acute oncology services regional chemo service review 30 th september 2009

Acute Oncology ServicesRegional Chemo Service Review

30th September 2009

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

Background and Context Changing Cancer Paradigm New Models of Treatment Delivery NI Chemotherapy Service Standards (Nov 06) Adverse Incidents in NI Recent NPSA Oral Chemotherapy Alerts NCEPOD: for better for worse, (Nov 08) NCAG (National Chemotherapy Advisory Group)

(Aug 09) NICaN Chemotherapy Service Review (Jan 09-Dec

10)


Acute Oncology Services (AOSs)

AOSs encompasses:

The management of patients who develop severe complications following chemotherapy

The management of patients who develop severe complications as a consequence of their previously diagnosed cancer

The management of patients who present as emergencies with previously undiagnosed cancer


Acute Oncology Services

Acute oncology necessarily involves clinicians working in emergency departments and in acute medicine, as well as in oncology and related disciplines

Baseline AssessmentIssues of relevance to this group


Background Increasing demand, scarce resource,

service pressure Baseline Assessment April - Aug 2009 Stakeholder interviews n=430 Positive, concerns, issues 4 working groups established

New Models of chemo delivery Workforce Development Capacity Planning Acute Oncology Services*


Current organisational model Hub and spoke model / CCentre and CUnits Centre based site specific oncs visit units

weekly Registrars travel out to units to support clinics Variation in staff grade support at units Resident hematologists at centre and units Common cancers treated at units CC acts as unit for local catchment area plus

regional service for complex cancers Appointments governed by CC Patient Notes leave CC and immediately

return following visit


5 locations:•Chemo assessment clinics•Chemotherapy administration•Review clinics

•Chemotherapy preparation and dispensing suite (pharmacy)•Chemo competent nurses

?


NI A/E Departments


Components of chemo service Service configuration Workforce configuration Leadership arrangement Governance arrangements Data and information technology Effective communication systems &

processes Commissioning arrangement


Underpinning principles for commissioning chemo services (NCAG, 2009)

Patients who might benefit from chemo are able to access quality services

Treatments which are delivered are appropriate to a patients condition

Services are delivered safely Services are convenient for patients Patient experience is good Services represent good value for

money

Delivery & treatment

environment

Pt, carer information, education

Urgent assessment,

management of complications

End of treatment record and care plan

Access & referral

Assessment , decision to

treat, consent

Prescribing & Dispensing


Current AE realities All patients are priorities with

competing interests not just oncology Only default mechanism is go to A/E /

can’t close its doors Palliative care pts arriving, deaths in

Dept, GP don’t want to take that responsibility, nobody wants to make decisions on these pts, location

Patients arrive even when bed available in cancer unit


Unsuitable Environment A/E worse place for these patients

unless require resus Inappropriate environment, waiting

on trolleys for 12 hours, beside drunks, ? infection

MAU 150% bed occupancy in 24hrs – infection control


Poor Clinical Information Flow Information poor, comes ad-hoc, no notes,

no documentation, no access to COIS ? Regime, CTs and drug interactions

Poor communication, no updates or information sharing

No alert cards, pts forget to say on chemo Tx intent unclear, ? Status, short decision

making time Difficulty in contacting Oncologist


Strained professional relationships

AE only get negative feedback and complaints

Little sense of team work across departmental boundaries

Dealing with “their” patients


A/E staff not expert in oncology Yet dealing with increasingly complex cancer

patients Training an issue, no liaison with Oncology

service, never approached, don’t know their names, no updates on what they are doing

A/E staff not expert in oncology issues, inappropriately investigated, sometimes inappropriately/over treated

Yet commonly bearer of bad news Concerns among non Oncology consultants in

peripheral hospitals pts admitted with post chemo complications who they feel ill equipped to manage and who they are unable to transfer to oncology units


Lacking pathways & ownership Neutropenic sepsis is easy, complications of

cancer is the problem In cancer unit, patients are treated by visiting

Cons with provision that we pick up the problem, no continuity, no holistic care

Orphan patients – where should they go? Major issues with ownership / orphan patients Cancer centre only for treatment – where should

others go? Difficulty in getting patients with recurrence back

into system Admitted to wards with infections, junior staff with

no oncology expertise, don’t get to see Oncologist


Unrealistic Expectations

Patients and professionals have unrealistic expectations of A/E

Because CC next door to A/E next they expect admission

Helpline raises expectations


AE Under-resourced

NCEPOD, difficulties in meeting door to needle times

A/E Departments remain open but not adequately resourced

Cancer charity funding, vast amount work given by acute care but AE don’t receive any funding


Suggestions for improvementBaseline Assessment


Suggestions for improvement

Complications serious but can be rare - should be kept in one area of expertise, need agreement on high dependency acute ward, skilled, knowledgeable staff

Pt should have USB passport / smart card Need obvious alert card Permanent alert on patients notes on

chemo A4 explicit careplan / care pathway -

Direction of travel Robust pathway to Specialist Oncologist


Suggestions for improvement Need for robust communication / information

systems Need shared care model Prompt referrals for opinions should go to

registrar, not F2 Continued care, shouldn’t just be about

delivering care, at least see patient and say nothing more we can do

Regional neutropenic sepsis audit in NI Regional audit, ”emergency presentations of

onc pts”


Underpinning principles for commissioning chemo services (NCAG, 2009)

Patients who might benefit from chemo are able to access quality services

Treatments which are delivered are appropriate to a patients condition

Services are delivered safely Services are convenient for patients Patient experience is good Services represent good value for

money

acute oncology services regional chemo service review 30 th september 2009

Documents

quality of cancer care

undiagnosed cancer slide

cancer survival background

continuous improvement

group slide

working groups

quality services treatments

following visit slide