Acute Oncology The National Picture 1 Philippa Jones Acute Oncology Forum Lead Macmillan Associate Acute Oncology Nurse Advisor United Kingdom Acute Oncology Nursing Society 2 1
Acute Oncology People with cancer often develop new and acute problems which require an urgent response, either as a consequence of their cancer illness or the treatment itself. Professor Sir Mike Richards (Royal College of Physicians 2012) 3 National Drivers 4 2
NPSA and NCEPOD Patients suffering from acute oncology emergencies not recognised, or appropriate treatment delayed by; Primary care teams Ambulance personnel Emergency care teams Oncology teams and Patients themselves 5 Emergency care NCEPOD 49% having room for improvement and 8% receiving less than satisfactory care. NCAG- There were 273,000 emergency admissions with a diagnosis of cancer in 2006/7. This is roughly equivalent to 750 emergency admissions each day across England. A typical Trust may have five emergency admissions with cancer per day 6 3
The National Chemotherapy Action Group (NCAG), guided partly by reports from NCEPOD and NPSA and from previous cancer peer review results, recommended that a more systematic approach should be taken to dealing with cancer-related emergencies. These recommendations have been embodied in the concept of the 'Acute Oncology Service'. 7 Acute Oncology Services Acute oncology services are being implemented at all acute trusts that accept unplanned and emergency cancer admissions. They centre on a team consisting of one or more nurse specialists or nurse practitioners with dedicated availability Monday to Friday and from one or more oncologist. These professionals interface with acute teams, specialist palliative care and others to improve the coordination of care with earlier access to the relevant specialist advice. They also have key roles in education and audit. 8 4
- Acute Oncology Nurse Who are Acute Oncology Patients? Two Patient Groups : 1. Patients with potentially acute complications of their cancer treatment.* 2. Patients potentially suffering from certain emergencies caused by the disease process itself whether the primary site is known, unknown or presumed * non-surgical treatment 10 5
Key Features of an Acute Oncology Service: Early review by an oncologist or acute oncology nurse specialist (within 24 hours) 24/7 access to telephone advice from an oncologist Fast track clinic access from A&E or MAU Access to information on individual patients across the Trust Protocols for the management of oncological emergencies and referral pathways from A&E and acute admissions unit Specific pathways for the investigation and treatment of malignant spinal cord compression Early management of MUO/CUP patients 11 Key Features of an Acute Oncology Service: Early review by an oncologist or acute oncology nurse specialist (within 24 hours) 24/7 access to telephone advice from an oncologist Fast track clinic access from A&E or MAU Access to information on individual patients across the Trust Protocols for the management of oncological emergencies and referral pathways from A&E and acute admissions unit Specific pathways for the investigation and treatment of malignant spinal cord compression Early management of MUO/CUP patients 12 6
Where are we now? What s out there to help at the moment? How can we promote a culture of Acute Oncology and support each other? How can we influence change? UK Picture Trusts throughout the UK are developing specialist acute oncology advice and assessment services in response to concerns raised in 2008 by the NCEPOD report. Scotland a number of acute oncology projects and the development of a national helpline service. Northern Ireland.aspects such as the adoption of UKONS triage tool. Wales. Acute oncology projects led by the cancer networks and UKONS triage tool. England.National uptake guided by the Peer Review measures. 7
Internationally UK leading the way! Hong Kong Australia Canada New Zealand Malta Ireland Saudi Arabia Is it worth it? Admission avoidance Decreased Length of stay Reduced investigations/intervention My favourites: Improvement in quality and safety Increased patient satisfaction Increased professional satisfaction 8
Peer Review Love it or loathe it Time consuming Loathe It? Prescriptive Directed at process and not outcomes 9
Love It? Describes the structure/framework of a service - development A framework for review monitoring A benchmarking tool comparison Evidence Education How reliable is the process? Can we be trusted to self assess? Can we be rely on our trust/network colleagues to assess us? 10
