Download What do primary care need? - The Family Doctor Association

Acute Oncology
Challenges & Solutions
3 useful Actions from today
1. Know the contact details for your local
AO Team and Chemotherapy Triage
2. Get a copy of the Acute Oncology
protocols
3. If in doubt, stop oral anticancer drugs
and call triage
What do primary care need?
Advice line
Access to procedures
Toxicity protocols
Home visits
Recognise emergencies
Early appointments
? Is it cancer pathway
Strategic advice and opinion
The Burden of Cancer
Emergency Cancer & Acute Hospitals
Inpatient care
25% increase, mainly emergency
6 million bed days per year
12% all acute inpatient beds
60% cared for by Gen Med.
50% cancer expenditure
New Cancer Diagnosis
23% new cancers
Present via emergency
pathways
Treatment Complication
60% increase in SACT
New drugs
Cancer Complication
MSCC
Brain Metastases
Service Configuration & Decentralised Care
Central control & delivery
via fixed Oncology OPD
sessions
Local Admission
Lack of
informatio
n
Lack of
expertise
Dislocated
care
unavoidable admission and poor
patient experience
What is Acute Oncology?
A new hospital-based service
recommended in 2009 to provide:
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Additional oncology sessions
(medical/nursing)
Facilitate early specialist review
To support education , pathway development
& protocols
To improve access to cancer information
To improve quality, safety and reduce hospital
length of stay
Acute Oncology Teams
Southport
Neville-Webb
Nurse
delivered
NCH
Ford
Aintree
Ton
Consultant
Oncology
CCC
24hr triage
Admin/office
5 day 9-5
RLUH
Madi
APH
Griffiths
COCH
Abdallah
StHK
Marshall
Generic Roles of AO
where can we help?
AO is currently focussed on inpatient care
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Provide oncology information, prognostication and
ceiling of care
Specific advice on clinical scenarios
Acute oncology treatment guidelines
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Patient and family support
Continuity of care, facilitate follow up and links with
primary oncology team (MDT)
Early discharge
Access to urgent radiotherapy pathways
If in doubt, let us know of admission
Generic Roles of AO
What we can’t do?
Do home visits or admit
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No inpatient beds
But we are developing ambulatory care options
Review every cancer in patient
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We need to prioritise resource
We need to engage primary site key workers
Offer specialist palliative care
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But we work closely with palliative care teams
Always give a straight answer due to MDT care!
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Rare cancers, complex cases, different opinions
Helpful Resources
CCC 24/7 Triage
Primary Care UKONS triage risk
Assessment tool www.macmillan.org
Network protocols:
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www.mccn.nhs.uk
Acute Care Toolkit 7– acute oncology
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www.rcplondon.ac.uk
Acute Oncology Problem solving handbook
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Clinical Publishing
On line learning
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Macmillan learn zone: learnzone.org.uk
Acute Oncology Apps
Acute Oncology Guidelines
TYPE I AO
Emergency Presentation of
New Cancers
New Suspected Cancers
Cancer of Unknown Primary
Mr M, 76 year old male, weight loss, deranged
LFTs, Ultrasound liver suspicious of metastases
CUP presentation is typically liver, bone or
‘stroke syndrome’
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? Is it Cancer ? Where is the Primary ? Which referral
pathway
Poor patient experience
Late presentation and emergency admission
MDT ‘tennis’ and late referral to palliative care
services
Carcinoma Unknown Primary
NICE CG104 - Principles
Every hospital to establish a CUP team –
usually AO driven
Only perform investigations if results affect
treatment decision and the patient is prepared
to accept treatment
Routine tumour markers unhelpful
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Tumour markers lack specificity
Do not ‘hunt’ the primary’
Consider CT chest/abdo/pelvis as first test
Refer or chat to local AO services
St Helen’s & Knowsley NHS Trust
CUP Pathway
LOS reduced
26days -11 days
Raise Awareness
Radiology Alert
GP referral*
Musculoskeletal
Rapid assessment by joint
Oncology/Palliative Care TEAM
Pathway*
Patient Information & Support
Site Specialist
MDT link
investigation based upon PS and
pattern of disease
Early Treatment
Day*
Biopsy
?
