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North of England Cancer Network

Network Acute Oncology Group (NAOG)

Cancer Clinical Guidelines

Title: NAOG Cancer Clinical Guidelines Authors: NAOG members Circulation List: As detailed on page 2 Contact Details: Dr N Storey, NAOG Chair Telephone: 01138 252971 Version History: Date: July 2013 Version: v1.0 Review Date: May 2014

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Position: NAOG Chair Name: Dr N Storey Organisation: South Tees Hospitals NHS FT Date Agreed: 14.07.13 Position: Medical Director Name: Dr M Prentice Organisation: Cumbria, Northumberland, Tyne and Wear Area Team Date Agreed: 30.09.13 Haematology NSSG members agreed the Guidelines on: Date Agreed: 10.07.13 Review Date: May 2014

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CONTENTS PAGE The Acute Oncology Service – An Introduction ................................................................... 4

Definition of Acute Oncology Patients .................................................................................. 5

Development of Acute Oncology Services within the NECN ................................................ 5

11-1A-304y, The Network Acute Oncology Group ............................................................... 6

Responsibilities of Network Acute Oncology Group ............................................................. 7

11-1E-101y, Network Acute Oncology Group Meetings ...................................................... 7

11-1E-102y, The Network Acute Oncology Group Annual Review, Work Programme and Report .................................................................................................................................. 7

11-1E-103y, The Network Consultant Oncologist Telephone On Call Service .................... 8

11-1E-104y, Acute Oncology Referral Guidelines ............................................................... 9

11-1E-106y, Induction Training in the use of the Acute Oncology Service .......................... 9

24/7 Acute Oncology Telephone Advice Service: Minimum Service Specification ............ 10

Acute Oncology Initial Management Guidelines ................................................................ 10

Telephone Advice Service Active Pathway Management Protocols .................................. 10

Malignant Spinal Cord Compression (MSCC) .................................................................... 11

11-1E-105y, Network Information on Early Detection of Malignant Spinal Cord Compression (MSCC) ........................................................................................................ 11

11-1E-107y, Training for MSCC Coordinators ................................................................... 11

11-1E-109y, MSCC Senior Clinical Advisor Service .......................................................... 11

11-1E-110y, The MSCC Case Discussion Policy .............................................................. 13

11-3Y-301, Responsibilities of Hospital Acute Oncology Lead .......................................... 14

Appendix 1 - NECN Acute Oncology Referral Guidelines .................................................. 17

Appendix 2 - Network Information on Early Detection of MSCC ........................................ 21

Appendix 3 - In Hours Metastatic Spinal Cord Compression High level Pathway .............. 23

Appendix 4 - Out of Hours Metastatic Spinal Cord Compression High Level Pathway ...... 24

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The Acute Oncology Service – An Introduction The National Chemotherapy Advisory Group (NCAG), guided partly by reports from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and National Patient Safety Agency (NPSA) and from previous cancer peer review results, has 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”. This has implications across cancer network organisational structures, hospitals of various types, chemotherapy, radiotherapy and other treatment delivery services, primary care and PCTs. The recommendations also include some for the initial management of patients diagnosed with a malignancy of unknown primary site. The recommendations span all relevant services, tumour types and treatment modalities. These measures also apply to some specific arrangements for one particular aspect of acute oncology, metastatic spinal cord compression (MSCC). This aspect takes into account, recommendations from the NICE guidance on MSCC. One of the key recommendations from NCAG report relates to the development of acute oncology. All hospitals with emergency departments should establish an Acute Oncology Service, which brings together the necessary expertise from emergency medicine, general medicine and oncological disciplines. This service should be responsible for the development of local policies and procedures and for ensuring appropriate training for senior and junior doctors and other staff. Arrangements for access to urgent specialist oncological advice need to be put in place where this is not already available. Oncologists will work closely with admitting physicians/surgeons and with palliative care physicians to provide advice on the care for cancer patients admitted as an emergency. Audit of emergency admissions of patients with cancer and cancer treatment-related complications should be routine. The specification of the Acute Oncology Services has been further defined by the NCAT Manual for Cancer Services

• There is a requirement for a network lead and network group for acute oncology (NAOG).

• There is a requirement for a network review of chemotherapy services and of the configuration of acute oncology as a whole, across the network.