Immediate Risks And Serious Concerns Services with IRs (SA/IV) Services with IRs (PR) % services with IRs Services with SCs (SA/IV) Services with SCs (PR) % services with SC AO MDT 2011-12 15 N/A 8 % 50 N/A 27 % 2012-13 0 31 17 % 0 127 69 % Specialist AO/MDT 2011-12 0 N/A 0 3 N/A 21% 2012-13 0 1 8 % 0 6 50% Generic AO 2011-12 15 N/A 8% 54 N/A 28% 2012-13 0 31 16% 0 132 68% AO In- Patient MDT 2011-12 15 N/A 8 % 52 N/A 27% 2012-13 0 30 16% 0 132 69% Acute Oncology Immediate Risks There are still many non-functioning and totally non-compliant Acute Oncology Services without sufficient planning to address this. There is a lack of staffing. There are problems across the board regarding the core members of the MDTs. Lack of appropriate training. Lack of access to an oncologist within 24hrs of presentation. Lack of a fully functioning electronic flagging system. Lack of administration support. 1 hour Antibiotic pathway in A&E not being observed. 11
Acute oncology immediate risks MSCC pathways are not sufficiently robust and in some instances have no formal documented pathway at all, resulting in patients not being discussed by appropriate clinical teams which has high levels of risk for this group of patients. Neutropenic sepsis pathways not being reviewed or audited and so remain unclear as to whether safe and effective care is being provided for these patients. Lack of engagement with A&E departments. Lack of engagement from Oncologists regarding the setup of the Acute oncology service No CUP (Cancer of Unknown Primary) service. Mismanagement and patient safety issues regarding there being two sets of notes (Main medical and Oncology) for patients receiving treatment which may not be available to A&E department. Acute Oncology Good Practice Co-ordination and leadership role of the AOS nurse. Trust-wide engagement from clinicians and nurses. Raising the profile of the acute oncology service within trusts and externally. The use of patient group directives for nurses and placing of sepsis trolleys in appropriate areas to improve time to first dose of antibiotics. Innovative and comprehensive training methods with the development of e-learning packages. Web based systems for well-developed policies and protocols with a variety of promotional screensavers. 12
Peer Review Is Here To Stay New Measures this year reinforced the role of the network groups in the development and review of acute oncology services. Outcomes Lives of people affected by cancer will be improved through using the AOS Service by: Reduction in length of stay Reduction in emergency admissions Timely and appropriate management of patients with potential neutropenic sepsis Timely review and assessment by members of the Acute Oncology service Reduction in unnecessary clinical investigations Reduction in waiting times Increase in patient satisfaction Reduction in complaints Reduction in avoidable deaths within 30 days of systemic anti-cancer therapy (NCEPOD 2009) 13
Forward Do you have defined outcome measures for your service? Would it be better to have nationally agreed outcome measures? Could you improve your Peer review? National Group Evidence Annual Peer Review against the measures for Acute Oncology Patient satisfaction Survey results Use of the Acute Oncology Services monitoring and outcome measures for Acute Oncology This data and information will be presented regularly in an agreed format at an agreed governance group meeting and any concerns regarding existing quality or concerns about maintaining quality will be escalated appropriately. The Acute Oncology Team will produce an annual report utilising the information listed above to evaluate the efficiency and quality of the service. 14
Data collection Why do we want/need to collect data Demonstrate outcomes and effectiveness Demonstrate financial aspects of service Demonstrate need for service expansion or improvement Demonstrate service demands Highlight common problems Evidence of practice - good and bad 15
Data collection National outcome measures enabling us to compare and not Local value how are we doing? National value how are we all doing? Do we have a problem or do we all have a problem ------- -How can we fix it? Data is crucial & powerful? What's out there to help A number a basic access data bases developed locally and available for sharing Assessment tools and log sheets for data collection Somerset Data Base working on an Acute Oncology Module to cover Acute Oncology,MSCC and MUO/CUP. 16