Early Discharge
Planning
TYPE II AO
Treatment Complications
Treatment complications
Generic guidance
Account for 40-50% of admissions
Risk of complications is greatest within 3-4 weeks
following Chemotherapy
Determine the drugs/regimen and last treatment date
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Patient held records/alert card
If in doubt - phone triage
High index of suspicion for neutropenic sepsis in all
patients irrespective of fever
STOP all oral/infusional chemo drugs on admission and
seek clarification
Is the patient on a trial? Inform triage
Neutropenic Sepsis
NICE CG 151 (2012)
Life threatening complication of
chemotherapy. Mortality doubled in
2001-10
Uncommon (<5cases per week at
DGH)
Typically occurs 10-14days
Fever, non specific symptoms
NICE guidance published:
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Poor evidence base
offer empiric antibiotics immediately.
1 hour target
MCCN Neutropenic Sepsis
Themes
Time to triage very quick
Majority of patients administered paracetamol
within 1hr (medic not required)
Delay in medical review
Delay in prescribing A/Bs
30% not febrile (at presentation)
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Gastrointestinal symptoms
Unwell, bruising
Cough, collapse, decreased mobility
MCCN NS Guidance
Raise awareness
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Patient information, Alert Card, 24/7 triage,
chemotherapy alert system in development
Key Actions
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Inform triage:
Treat suspected neutropenic sepsis as an
acute medical emergency and offer empirical
antibiotic therapy immediately. Do not wait for
results of full blood count.
Scope for community/paramedic antibiotics?
Other Common Complications
Cardiac (5FU, capecitabine, cisplatin)
 Arrhthymia (QT prolongation)
Oral ‘ibs’ – eg vemurafenib
 Ischaemia (cardiac, stroke, limb)
Diarrhoea (5FU, oral capecitabine, Irinotecan)
 Exclude infection (CDiff), Fluids, loperamide ,
Diabetes
 Steroids, con meds, diet, GI toxicity
IF IN DOUBT: STOP ANTICANCER THERAPY AND CALL
TRIAGE
TYPE III AO
Complications
of
Cancer
Metastatic Spinal Cord Compression
NICE CG75 (2008)
MSCC is an medical emergency
May lead to irreversible
neurological damage damage
Progressive bone pain +/neurological symptoms or signs
Most commonly thoracic
vertebrae
Plain Xrays unhelpful
Patient information and alert cards
Prognosis correlated with
functional reserve – loss of motor
power >48hrs unlikely to recover
Metastatic Spinal Cord Compression Pathway
Progressive spinal pain
MRI whole spine
Allow treatment
within 7 days
*Network
MSCC
coordinator
(Walton)
Is patient
Fit for
Treatment!
?
Progressive spinal pain
And neurological signs
Urgent MRI whole spine
Allow treatment within
24hours
Confirmed MSCC
Admit
Nurse Flat*: NBM
LMWH
Dexamethasone 16mg
Contact Walton
Joint spinal surgeon/oncology opinion
*High risk
patients
provided with
PIS
Other Cancer Complications
Hypercalcaemia
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Myeloma, breast, kidney, lung
Dehydration, confusion, constipation
Associated with poor prognosis
Rehydation + /- bisphosphonates
Brain metastases
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Dexamethasone 16mg 48hrs and review
Review management plan with AO or primary team
SVCO: not an emergency
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Dexamethasone 16mg 48hrs and review
? Stent vs chemotherapy vs radiotherapy
Pulmonary embolus
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LMWT heparin (withhold orals – interactions)
Consider Early discharge (asymptomatic)
What do primary care need?
Advice line
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Ao office each hospital/bleep
CCC triage line 24/7
Toxicity protocols
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Primary care UKONs tool
Acute Oncology – apps/links
Chemotherapy – apps/links
Recognise emergencies
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FN
MSCC
Access to procedures
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BTF
Ascites/pleural
Home visits
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Palliative care
Onco-geriatrics
Early appointments
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Free up capacity and risk adapted
follow up
? Is it cancer pathway
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AO/CUP service
Strategic advice and opinion
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AO on CCG
AO: Next Steps
Develop Admission Avoidance Strategies
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Access to Fast track oncology clinics (more capacity)
Align services with A&E/MAU/GPAU
Increase options for day procedures (drains, biopsy)
Unexpected radiology pathways
Electronic alert systems
Develop a comprehensive triage and helpline for
professionals & linked to palliative care
Improve coordination of cancer care in
community (& provide alternatives to admission)
Provide Out of hours provision