• There is a requirement for an acute oncology team (AOT) for each acute hospital, combining staff from A&E departments, acute medicine, oncology and palliative care. This has the role of coordinating the service in that hospital.

• There are training requirements in acute oncology for medical and nursing staff.

• There are operational policies and protocols describing timely and correct communication between primary care, the AOT, providers of emergency treatment, oncologists, telephone advice services and patients and carers.

• There are protocols for the treatment of the acute oncology presentations.

• There are Information Technology (IT) applications to identify potential acute oncology patients (“flagging systems”).

• There is a minimum requirement of oncologists’ and specialist nurses’ time specified for providing rapid acute oncology triage, and consultant assessment within 24 hours.

• There is a target to deliver antibiotics within one hour of arrival in the hospital to patients with potential neutropaenic sepsis (“1 hour to antibiotic policy”).

• There is a requirement for fast track slots in clinics, specified for acute oncology patients.

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• Whatever the degree to which the network chooses to combine the infrastructure for acute oncology and MSCC, there is a requirement for specifically designated senior clinical advisors for MSCC for the network, including spinal surgeons with specific practice requirements.

• There are audits of the treatment of neutropaenic sepsis and of the MSCC service. Definition of Acute Oncology Patients

There are three distinct arms of an acute oncology service:

• Patients presenting with complications of anticancer treatment, during treatment and within 6 weeks of that treatment finishing.

• Patients with a known diagnosis of cancer who have already had treatment or not required treatment (>than 6 weeks since active treatment).

• Patients presenting acutely unwell where cancer is suspected. Some of this group will require urgent admission; others might be appropriately referred to a rapid access clinic.

The management of patients with a malignancy of unknown primary not ill enough to present as an emergency is now the subject of specific Carcinoma of Unknown Primary (CUP) peer review measures. Development of Acute Oncology Services within the NECN The successful implementation and commissioning of Acute Oncology Services will be achieved through a collaborative and systematic approach, taken by the Trust Providers, Commissioning leads, the Network Board and the Network Acute Oncology Group. The aim of this collaborative development is safer and equitable standards of care for patients presenting with acute problems caused by their cancer and its treatment throughout the NECN.

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11-1A-304y, The Network Acute Oncology Group NAOG Chair Nicola Storey NAOG Vice Chair Chris Jones Senior Clinical Advisor for MSCC and MSCC Chair

CUP Chair Syed Zubair Chair of Network Chemotherapy Group

Steve Williamson

Chair of Network Radiotherapy Group

Chris Walker

Patient & Carer Representatives

Clare Singleton/Norman Mackey

Clinical Oncologist Nicola Storey Medical Oncologist Chris Jones Haemato-Oncologist Victoria Hervey A & E Consultant Mike Rickards Consultant in Palliative Medicine

Anne Pelham

Consultant Physician Neil Munro

AHP Lead (Physio) Ruth Murringa OT Helen Caudren Specialist Nurse Alison East/Louise Davison Oncology Pharmacist Steve Williamson/Calum

Polwart Audit Lead Nicky Hand Admin Support Peer Review Co-

ordinator/Network Administration team

Hospital Acute Oncology Leads: Trust Lead Deputy Co Durham & Darlington Neil Munro Jayne McClelland/Pauline

Burton Gateshead Alison East Newcastle Chris Jones Angela Simpson North Cumbria Helen Roe TBC South Tees Nicola Storey Nicky Hand

South Tyneside Oliver Schulte Elaine Kilgannon Sunderland Melanie Robertson Victoria Hervey/Louise

Davison Northumbria Ian Neilly Gill Starkey North Tees & Hartlepool Dawn Ashley Tracy Nugent

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Responsibilities of Network Acute Oncology Group The NAOG has the following responsibilities:

• To be the network’s primary source of advice on issues relating to acute oncology in the network;

• To be the group with corporate responsibility, delegated by the Network Board for ensuring co-ordination and consistency across the network for implementing the acute oncology measures, and for ensuring co-ordination, equity and consistency across the network for the acute oncology practice in hospitals;

• To be the group for consulting with the NSSGs and the network chemotherapy and radiotherapy groups on the acute oncology treatment and referral;

• To act as a forum for sharing good practice across all trusts within the Network;

• It will include a sub-group responsible for MSCC and that group will take responsibility for the coordination and monitoring of diagnosis, treatment and outcome for MSCC patients across the network.

