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16/07/2014
1
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
16/07/2014
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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.
3
Professor Sir Mike Richards (Royal College of Physicians 2012)
National Drivers
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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
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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
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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'.
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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.
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- 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
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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
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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
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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.
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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
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Love it or loathe it
Peer Review
Loathe It?
Time consuming
Prescriptive
Directed at process and not outcomes
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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?
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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.
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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.
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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)
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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.
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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
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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.
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• 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!
The future
• 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.
Acute Oncology Forums
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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.
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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.
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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.
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321TOXICITY
GRADE GRADE GRADE GRADE
0 4
ONCOLOGY/HAEM ATOLOGY HELPLINE TRIAGE TOOL
Fever and receiving cytotoxic chemotherapy or immunocompromised
IF TEMP 37.5ºC OR ABOVE or BELOW 36ºC or GENERALLY UNWELL – URGENT Assessment AND MEDICAL REVIEW – Follow neutropenia pathway
ALERT – Pt’s on steroids/analgesics or dehydrated may not p resent with pyrexia but may still have infection (If in doubt do a count)
Chest painOnset? What makes it worse?
Radiation? Any cardiac history
STOP CAPECITABINE or INFUSIONAL 5FU
None
Advise URGENT A&E for medical assessment
Performance StatusHas there been a recent change in performance status?
Asymptomatic Symptomatic but completelyambulant
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bed bound
Bed bound
NauseaHow many days? What is the patient ’s oral intake?
Is the patient taking antiemetics as prescribed?
Assess patients urinary output
None Able to eat/drink reasonable intakeReview anti emetics as prescribed
Can eat/drink but intake significantly decreasedReview anti emetics according to local policy
No significant intakeArrange urgent assessment
and review
VomitingHow many days/episodes?
What is the patient ’s oral intake?
Does the patient have constipation or diarrhoea?
(See specific toxicity)
Assess patients urinary output
None 1 episode in 24 hours
Review anti emetics as prescribed
2-5 episodes in 24 hours
Review anti emetics according to local policy
6-10 episodes in 24 hours
Arrange urgent assessment
and review
>10 episodes in 24 hours
Arrange urgent assessment
and review
Oral/stomatitisHow many days?
Is there evidence of mouth ulcers?
Is there evidence of infection?
Are they able to eat/drink?
Assess patients urinary output
None Painless ulcers, erythema,mild soreness able to eat/drinkUse mouthwash as
recommended
Painful erythema, oedema
or ulcers but can eat/drinkContinue to use mouthwash, drink plenty of fluids. Use painkillers either as a tablet
or mouthwash
Painful erythema di fficulty with eating and drinkingArrange urgent assessment
and review
Mucosal necrosis and/or
requires parenteral or
enteral supportArrange urgent assessment
and review
If your patient scores RED or AMBER for any toxicity you should contact the 24 Hour Helpline immediately for a full triage assessment.
ONCOLOGY/HAEMATOLOGY RISK ASSESSMENT TOOL FOR PRIMARY HEALTH CARE PROFESSIONALS INSTRUCTIONS FOR USE
AnorexiaWhat 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
DiarrhoeaConsider infection!
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 breathIs 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 pathwayHas 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
Fever and/or generally unwell and recieved systemic anti-cancer therapy (chemotherapy oral or I.V.) within the last6 weeks or disease related immunosuppression
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)
TOXICITY
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 hoursAdvise - Dietary advice,
supportive medication
Increase to 2-3 bowel movements a day or overpre-treatment movements
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 activitiesAdvise - Rest accompanied with intermittent mild activity
n/a
Moderate or causing
activities
> 37.5 C - 38 C
Severe loss of ability to perform some activities Bedridden or disabling
No new symptoms
Increase to 4-6 episodes a day or nocturnal movement/moderate cramping
Dyspnoea on exertionDyspnoea at normal level of activity
Dyspnoea at rest or requiring ventilatory support
Increase to 7-9 episodes a
day or incontinence
Severe cramping
Increase to > 10 episodes a day or grossly bloody diarrhoea or need for parenteral support
Moderate - no bowel movement in last 48 hours
Severe - no bowel movement in last 72 hours.
Consider bowel obstruction
and/or perforation.
Life threatening sepsis
Consider bowel obstruction
and/or perforation.
Arrange URGENT A&E attendance for medical assessmentA number of chemotherapy drugs are cardio toxic urgent assessment is essential.
Moderate petechia/purpuraGeneralised bruising
Generalised petechia/purpura
Generalised bruising
Uncontrolable haemorrhage -
Arrange URGENT A&E attendance for medical assessment
Oral intake altered without
malnutrition
Oral intake altered in
weight loss/malnutrition
Life threatening complications e.g collapse
None
None
None
None
None
None
None
Normal > 38 C - 40 C > 40 C
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.
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.
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.
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
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CERT APP is now live in iTunes, you can download it below.
https://itunes.apple.com/gb/app/cancer-emergency-response/id711709486?mt=8&ign-
mpt=uo%3D2
Initial assessment and
management.
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Initial Management Guidelines UKONS- generic initial
management guidelines.
RAG rated assessment and guide for early management.
Available for local adaptation.
Meets peer review requirements
(As well as not instead of trust toxicity prevention and management policies)
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?
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.
ACTION: Grade 1
See specific toxicity guidelines
Advise patient to phone back if getting worse
Document call and advice given
ACTION: Grade 2
See specific toxicity guidelines
Assess for admission if two grade 2 toxicities or toxicity not settling despite initial advice
Advise patient to phone back if getting worse
Phone/review patient within 24 hours to ensure settling
Document call and advice given
ACTION: Grade 3 and 4
Admit for assessment, investigation and parenteral management.
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.
Document call and advice given and inform specialist team
NB – rapid deterioration possible. Chemotherapy toxicities are reversible but need aggressive management
Please ensure that your Acute Oncology Team are informed of the patients admission as soon as possible
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
Midlands
Acute
Oncology
Nurses Forum
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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)
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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
Forum members are
working alongside
Macmillan to complete
an online Acute
Oncology Induction
Training Programme.
16/07/2014
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In the pipeline
• MSCC patient information
• MSCC Care and management plan
The message is getting through!
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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.
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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?
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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 38.00c whilst
on paracetamol. Patient presented at chemotherapy
clinic, unwell, pyrexia 38.00c and neutrophils 0.1x10x9/L.
Immediate admission for treatment of neutropaenic
sepsis.
58
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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 380c 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