The future Many of us are looking to build upon existing developments and utilise existing good practice. There is also recognition that the standardisation of training and patient management in the acute setting is a sensible strategy to support safe, high quality care. And it also saves valuable time and energy! Acute Oncology Forums To offer a group voice and collective opinion on matters relating to Acute Oncology Nursing. To provide support and guidance by connecting acute oncology nurses across the UK. To promote and facilitate the sharing of good practice. To work together as a forum to develop guidelines, practical tools and pathways to aid in the implementation of first class acute oncology services. To provide a resource for the health community by gathering a pool of expertise all can access. To support education and showcase excellent practice through workshops, study days etc. To support multi agency project working with professional organisations such as the Macmillan Cancer Support and the Royal Colleges. 17
Existing forums There are a number of regional forum in existence UKONS launched a national group in November 2013- Now has 600+ on the distribution list National Multi Disciplinary directory currently being collected to support the work of the National Group. Developments to date. 18
24 Hour Helpline Assessment 37 Progress A tool that will determine the patient s level of risk and prioritise the level of urgency indicated by the presenting symptoms and will aid in identifying potential emergency situations Uptake continues at a pace in both the NHS and Private sector in the UK and internationally 160 trusts known (please look at the map). The Pilot of the Paediatric version developed in partnership with the RCN is almost complete, evaluation is underway. Review and update in 2014 expand scope. 19
Primary Care Triage Services Shropshire care coordination and GP out of hours service. Macmillan funded pilot. DH funded pilot in Scotland with NHS24. Very positive results to date. A Primary Care version A Primary Care version has been developed in collaboration with Macmillan GP s and Nursing forum. It is now available as a PDF or hard copy. Really well received by the Primary Care Teams. 20
UKONS Primary Care Guidelines generic guidelines supported by Macmillan. Will be available as a pocket tool for order on the Macmillan web-site with the facility to add trust contact details. Developed by UKONS and The Macmillan GP Team Approved by: Greater Midlands Cancer Network. Midlands Acute Oncology Nurses Forum. Electronic version and App in development. INSTRUCTIONS FOR USE The UKONS 24 Hour Triage Tool is a widely utilised recognised tool that is used to a perform risk assessment for patients who have : Received systemic anti-cancer therapy including chemotherapy in the previous 6-8 weeks Radiotherapy Disease related immunosuppressuon It is a simple reliable evidence based process that grades the toxicities according to the advises action accordingly. It is important that the effects of treatment are of lower level amber toxicites is recognised. Risk assessment process There are a number of questions to ask and information that will need to be collected to make sure that the correct advice is given. Step 1. The user moves methodically down the triage assessment tool, asking appropriate questions. e.g. do you have any nausea? If NO move on. If YES use the questions provided to help you grade the problem and note either amber or red and initiate action according to step 2. Step 2. Red and/or Amber: If your patient scores RED or Amber for any toxicity you should contact the 24 Hour Helpline immediately for a full triage assessment unless URGENT referral to A&E is advised. Patients may require urgent assessment in a suitable clinical area that provides access to investigation and treatment facilities. The helpline team will arrange assessment and/or further monitoring for the patient. Green:- If your patient scores green in all toxicities they should be reassured that the problem at present does not give cause for concern but they should be vigilant and if the situation gets worse or does not improve they should call the Helpline immediately. ONCOLOGY/HAEMATOLOGY RISK ASSESSMENT TOOL FOR PRIMARY HEALTH CARE PROFESSIONALS Fever and/or generally unwell and recieved systemic anticancer therapy (chemotherapy oral or I.V.) within the last 6 weeks or disease related immunosuppression Anorexia What was their weight before? What is appetite like? Any contributory factors e.g. dehydration, diarrhoea, vomiting, mucositis, and nausea? Bleeding Is it a new problem? Is it continuous? What amount? Where from? Is the patient on anticoagulants? Bruising Is it a new problem? Is it local/generalised? Is there any trauma involved? Chest Pain Onset? What makes it