11-1E-101y, Network Acute Oncology Group Meetings 11-1E-102y, The Network Acute Oncology Group Annual Review, Work Programme and Report The NAOG will normally meet every 6 months. During the development of the service the group has met more often. Attendance at meetings will be recorded and the minutes from the meeting will be circulated to all members of the group, and also published on the NECN website. The NAOG will prepare a work progamme that will be updated annually. The NAOG will prepare an annual report for the Network Board. The annual report will be presented to the Network Medical Director by the Chair of the NAOG.

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11-1E-103y, The Network Consultant Oncologist Telephone On Call Service The minimum requirements of the Consultant Oncology Telephone On Call Service are:

• It is available, 24 hours a day, seven days a week, for telephone advice to health professionals only.

• There is coverage from one service arrangement or another, over the whole network.

• It may be divided into more than one local service, each covering one or more localities, each service with its own contact number, or it may have one service and one contact number for the whole network.

• Each contact number should give telephone access during the time of the call to a consultant oncologist, making up a 24/7 duty rota.

Newcastle Hospitals Consultant Oncology Advice Service Access via Freeman Hospital Switchboard Telephone: 0191 2336161 Hospitals covered: Royal Victoria Infirmary Freeman Hospital North Tyneside General Hospital Wansbeck General Hospital Hexham General Hospital Sunderland Royal Hospital South Tyneside District Hospital Queen Elizabeth Hospital University Hospital of North Durham Localities covered: NHS North of Tyne NHS South of Tyne and Wear NHS Durham James Cook Consultant Oncology Advice Service Access via James Cook University Hospital Switchboard Telephone: 01642 850850 Hospitals covered: James Cook University Hospital Friarage Hospital University Hospitals of North Tees University Hospital of Hartlepool Darlington Memorial Hospital Bishop Auckland General Hospital Localities covered: NHS Tees NHS Durham

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Carlisle Consultant Oncology Advice Service Telephone: Hospitals covered: Cumberland Infirmary West Cumberland Hospital Localities covered: NHS Cumbria

Important note The Carlisle Consultant Oncology Advise Service is only currently available Monday-Friday 9am-5pm. There is no consultant advice service available outside of these hours.

11-1E-104y, Acute Oncology Referral Guidelines The NAOG in consultation with the chemotherapy heads of service, the radiotherapy heads of service and the hospital acute oncology leads, has produced guidelines which cover the following:

• Primary Care referral guidelines for relevant contact points of the acute oncology service

• Referral guidelines for agreed treatments and procedures provided at Specialist Cancer Hospital contact points for the hospital MSCC co-ordinators

• Contact points for local hospital MSCC co-ordinators

• Symptoms and signs suggestive of MSSC The NECN Acute Oncology Referral Guidelines are shown in Appendix 1. 11-1E-106y, Induction Training in the use of the Acute Oncology Service The NAOG, in consultation with the hospital acute oncology leads has agreed network induction training in the use of the acute oncology service. It covers the following:

• The network configuration of the acute oncology service

• The acute oncology referral guidelines

• The protocols associated with the acute oncology service

• The roles and responsibilities and relevant contact points associated with; the NAOG, the hospital AOTs, the acute oncology assessment service, the 24/7 chemotherapy patient advice service, fast track referral to OP clinics, the consultant oncologist on call service, the MSCC hospital co-ordinators and the MSCC senior clinical advisors

• It should contain locally specific information

• It needs written confirmation of completion. The NECN AOS Induction Training package is available on the NECN website. A list of accredited trainers is also shown. This training may be supplemented locally with additional information. All local “packages” will be reviewed annually so that any local innovations or good practice make be incorporated into the network package following discussion at the NAOG.

