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What does the development of acute oncology services mean for you? Acute oncology services are to be put in place in all trusts in England that have an A&E department. Anne Hines examines the implications of this development for pharmacy staff For those who practise it, acute oncology seems a normal part of care for cancer patients. But for most others, acute oncology is a new therapeutic area that will bring the care of oncology patients in England into the heart of local clinical and pharmacy services. Acute oncology can be defined as the care of acutely ill cancer patients, including those who: • Become ill due to side effects of current or recently completed systemic anticancer therapy (SACT) – usually chemotherapy or radiotherapy • Are admitted to hospital with an oncologic emergency who may or may not be undergoing SACT • Are admitted with an oncologic emergency but who do not yet have a diagnosis of cancer (i.e. termed ‘unknown primary’ patients). All of these types of patients will be treated by acute oncology teams but those who are in the first of these bullet points are the most likely to impact immediately on local pharmacy services. The National Chemotherapy Advisory Group in their ‘Chemotherapy services in England: ensuring quality and safety’ report recommends that all NHS trusts with an A&E department should have acute oncology services (AOS) even if the trust does not host or offer its own chemotherapy service. The effect of this will be to bring the care of acutely ill cancer patients who may previously have been directed to cancer centres into local hospital wards. It is important to note that NCAG does not envisage that acute oncology teams will have their own beds so patients will remain under the care of the admitting consultant, rather like the current arrangements for palliative care patients. NCAG suggests that an acute oncology team should consist of two 0.5 working time equivalent specialist nurses working opposite each other and a minimum of two 0.5wte oncologists contributing 1 programmed activity of acute oncology per day between them. AOTs will be expected to liaise with A&E services, haematology services, and palliative care teams. Office and secretarial support is suggested but there is no specific mention of any designated pharmacy staff support. Pharmacy implications Despite the lack of specific mention in the NCAG report regarding pharmacy staff time, it is clear that acute oncology will have an impact on pharmacy team members. The extent of this will depend on, for example, how much interaction pharmacists currently have with oncology patients. Policies and procedures Pharmacists must make sure they are involved with any new policies or procedures that acute oncology may bring. It is essential that policies (e.g. for neutropenic sepsis) fit existing trust pathways, are merged with any existing haematology policy, and are written in conjunction with A&E departments. The NCAG report requires trusts to meet a 1h ‘door to needle or door to swallow’ time for antibiotics to be given to patients acutely ill with neutropenic sepsis. This will necessitate major changes for pharmacy staff in some hospitals. Formularies New acute oncology teams are likely to consist of staff who have been based previously at a cancer centre and so are likely to be familiar with the centre’s formulary. This may differ markedly from the formulary at the institution in which they now provide AOS in, for example, the choice of which low molecular weight heparins or antibiotics to use, or choice of growth factor support. Prescribing for acute oncology patients must fit local trust guidelines and, if the local guidelines are not sufficient, then they must be revised to fit with the care of acute oncology patients. BOPA Bulletin Issue 1 Summer 2010
Out of hours arrangements and triage Again the impact on pharmacy on call services will differ depending on the exposure of local pharmacy departments to oncology services. For example, within the Merseyside and Cheshire Cancer Network (MCCN), the cancer centre has always operated a single centralised 24h help line and a triage service back to the centre. This has the advantage of simplicity with little chance of confusion. However, the disadvantage is that the staff at the centre dealing with the call may not have access to clinical information, particularly if a patient has been treated at a cancer unit. Acute oncology shifts the emphasis of triage and treatment away from the centre back towards the cancer unit. Centralised triage services and help lines are not incompatible with acute oncology but extra care is needed to be sure that patients know exactly who to contact and when. Likewise, local pharmacy on call services may be asked to deal with chemotherapy related queries that previously would have been directed to the cancer centre pharmacy. Education and training It goes without saying that successful implementation of AOS locally must be underpinned by good education and training of all concerned. All pharmacists who might come into contact with oncology patients need to have a thorough understanding of polices and procedures as well as the fundamentals of caring for patients with neutropenic sepsis. Pharmacy departments should make use of the skills of haematology pharmacists to provide education and training in basic patient management. Also, cancer centres should consider using their expertise in treating acute oncology patients to educate and train other local pharmacy staff. Communication Good communication is absolutely essential and is the backbone of any AOS. All acute oncology patients admitted to hospital (during Monday to Friday) should be seen by an oncologist within 24h – this time frame applies if possible for those admitted over a weekend. An oncologist should be available ‘24/7’ over the telephone and all patients should be referred to the acute oncology team within 24h of an admission. A trust or cancer centre that admits cancer patients but does not have facilities for acute medical or surgical services must have pathways in place to ensure that patients have 24h access to emergency assessment. To manage these pathways successfully, particularly with regard to medicines’ policies, will require good links between cancer units and cancer centres and especially between staff in their respective pharmacy departments. Acute oncology sprang into existence with the publication of the ‘National confidential enquiry into patient outcome and death report: for better or for worse’ (NCEPOD), which reviewed the care of patients who died within 30 days of receiving a last dose of systemic anticancer therapy (SACT). The enquiry found examples of good practice but, overall, was critical of the care that acutely ill cancer patients received when they were admitted to hospital, particularly where patients were admitted to a different hospital from that where they had received their chemotherapy. Reported problems included a lack of access to clinical notes, poor understanding of the need for urgency in treating patients with Helen Clark, chief pharmacist at Clatterbridge Centre for Oncology (CCO) explains that one of their first initiatives regarding acute oncology was to organise a network-wide chief pharmacists’ briefing meeting. This highlighted the need to: • Perform an audit of ‘long stay’ high dependency acute oncology patients • Establish the means to identify acute oncology patients upon admission • Understand current patient pathways and information flow between, centres and cancer units Lead Article Background to acute oncology services neutropenic sepsis and little or no timely communication between the team treating acutely ill patients and the team responsible for the SACT. NCAG responded with its ‘Chemotherapy services in England: ensuring quality and safety’ report (more commonly known as the ‘NCAG report’), released the same day as NCEPOD. This report is on a similar footing to ‘NICE improving outcomes guidance’ and makes recommendations for improving the quality and safety of chemotherapy services across the board. A major part of the report introduces the concept of acute oncology and lays out how cancer networks may achieve such services. A view from a district general hospital Marie Brazil, consultant haematology pharmacist at Wirral University Teaching Hospital NHS Foundation Trust, welcomes the advent of acute oncology because it gives teams within district general hospitals a great opportunity to work in partnership with cancer centres. “As part of a haematology team providing a chemotherapy service within a district general hospital only five miles from a cancer centre, we are used to acute admissions of cancer patients with complications of SACT or with concomitant diseases. The admission of such patients has previously been complicated at times by a lack of communication in both directions but having an acute oncology team in place can only serve to improve this situation. The NCAG report has given us direction and has allowed us to galvanise the support of acute physicians and our microbiology colleagues to produce a pathway to address ‘door to treatment’ time in neutropenic sepsis patients. We hope these improvements will only be enhanced by the involvement of our oncology colleagues once our oncology team is up and running.” A view from a cancer centre • Employ pharmacy expertise from the cancer centre to educate and train colleagues in local hospitals about chemotherapy and to support the development of acute oncology • Ensure that local hospital and cancer centre protocols for managing acute oncology patients are consistent. Indeed, CCO have now appointed a new teacher practitioner, in conjunction with Liverpool John Moores University, to encourage best practice and support local audit of current practice within the MCCN’s pharmacy departments. BOPA Bulletin Issue 1 Summer 2010 9
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