1. A systematic approach to dealing with cancer related emergencies (Acute Oncology) Jackie Tritton Nurse Director Mount Vernon Cancer Network. YALE International Health Care Management Programme July 2011

2. Not sure what to do when you feel ill?

3. Problem The National Chemotherapy Advisory Group report (NCAG 2009) recommends reform in the way urgent care is provided for cancer patients. The current Mount Vernon Cancer Network hub and spoke elective oncology services model is unable to meet the NCAG report recommendations thus resulting in delayed oncology assessment, inappropriate admissions, prolonged length of stays and poor patient experience.

4. OBJECTIVES To establish an integrated Acute Oncology Service (AOS) model within each of the three acute hospital trusts that:  Has implemented the five agreed clinical pathways regardless of the patient’s point of entry into the hospital.  Provides an AOS educational programme for the Acute Medical and Accident & Emergency hospital workforce.  Provides a 24-hour consultant oncologist telephone on-call service for professionals  Has established a flagging system which alerts when known cancer patients are seen in A&E.  Has an established system for early oncology assessment / review (within 24 hours).  Has a defined care pathway for the recognition and management of Metastatic Spinal Cord Compression (MSCC).  Demonstrates an overall reduction in cancer in-patient length of stays.

5. FACTS  In patient (IP) care accounts for around 50% of all cancer expenditure.  IP cancer care accounts for 12% of all acute in-patients stays.  40% of in-patient cancer stays are non- elective admissions.  Typical trust has five emergency cancer admissions a day.

6. Mt Vernon Cancer Network Serves a population of 1.4 million. Covering Herts, Luton and South Beds.  1 Cancer Centre- (Chemotherapy & Radiotherapy-No surgery or A&E.)  3 Cancer Units (Chemotherapy, perform common and specialist designated cancer surgery and four A&E departments )  3 NHS PCT’s.  3 Community Care Services.  9 independent hospice providers.

7. Why…..  No capacity in the oncologists’ work plans.  No clear, defined local care pathways in place  No awareness of access to 24 hour Oncology telephone advice line.  No flagging systems in place.  No network wide treatment protocols.  No training programme for the management of the Acute Oncology patient  Potential destabilisation of the Cancer Centre oncologist workforce ** The NCAG report concludes that the delivery of the service changes required should not require additional resources and that potential cost savings from reducing emergency bed days could fund the service redesign requirements.

8. AOS Implementation Plan. Agreement of common clinical pathways. Consequences of disease. Side effects of treatment. Palliative/ End of Life Care. Suspected Cancer. Non cancer related. Business Planning: QIPP - Quality, Innovation, Prevention & Productivity Agreed network wide service specification. Chemotherapy and AOS service review. Business case to support trusts to invest in AOS, Cost analysis spend to save Structure: Establish a MVCN NAOG Three locality implementation groups Membership Network wide symptom management protocols and training Mapping of current policies – to identify gaps MVCN AOS Train-the-Trainer programme AOS Service Model Proposed AOS triage roles Mapping of medical oncology workforce/capacity Network wide 24 hour advice line..

9. Lessons Learned  Importance of engagement,  Cost benefits vs outcomes.  Model of care - destabilising  Processes not People.  Importance of patient engagement and education  Professional tribalism  Managing external influences and mitigating the risks..

10. EXPECTED OUTCOMES  Reduction in inappropriate admissions.  Proactive rather than reactive management of oncology admissions. RAPPA, can reduce LOS by 25%.  Reduction in length of stay for people admitted with oncology emergencies. Evidence that AOS will reduce emergency beds days by 10%  Greater patient satisfaction

11. However!! There’s no thrill in easy sailing, When the sky is clear and blue. There’s no joy in merely doing Things which anyone can do. But there is some fulfillment That is mighty sweet to take, When you reach a destination, You thought you couldn’t make. Unknown