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24/7 Acute Oncology Telephone Advice Service: Minimum Service Specification Assessment A 24/7 Acute Oncology Telephone Advice Service should be provided by all hospitals delivering radiotherapy and cytotoxic chemotherapy. This service should be available to patients, or their carers, while receiving chemotherapy or radiotherapy, or within 6 weeks of completing such treatment. Patients calling the service should be assessed using the Oncology/Haematology 24-Hour Triage Rapid Assessment and Access Toolkit. The traffic light format provides a framework by which acute oncology patients may be assessed. It will guide all staff, including those less experienced in the management of acute oncology patients, as to which patients can be safely reassured and discharged, and which patients require admission for assessment. A copy of the 24 hour triage assessment should be faxed or emailed to the acute oncology team in all cases. Where necessary, the patient can then be contacted to ensure that the problem had been appropriately resolved, either following the telephone advice or by the admission of the patient In those patients receiving active chemotherapy, special consideration should be given to the possibility of underlying neutropenic sepsis. All patients in this category should be assessed urgently, and if the patient demonstrates signs or symptoms suggestive of this diagnosis, antibiotics should be given immediately without waiting for blood results, in accordance with the NECN Neutropenic Sepsis Protocol. The provision of a 24 hour telephone advice service is not currently part of the Acute Oncology Peer Review Measures but is considered to follow best practice for all hospitals delivering chemotherapy and radiotherapy. Acute Oncology Initial Management Guidelines The NECN has collaborated with Greater Midlands Cancer Network in the development of initial management guidelines for patients admitted with acute problems. These guidelines cover the first 24 hours of in-patient care until specialist oncology review. This allows acute teams to manage the immediate complications of cancer and its treatments. A copy of the guidelines is available the NECN website, link below: http://www.necn.nhs.uk/group/network-acute-oncology-group/ These guidelines will be reviewed annually. Telephone Advice Service Active Pathway Management Protocols It is accepted that proactive management of problems encountered by patients on active treatment may prevent later emergency admissions to hospital. The integration of the Triage Assessment Tool into the Acute Oncology Service can alert them to patients who might be struggling with their treatment. The NAOG would support the development of active management pathways as outlined below: Those patients falling within green categories may be reassured. For all other patients, where specific advice is given, or attendance for review advised, there will be active follow-up as outlined below:

• That within 24 hours of giving a caller advice, the advice service will confirm that their problem has been dealt with or has resolved, by either contacting the particular service which the caller was advised to attend or consult, and/or contacting the caller again.

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• That within 24 hours of receiving a call, or on the next working day, the advice service will inform the consultant currently responsible for the patient’s cancer management, of the call, the patient’s problem and the advice given. This can be achieved by faxing, or electronically sending, a copy of the triage assessment to the consultant’s secretary.

• The result of the follow-up call can also be recorded, allowing audit of helpline advice, in addition to ensuring that the problem has been dealt with.

The aspiration of the NAOG is that all advice services within the Network should present an annual audit of their service to the NAOG. This can be produced by using the audit pathway tool available with 24-Hour Triage Rapid Toolkit. Malignant Spinal Cord Compression (MSCC) 11-1E-105y, Network Information on Early Detection of Malignant Spinal Cord Compression (MSCC) It is not practical or appropriate to require cancer patients to be given guidance on all the possible acute presentations of malignancy. An exception to this principle is the recommendation in the NICE guidance on MSCC. Here, the consequences of failing to detect this at a very early stage, and the rapidity of deterioration beyond the point of salvage, are the rationale behind developing patient information on the early signs of MSCC. This information may be offered to patients and/or carers of patients with spinal metastases, or at high risk of developing spinal metastases. The information describes the signs and symptoms that may enable them to detect impending MSCC at a salvageable stage. The NECN information leaflet is shown in Appendix 2. The telephone advice/contact number should be personalised by individual hospitals and should be the contact number for the local spinal cord compression coordinator. 11-1E-107y, Training for MSCC Coordinators The NAOG has, in consultation with the MSCC senior clinical advisors, agreed the professional qualifications and training, prerequisite for a staff member to be on the MSCC hospital co-ordinator rota, additional to the induction training in the use of the acute oncology service (See NAOG Constitution, Appendices 7-9). There will be a single list of authorised assessors of competence for the training for MSCC co-ordinators. They should be able to assess competence from the point of view of use of the acute oncology service in general and the additional training specific to MSCC co-ordinators (See NAOG Constitution Appendix 9). 11-1E-109y, MSCC Senior Clinical Advisor Service The NAOG has, in consultation with the hospital acute oncology leads, produced a minimum service specification for a network MSCC, senior clinical advisor service, which includes the following:

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• It is available 24 hours a day, 7 days a week for advice to secondary care clinicians and MSCC co-ordinators, managing or referring patients with MSCC who have been judged suitable for active definitive treatment

