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Acute Oncology What is it? Overview of Acute Oncology • Encompasses management of patients with severe complications following the treatment of, or as a consequence of their previously diagnosed cancer • Management of patients who present as emergencies with previously undiagnosed cancer • AOS brings together expertise from oncology disciplines, emergency medicine, palliative care, and general medicine and general surgery Key Features of an Acute Oncology Service: (NCAG Report) • Early review by an oncologist or oncology nurse specialist (within 24 hours) • 24/7 access to telephone advice from an oncologist • Fast track clinic access from A&E • 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 Acute oncology presentations The following, as caused by the systemic treatment of cancer: • • • • • • • Neutropaenic sepsis. Uncontrolled nausea and vomiting. Uncontrolled diarrhoea. Complications associated with venous access devices. Uncontrolled mucositis. Hypomagnesaemia. Extravasation injury. •Acute hypersensitivity reactions including anaphylactic shock. Acute oncology presentations 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. Acute oncology presentations The following, as caused directly by malignant disease and presenting as an urgent acute problem. •Pleural effusion •Pericardial effusion •Lymphangitis carcinomatosa •Superior superior vena caval obstruction •Abdominal ascites •Hypercalcaemia •Spinal cord compression including MSCC •Cerebral space occupying lesion(s) Referral guidelines The Acute Oncology Service is intended for ACUTE problems It doses not replace existing pathways for the diagnosis of new cancers or their planned treatment •During treatment and 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 •GPs and patients will also be advised to refer to/attend their local hospital/A&E department if patients present with immediate life threatening complications Assessment of treatment complications All patients should be issued with an alert card with 24 hour contact numbers. Chemo units should rehearse situations with patients to ensure that they understand when and who they should contact if they have a problem 5/8/2017 Philippa Jones Chemotherapy Redesign Manager, Greater Midlands Cancer Network 10 • ATriage tool that Tool will determine “the patient’s level of risk” • Prompt the practitioner with appropriate questions to ask in order to gain information from the patient • Provide a reliable guide to toxicity/problem grading • Prioritise the level of urgency indicated by the presenting symptoms and will aid in identifying potential emergency situations 5/8/2017 Philippa Jones Chemotherapy Redesign Manager, Greater Midlands Cancer Network 12 Contact Record Triage Log sheet • • • • 5/8/2017 It is vitally important that the data collection process is methodical and thorough in order for it to be useful and provide an accurate record of the triage assessment. A log sheet should be completed for all calls and unscheduled patient visits. This will facilitate audit of the helpline service. The Triage boxes MUST all be marked accordingly. IF YOU HAVEN’T TICKED IT,YOU HAVEN’T ASKED IT !!! Philippa Jones Chemotherapy Redesign Manager, Greater Midlands Cancer Network 13 Assessment tool • • 5/8/2017 RED- any toxicities graded here take priority and assessment should follow immediately. 2 AMBER-Two or more amber toxicities should be escalated to red action and assessment should follow immediately.. • Amber one toxicity in amber should be reviewed/ followed up within 24 hours and the caller should be instructed to call back if they continue to have concerns or their condition deteriorates • Green callers should be instructed to call back if they continue to have concerns or their condition deteriorates. Philippa Jones Chemotherapy Redesign Manager, Greater Midlands Cancer Network 14 A patient has presented with an acute oncology problem Is it neutropenic sepsis? Could it be neutropenic sepsis? Do they need admission? How do you treat the complications of chemotherapy? Could their problem be dealt with by an early review in clinic? Can they be discharged? How can the Acute Oncology Service Help? The Acute Oncology Assessment Service Available Monday - Friday •Acute oncology specialist nurses •Access to consultant oncologist advice and assessment if needed •Malignant spinal cord compression co-ordinator Telephone advice is available from a consultant oncologist, 24 hours a day, seven days a week Patient in A&E/ AAU CARCINOMA OF UNKNOWN PRIMARY Complication of known cancer IS THIS NEUTROPENIC SEPSIS Acute medical review/ AOS review >TREAT WITH ANTIBIOTICS< On active treatment Referral to AOS Identified by alert AOS review/ AO Specialist nurse SPINAL CORD COMPRESSION Pericardial effusion