre
n
m
e
Fa
t ig
ue
e
pt
om
40
35
30
25
20
15
10
5
0
No
n
ym
Fe
br
il
G
Is
No. of patients
Results:
Reason for Hospital Admission N = 116
34
14
15
3
Staff Experience





Continuity of care in an outpatient setting
New learning experiences
Experienced nurses with inpatient knowledge
Training nurses and a small service
Skill mix and staffing difficulties
Patient and Carer Questionnaires





Empowering experience for patients / carers
Allows for formation of working partnerships
with healthcare professionals
Opportunity to become more involved in care
↑ in patient’s general morale
Allows for more ‘normality’
What Next?






Merging haematology services with Royal Free NHS Trust
Increase chair and bed spaces (10+6)
Restructuring our diary and nursing team
Pushing for chemistry analyser specifically for Cancer
Centre
Increase AC at home
Utilising UCLH at Home
How AC could work for you?



AC at home
Utilising district nurses
Working with a primary care centre
Questions?
Contact details
Diana Comerford
Ambulatory care cancer services
Univeristy College Hospital Macmillan Cancer Centre
2nd floor,
Huntley Street
London, WC1E 6AG
+44 7946 535 703
[email protected]