• Each senior clinical advisor will be able to view the patient's imaging during the discussion. The caller will provide the clinical case details and ensure that the imaging and a local report of the finding is available on the centre’s PACS system

• It is divided into more than one local service, each covering one or more hospitals, each service having its own contact number (see below)

• There is a rota made up of consultants (known as the senior clinical advisors for MSCC) from the three disciplines: (i), spinal surgery, (of orthopaedic or neurosurgical disciplines), (ii), clinical oncologists who treat MSCC, (iii), radiology

• Contacting the service will enable the caller to initiate a discussion of the case in question between at least a spinal surgeon from the rota, a clinical oncologist from the rota (and a radiologist from the rota, if this is deemed necessary).

The pathways agreed by the NAOG and MSCC group are shown in Appendix 3 and Appendix 4. The configuration of the service mirrors that of the consultant oncologist on-call. Newcastle MSCC Advice Service Access via Freeman Hospital Switchboard Telephone: 0191 2336161 Hospital covered: Royal Victoria Infirmary Freeman Hospital North Tyneside General Hospital Wansbeck General Hospital Hexham General Hospital Sunderland Royal Hospital South Tyneside District Hospital Queen Elizabeth Hospital University Hospital of North Durham Localities covered: NHS North of Tyne NHS South of Tyne and Wear NHS Durham

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James Cook MSCC Advice Service Access via James Cook University Hospital Switchboard Telephone: 01642 850850 Ask for Consultant Oncologist On-Call Hospitals covered: James Cook University Hospital Friarage Hospital University Hospitals of North Tees University Hospital of Hartlepool Darlington Memorial Hospital Bishop Auckland General Hospital Localities covered: NHS Tees NHS Durham (Darlington PCT) 11-1E-110y, The MSCC Case Discussion Policy All patients with MSCC should be discussed with a member of the MSCC Senior Advisory Service. The MSCC Senior Advisory Service comprises the Consultant Clinical Oncologists and Consultant Spinal Surgeons who make up the on-call rotas of the MSCC Treatment Centres. During normal working hours this would most appropriately be the patient’s primary oncologist. Out of hours, or where the primary oncologist is unavailable, the patient should be discussed with the MSCC Co-ordinator at the MSCC Treatment Centre. All patients with MSCC should be discussed prior to definitive treatment by a member of the MSCC Advisory Sevice. This discussion will usually be initiated by the local MSCC co-ordinators contacting the centre MSCC co-ordinator in either Newcastle or James Cook. The local co-ordinators will be responsible for ensuring that all local imaging, and the local radiologist’s report of that imaging, has been transferred to the central PACS system to enable the senior clinical advisors to view MRI scans at the time of discussion. Outside normal working hours all trusts within the network should ensure that they have a clearly defined pathway to contact the central MSCC co-ordinator, usually the consultant clinical oncologist on-call, and to transfer local imaging and a report of that imaging to the centre for discussion. Where there is doubt about a given patient’s fitness for definitive treatment this patient can also be discussed with a member of the MSCC Clincial Advisory Service and advice will be given over the appropriateness of proceeding to a full case discussion. Where a patient is not felt to be fit enough for surgical intervention a discussion should still be initiated with a clinical oncologist as radiotherapy remains an option for the majority of patients.

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11-3Y-301, Responsibilities of Hospital Acute Oncology Lead Each hospital lead should have at least one session (PA or timetabled notional half day, as relevant to their discipline’s job planning convention) specified in their job plan for the duties of the post and sessions worked in that hospital. The post holder can be from any of the clinical professional groups associated with Acute Oncology (nursing, medical, pharmacy etc) but should be of consultant status. Responsibilities

• to ensure that objectives of an Acute Oncology Service (as laid out in the NCAG Report and Manual of Cancer Services) are met:

• to ensure that designated specialists work effectively together in the team such that decisions regarding all aspects of diagnosis, treatment and care of patients and decisions regarding the team’s operational policies are multidisciplinary decisions;

• to ensure that care is given according to recognised guidelines and that appropriate information being collected to inform clinical decision making and to support clinical governance/audit;

• overall responsibility for ensuring that Acute Oncology Team (AOT) meet peer review quality measures;

• ensure attendance levels of core members are maintained, in line with quality measures;