Pleural effusion Brain mets Ascities Transfer to specialist ward Fast track protocols MSCC co-ordinator/ On-call oncologist MRI scan Advice/review by Consultant Oncologist 24/7 Review in rapid access clinic/ acute oncology assessment unit Transfer to MSCC treatment centre Spinal surgeons/ Radiotherapy Carcinoma of unknown primary (CUP) Most patients with newly diagnosed cancer are found to have a clearly defined primary tumour, and can then be swiftly referred on to a “site specialist team” 4% patients are found to have cancer without an identifiable primary site, despite exhaustive tests Because of the lack of dedicated clinical services, patients who have malignancy without an identifiable primary site can be denied the care offered to patients with site-specific cancers North of England Cancer Network MSCC Centres NCC, Freeman Hospital James Cook Hospital Radiotherapy Centres NCC, Freeman Hospital James Cook Hospital Cumberland Infirmary LOCAL PATHWAYS???? Which services at which hospital AOS team 24/7 chemo advice service Fast track clinics Consultant oncologist on-call service Out of hours ? Treatment protocols Complications of the systemic treatment of cancer: • • • • • • • Neutropaenic sepsis. Uncontrolled nausea and vomiting. Uncontrolled diarrhoea. Complications associated with venous access devices. Uncontrolled mucositis. Hypomagnesaemia. Extravasation injury. Remember there is an on-call oncologist available for telephone advice at the cancer centre 24/7 Acute oncology presentations The following, as caused directly by malignant disease and presenting as an urgent acute problem. •Pleural effusion •Pericardial effusion •Lymphangitis carcinomatosa •Superior superior vena caval obstruction •Abdominal ascites •Hypercalcaemia •Spinal cord compression including MSCC •Cerebral space occupying lesion(s) In Hours Metastatic Spinal Cord Compression High level Pathway Information pack for patients Known cancer patient (aware of risk) Discharge Rehab Centre (local unless otherwise agreed) Patient attends GP Cancer patient unaware of the risk (undiagnosed) Transfer patient to Centre for definitive treatment Co ordinator (collate clinical information) Admission via A&E or Medical Admissions Unit MRI local /central Coordinator link with local / centre Oncologist Oncology / Surgery patient discussion Supportive / Palliative care Key worker Routine O.P. appt. Discharge Ward patient Member of Primary Care Team GP informed (+/- D.N. / Primary Care Team) Not Appropriate for admission / active treatment Key worker EOL In Hours Metastatic Spinal Cord Compression High level Pathway Information pack for patients Known cancer patient (aware of risk) Discharge Rehab Centre (local unless otherwise agreed) Patient attends GP Cancer patient unaware of the risk (undiagnosed) Transfer patient to Centre for definitive treatment Co ordinator (collate clinical information) Admission via A&E or Medical Admissions Unit MRI local /central Coordinator link with local / centre Oncologist Oncology / Surgery patient discussion Supportive / Palliative care Key worker Routine O.P. appt. Discharge Ward patient Member of Primary Care Team GP informed (+/- D.N. / Primary Care Team) Not Appropriate for admission / active treatment Key worker EOL Out of Hours Metastatic Spinal Cord Compression High Level Pathway Known cancer patient (aware of risk) Discharge Coordinator reviews log next working day Cancer patient (unaware of the risk) SPR Review (Newcastle) clinical information with on call Consultant Oncologist Patient contacts Primary Care Log call Admission via A&E or Medical Admissions Unit Consultant Oncologist / SPR on Call (at Centre) Transfer patient to Centre for definitive treatment Ensure MRI completed local / centre Joint Oncology / Surgery patient review Supportive & Palliative Care Record clinical information Ward patient with or without a known cancer Rehab Centre (local unless otherwise agreed) +/- review with patients Oncologist Key worker Discharge EOL Out of Hours Metastatic Spinal Cord Compression High Level Pathway Known cancer patient (aware of risk) Discharge Coordinator reviews log next working day Cancer patient (unaware of the risk) SPR Review (Newcastle) clinical information with on call Consultant Oncologist Patient contacts Primary Care Log call Admission via A&E or Medical Admissions Unit Consultant Oncologist / SPR on Call (at Centre) Transfer patient to Centre for definitive treatment Ensure MRI completed local / centre Joint Oncology / Surgery patient review Supportive & Palliative Care Record clinical information Ward patient with or without a known cancer Rehab Centre (local unless otherwise agreed) +/- review with patients Oncologist Key worker Discharge EOL LOCAL CONTACT DETAILS FOR SPINAL CORD COMPRESSION PATHWAY ?????? SUMMARISE LOCAL INFORMATION