worse? Radiation? Any cardiac history? Constipation How long since bowels opened? What is normal? Does the patient have any abdominal pain/vomiting? Has the patient taken any medication? Consider obstruction and/or perforation Diarrhoea Consider infection! TOXICITY How many days has this occurred for? How many times in a 24 hour period? Does the patient have any abdominal pain/discomfort? For how long? Has the patient taken any medication? N.B If taking CAPECITABINE (Xeloda) chemotherapy please ask patient to discontinue treatment until they have had helpline review. Dyspnoea/Shortness of breath Is it a new symptom? Is dyspnoea worsening? What can the patient do? (alteration in Performance status) Consider SVCO/Anaemia/Pulmonary ebolism Extravasation - drug leakage around infusion site or along infusion pathway Has the patient got pain, soreness or ulceration around or along the infusion pathway/injection site/central venous catheter? Fatigue How many days has this occurred for? Any other associated symptoms? Fever Patients who are at risk of immunosuppression who have an abnormal temperature should be referred to the helpline for assessment If your patient scores RED or AMBER for any toxicity you should contact the 24 Hour Helpline immediately for a full triage assessment. If temperature is 37.5 C or above or below 36 C or generally unwell - Contact telephone helpline for URGENT Assessment - Risk of neutropenic sepsis ALERT - Patients on steroids/analgesics or dehydrated may not present with pyrexia but may still have infection (if in doubt phone for advice) None None None None None None None None Loss of appetite without alteration in eating habits Mild, self limited controlled by conservative measures Petechia/bruising, localised Mild - no bowel movement in last 24 hours Advise - Dietary advice, supportive medication Increase to 2-3 bowel movements a day or over pre-treatment movements No new symptoms Intravenous therapy Certain chemotherapy drugs can cause long term severe tissue damage if extravasation (leakage) occurs. Chemotherapy extravasation requires urgent specialist review and management. Increased fatigue but not altering normal activities Advise - Rest accompanied with intermittent mild activity Oral intake altered without malnutrition Moderate petechia/purpura Generalised bruising Arrange URGENT A&E attendance for medical assessment A number of chemotherapy drugs are cardio toxic urgent assessment is essential. Moderate - no bowel movement in last 48 hours Increase to 4-6 episodes a day or nocturnal movement/ moderate cramping Dyspnoea on exertion Moderate or causing activities Oral intake altered in weight loss/malnutrition Uncontrolable haemorrhage - Arrange URGENT A&E attendance for medical assessment Generalised petechia/purpura Generalised bruising Severe - no bowel movement in last 72 hours. Consider bowel obstruction and/or perforation. Increase to 7-9 episodes a day or incontinence Severe cramping Dyspnoea at normal level of activity Severe loss of ability to perform some activities Life threatening complications e.g collapse Life threatening sepsis Consider bowel obstruction and/or perforation. Increase to > 10 episodes a day or grossly bloody diarrhoea or need for parenteral support Dyspnoea at rest or requiring ventilatory support Bedridden or disabling Normal n/a > 37.5 C - 38 C > 38 C - 40 C > 40 C Patient versions North of England Cancer Network Patient held Chemotherapy record ( Lilly diary) Cancer Emergency Response Tool,an app for patients Dr. Richard Osborne,Dorset Cancer Centre 21
CERT APP is now live in itunes, you can download it below. https://itunes.apple.com/gb/app/cancer-emergency-response/id711709486?mt=8&ignmpt=uo%3d2 Initial assessment and management. 22
Initial Management Guidelines Generic management guidelines for chemotherapy toxicities (see specific algorithms for management of each toxicity) Grade 1 (Green) Grade 2 (Amber) Grade 3 (Red) Grade 4 (Red) Mild Moderate Severe Life threatening Also consider factors which lower threshold for inpatient admission: Symptoms needing urgent admission temperature, chest pain, bleeding? Might be neutropenic? More than one Grade 2 toxicity? Poor historian/ difficult to assess on phone? Compliance of patient / ability to understand and follow instructions Grade 2 toxicity not settling despite maximal outpatient efforts? Becoming weak/dehydrated? ACTION: Grade 1 See specific toxicity guidelines ACTION: Grade 2 See specific toxicity guidelines ACTION: Grade 3 and 4 NB Neutropenic sepsis needs urgent admission and immediate iv broad spectrum antibiotics/fluids. Do not get GP out