• provide link to Network Acute Oncology Group (NAOG) either by attendance at meetings or by nominating another AOT member to attend;

• lead on or nominate lead for service improvement;

• organise and chair annual meeting examining functioning of team and reviewing operational policies and collate any activities that are required to ensure optimal functioning of the team (eg training for team members);

• ensure AOS activities are audited and results documented;

• arrange and chair AOT meetings at least every six months and ensure that the attendance and minutes of the meeting are clearly recorded

11-3Y-404, The NECN Acute Oncology Assessment Policy The North of England Cancer Network (NECN) support the Manual for Cancer Services: Acute Oncology Measures, and specifically the Acute Oncology In-patient Assessment Service, measures 11-3y-401 to 11-3y-404. We agree that there should be a rota of Consultant Oncologists available in cancer units on a daily basis, covering the week, Monday to Friday. The strength of this measure is in the provision of the best advice and support for patients admitted with complications of their cancer and the treatment of that cancer. We feel that the benefits to patients and their carers, and also non-specialist medical and nursing staff caring for the patients are:

• Appropriate advice on the clinical management of the complications of cancer treatments

• Information about how this presenting clinical problem could impact upon the patients present cancer management plan or prognosis.

• Information about the patients prognosis where this may influence treatment decisions regarding the presenting problem

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• Open and honest discussion with the patient and family where the presenting problem is a transition towards best supportive care as a main treatment focus.

• To facilitate patient choice around preferred place of care if this is clinically appropriate, facilitating speedy discharge, reduced length of hospital stays, and avoidance of hospital admissions.

• To recommend appropriate investigation, and avoid un-necessary investigation.

• To ensure that the current cancer management plan is reviewed to ensure further complications of treatment are avoided.

In a significant proportion of cases the rapid assessment of the patient by a senior and experienced oncologist will fulfill many of these objectives, enhance the patient’s experience and reduce unnecessary time in hospital. It should be recognized however that oncologists work in multi-disciplinary teams, and that other members of the team are also highly skilled and in some cases may have more appropriate skills to deal with a given patient. Within many hospitals in the NECN there has been considerable investment in, and training of, senior and experienced specialist oncology nurses. Many valuable service improvement initiatives in oncology throughout the region have been led by nursing staff. The NECN believe that our senior oncology nurses have the appropriate skills, experience and knowledge to manage certain patients offering the input described above. AOS nurses will discuss patients, and any recommendations given, with the AOS Oncologist on a daily basis. In a number of cases formal review by an Oncologist may not be felt to be necessary. For example, a patient may be recognized to be on a pathway of best supportive care and direct referral to specialist palliative care may be more appropriate, or a patient admitted with a recurrent pleural effusion may be admitted under an experienced respiratory physician who clearly has all the skills to deal with this particular cancer complication. The NECN Acute Oncology Group therefore propose that the measure 11-3y-404 be amended as follows:

There should be an acute oncology assessment policy for the hospital which specifies the following: For hospitals under review which are not specialist cancer hospitals; for the working days, Monday to Friday, an acute oncology admitted case should be seen and assessed during the day of admission, (or for admissions after midday, by the morning of the next working day), by a member of one or other of the acute assessment rotas or by any consultant oncologist. If not seen and assessed by a consultant oncologist during the above period, they should be discussed with the oncologist within 24hrs of admission. For patients admitted during the weekend, they should be seen and assessed by a member of the acute oncology assessment team, and discussed with a consultant oncologist during Monday morning. If necessary they should be seen by the consultant oncologist following this discussion.

An audit of admissions will be performed to confirm that this assessment has taken place within the timeframe set out above, and that all cases have been discussed with a consultant oncologist. In addition, a review of randomly selected case notes will be conducted on a six monthly basis by a Consultant Oncologist to reflect upon advice given in order to ensure the quality of the service and as a basis for further learning. A prospective

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patient experience audit will also be conducted to ensure satisfaction on the part of the patient and their carers with the service provided. Acute Oncology This diagrammatic representation of the “reach” of Acute Oncology conveys the areas, which this new discipline impinges on. Essentially, any aspect of “unplanned cancer care“ can be regarded as potentially benefiting from Acute Oncology oversight and involvement, to improve efficiency and quality.

Reference: National Cancer Action Team: Developing an Acute Oncology Service, March 2012.

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Appendix 1 – NECN Acute Oncology Referral Guidelines Introduction The majority of acutely unwell patients with cancer are admitted to their local hospital under acute medical or surgical teams. The concept of the acute oncology service (AOS) has been developed to ensure urgent access to specialist oncology advice and assessment for patients presenting with acute cancer problems. The AOS brings together the skills and expertise of staff working in A&E, general medicine, oncology and palliative care. The aim of the service is to provide timely management of acute treatment related toxicity and to ensure that cancer patients, and suspected cancer patients, who are admitted as an emergency are assessed promptly and their care managed by the most appropriate clinical team. Patient Groups It is intended for the following groups of patients:

• Patients presenting with acute complications of chemotherapy.

• Patients presenting with acute complications of radiotherapy.

• Patients presenting with certain acute complications of cancer

• Patients with features suggestive of possible metastatic spinal cord compression(MSCC)

• Patients with suspected malignancy of unknown origin. Acute Oncology Presentations The most common acute oncology presentation are shown below. Those caused by systemic anti cancer treatment (SACT)

• Neutropaenic sepsis

• Uncontrolled nausea and vomiting

• Extravasation injury

• Acute hypersensitivity reactions including anaphylactic shock

• Complications associated with venous access devices

• Uncontrolled diarrhoea

• Uncontrolled mucositis

• Hypomagnesaemia The following, as caused by radiotherapy

• Acute skin reactions

• Uncontrolled nausea and vomiting

• Uncontrolled diarrhoea

• Uncontrolled mucositis

• Acute radiation pneumonitis

• Acute cerebral/other CNS, oedema.

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The following as caused directly by malignant disease and presenting as an urgent acute problem. (These patients may be known to have cancer, or this may be the presenting problem in a previously undiagnosed cancer.)

• Effusion

• Pericardial effusion

• Lymphangitis carcinomatosa

• Superior mediastinal obstruction syndrome, including superior vena cava obstruction

• Abdominal ascites

• Hypercalcaemia

• Spinal cord compression

• Cerebral space occupying lesion (s) Acute Oncology Service Provision in the NECN

Patients thought to be suffering from any of the complications of cancer but who have not yet been formally diagnosed or seen by an oncologist should be referred through the acute medical teams in the geographically relevant hospital. The acute oncology assessment team will see patients within 24 hours of an acute admission. Currently these services runs 5 days per week, so patients admitted after midday on Friday will be seen routinely on Monday morning. All acute admissions units in the NECN have access to 24 hour telephone advice from an on-call Consultant Oncologist. Malignant Spinal Cord Compression Referral Guidelines Contact the MSCC coordinator urgently (within 24 hours) to discuss the care of patients with cancer and any of the following symptoms suggestive of spinal metastases:

• Pain in the middle (thoracic) or upper (cervical) spine

• Progressive lower (lumbar) spinal pain

• Severe unremitting lower spinal pain

• Spinal pain aggravated by straining e.g. at stool, or when coughing or sneezing

• Localised spinal tenderness Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency:

• Neurological symptoms including radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction

• Neurological signs of spinal cord or cauda equine compression These patients require urgent assessment.

During active anticancer treatment, and in the 6 weeks after treatment, patients and GPs are advised to contact the original treating hospital. All patients receiving chemotherapy and radiotherapy will have been given the relevant contact numbers. If patients present with immediate life threatening complications they should be referred to / attend their local hospital / A&E department.

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The following hospitals in the NECN offer acute oncology services. The acute oncology team in each hospital works within the NECN acute oncology guidelines and is supported by Consultant Oncologist on call and a Malignant Spinal Cord Compression Co-ordinator. Trust Hospital In hours