first. Do not wait for FBC before giving antibiotics. See specific guideline for further detail. Admit for assessment, investigation and parenteral management. UKONS- generic initial management guidelines. RAG rated assessment and guide for early management. Available for local adaptation. Meets peer review requirements Advise patient to phone back if getting worse Document call and advice given Assess for admission if two grade 2 toxicities or toxicity not settling despite initial advice Advise patient to phone back if getting worse See specific toxicity guidelines and sections on management of inpatients with chemotherapy toxicities on page 3 If not needing admission, ensure FBC, U+E checked, good oral intake and daily contact with patient until improving, with low threshold for admission. Phone/review patient Document call and advice given and inform specialist within 24 hours to ensure team settling NB rapid deterioration possible. Chemotherapy Document call and advice toxicities are reversible but need aggressive given management Please ensure that your Acute Oncology Team are informed of the patients admission as soon as possible (As well as not instead of trust toxicity prevention and management policies) Midlands Acute Oncology Nurses Forum UNPLANNED ADMISSION LOG SHEET Standardised Assessment Process Evidence Based Assessment Tool Check List/aid memoir Audit Tool Record Keeping Evidence of practice Training and education Communication tool 23
Midlands Acute Oncology Nurses Forum Macmillan Learn Zone Macmillan are kindly supporting a Special Interest Group for the Midlands Acute Oncology Nurses Forum on Learn Zone. This provides a forum discussion facility and a document library allowing us to share good practice and seek opinion and/or advice. This is not restricted to nurses working within the Midlands you are all welcome to join and make use of this facility. Accessing the Acute Oncology Special Interest Group on Learn Zone - Go to : http://learnzone.org.uk/ In the green bar click on special interest groups It will ask you to enrol-click continue You will need to either log in or create an account. It will then list the special interest groups, select: Midlands Acute Oncology Nurses Forum For first time access the password is ---MidA0N ( the 0 is a zero) 24
Forum members are working alongside Macmillan to complete an online Acute Oncology Induction Training Programme. A web based Generic Acute Oncology Induction Training Programme. Developed by Acute Oncology Nurses and Macmillan using the East Midlands Cancer Network template. Due to be launched end of 2013 25
In the pipeline MSCC patient information MSCC Care and management plan The message is getting through! 26
National Developments National working party linked to Chemotherapy Reference Group (CRG):- England - National Acute Oncology Service Specification National Outcome Measures Review of current service provision- what's out there? is it working? Are the PEER review measures appropriate? How do we take the service forward The message Avoid repetition. Don t work in isolation. Don t keep good things to yourself Lets work together, join forces. Standardise and share Support each other Nationally contribute and collaborate. 27
Remember AOS brings together expertise from oncology disciplines, emergency medicine, palliative care, general medicine, general surgery and the community Why do we need to succeed? 28
Patient contacted chemotherapy helpline symptoms described in line with spinal cord compression. Advised to ring 999 for assessment in ED. Patient contacted help line again 3 days later condition worse had attended ED as directed previously but was discharged after a 5 hour wait. Patient now immobile. Patient was later admitted to ward and treated for MSCC. 57 Patient receiving chemotherapy with a history of neutropaenic sepsis following each previous cycle of treatment. Telephoned A&E for advice as she had a raised temperature. She was advised to take regular paracetamol and to report if temperature of 38.0 0 c whilst on paracetamol. Patient presented at chemotherapy clinic, unwell, pyrexia 38.0 0 c and neutrophils 0.1x10x9/L. Immediate admission for treatment of neutropaenic sepsis. 58 29
The patient was discharged post chemotherapy with recovering blood counts. The Clinical Nurse Specialist contacted the patient and gave them aftercare advice and the emergency contact number. When the patient became pyrexial 38 0 c he followed CNS advice and contacted the Helpline number/ward. The person who took the call told him to take some paracetamol. 59 Any questions? Thank you 30
philippajones@nhs.net 31