chemotherapy helpline contact

Out of hours Chemotherapy helpline contact

MSCC Contact In Hours

MSCC Contact Out of Hours

South Tees Hospitals NHS FT

James Cook University Hospital Friarage Hospital

Chemotherapy Day Unit

JCUH Ward 14 01642 854514

Oncologist on call via JCUH switchboard 01642 850850

Oncologist on call via JCUH switchboard 01642 850850

North Tees & Hartlepool NHS FT

University Hospital of North Tees University Hospital of Hartlepool

Acute Oncology Specialist Nurse Bleep 6661/2

Acute Oncology Specialist Nurse Bleep 6661/2

County Durham & Darlington NHS Foundation Trust

Darlington Memorial Hospital

Catherine Simpson AOS Nurse Specialist Tel: 07917092602

Catherine Simpson AOS Nurse Specialist Tel: 07917092602

University Hospital of North Durham

Thelma Rosenvinge AOS Nurse Specialist Tel: 07917092604

Thelma Rosenvinge AOS Nurse Specialist Tel: 07917092604

Oncology Registrar on call Freeman Hospital 0191 2821855

Newcastle Hospitals NHS FT

Royal Victoria Infirmary Freeman Hospital

Acute Oncology Service, Royal Victoria Infirmary Tel: 01912821855 (M-F 9-5)

Ward 33 (Haemato-oncology), Wd 34 (Haemato-oncology and Oncology), Wd 35 (oncology) 0191 2336161

MSCC co-ordinator via Switchboard 0191 2336161

City Hospitals Sunderland NHS FT

AOS Nurse Specialist contact: 01915656256 Ext: 47444 52156/52593

0191 5699728 AOS Nurse Specialist contact: 01915656256 Ext: 47444 52156/52593 Out of hours 0191 5699734

Oncology Registrar on call Freeman Hospital 0191 2821855

Gateshead Health NHS FT

Queen Elizabeth Hospital

Medical Consultant On-call 07538799765

Out of hours advice 07538799765

Medical Consultant On-call via 0191 4820000

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Trust Hospital In hours

chemotherapy helpline contact

Out of hours Chemotherapy helpline contact

MSCC Contact In Hours

MSCC Contact Out of Hours

Northumbria Healthcare NHS FT

South Tyneside NHS FT

South Tyneside District Hospital

AO CNS Tel: 0191 202 2107 or 4041000 bleep 108

0191 404 1000 Bleep 601

AO CNS Tel: 0191 202 2107 or 4041000 bleep 108

North Cumbria University Hospitals NHS Trust

No formal pathway – to link into Newcastle when pathway is finalised

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Appendix 2 - Network Information on Early Detection of MSCC

Further information and advice is available from:

North of England Cancer Network

0191 275 4608

www.necn.nhs.uk

Macmillan

0808 808 0000

http://www.macmillan.org.uk

If you have any of the symptoms

listed overleaf please contact

Please insert local

number

Metastatic Spinal Cord Compression

Information for patients

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Introduction Sometimes when people have cancer it can spread to the spinal

column and cause the spinal nerves to be squeezed. This leaflet is

not intended to scare you but to help you recognise the important

symptoms to report early so that tests and treatment may be done

as soon as possible. When the spinal nerves are squeezed it can

cause damage to the spinal cord to the point of complete paralysis

from the neck, chest or waist down. This is called Metastatic Spinal

Cord Compression (MSCC) and is quite rare and unlikely to affect

you, but it is very important to pick it up quickly as the earlier

treatments are started the better the result usually is.

MSCC only occurs in a small number of people.

Symptoms to watch out for:

� Back pain in areas of your spine that is severe, distressing or

different from your usual pain (especially if it affects the upper

spine or neck)

� Severe increasing pain in the spine that changes when:

- lying down or standing up

- lifting or straining

- it wakes you at night or prevents sleep

� Pain which starts in the spine and goes around the chest or

abdomen

� Pain down the leg or arm

� A new feeling of clumsiness or weakness of the arms or legs

or difficulty walking

� Numbness in the arms / hands or legs / feet

� Difficulty with urinating (not being able to pass urine or being

aware that you have passed urine) or problems with

controlling bowel function

If you have any of these symptoms:

� Speak with a doctor / health professional as soon as is

practical (certainly within 24 hours)

� Tell them that you have cancer, are worried about your spine

and would like to see a doctor

� Show the doctor / health professional this leaflet

� Try to bend your back as little as possible

The earlier MSCC is diagnosed, the better the chances of the

treatment being effective.

What will happen next?

If your doctor / health professional is concerned that your spinal

nerves are being squeezed (spinal cord compression) he or she will

usually send you straight to hospital, so that you can have an urgent

scan and start the right treatment.

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Appendix 3 - In Hours Metastatic Spinal Cord Compression High level Pathway

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Appendix 4 - Out of Hours Metastatic Spinal Cord Compression High Level Pathway