Consultant physicians working with patients - Royal College of ...

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2 Specialties HaematologyTable 2 A summary of the staffing requirements and facilities for different levels of care as outlined by theBritish Committee for Standards in Haematology (BCSH) 2Levelsof careIntensity and complexityof treatment regimen Medical staffing Nurse staffing Facilities1 Usually outpatient basedwith regimens that areunlikely to result inbone-marrow suppressionConsultants not usuallybased on site but work aspart of a wider network andprovide sessional input;should be 24-hourtelephone access toconsultant adviceDedicated specialist nursesessions provision duringthe working week withprofessional links to level 2or above centreAccess to day care facility;inpatients should beadmitted as part of thegeneral medical admissionprocess2aOutpatient and day-casebased with regimens thatmay result in short,predictable periods ofbone-marrow suppressionConsultants should providecover on a 24-hour/7days-a-week basis; this maybe provided by cross cover;junior medical staff shouldbe available to support carefor inpatientsDedicated specialist nurseprovision during theworking weekAccess to day-case facilitiesthat include facilities forintravenous infusions of along duration; inpatientbeds should be available onone ward designated forhaematology with accessto single rooms withen-suite facilities2bIncludes inpatientregimens that cause apredictable prolongedperiod of bone-marrowsuppression24-hour on-site consultantcover with designatedjunior trainee or non-careergrade staff provided duringthe working week24-hour cover byhaemato-oncology trainednurses with resources toachieve a nurse:patientratio of 1:2 for inpatientsrequiring high dependencynursing, if required; thereshould be on-site dedicatednurse specialists during theweekAs for 2a with additionalprovision for direct accessto a dedicatedhaematology ward3 Includes inpatientregimens that are complexand have a high incidenceof complications; includestreatment for rarehaematologicalmalignanciesAs for level 2b plus 24-hourspecialist middle-grademedical staff cover duringthe weekdays andweekendsAs for 2bAs for 2bPaediatric haematologyA small number of haematologists specialise in childrenwith benign and malignant haematological disorders.3 Working with patients: patient-centredcareInteraction with patientsPatients with any haematological disorder receive adetailed explanation of their disorder (including easilyunderstood written information) and its treatment. Thisis usually provided in conjunction with a haematologyspecialist nurse, and adequate time is allowed for jointdecision making and discussion about the expectedbenefits and toxicities of treatment. Patients should beoffered treatment in a clinical trial when available, andwritten informed consent should be obtained.Involving patients in decisions about theirtreatmentPatient education plays a crucial role in the safemanagement of patients with haematological disordersby enabling patients to recognise symptoms that needurgent self-referral, such as fever and bleeding.C○ Royal College of Physicians 2013 129
Consultant physicians working with patientsMany patients and their carers are taught to administerpart of their treatment at home, including coagulationfactors for inherited bleeding disorders, subcutaneousheparin, iron chelation and home chemotherapy.Patients on OACs may self-test at home, with dosingsupervised by a nurse specialist by telephone.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team workingMultidisciplinary team (MDT) meetings for patientswith haematological malignancies, severe bleedingdisorders, haemoglobinopathies andpregnancy-associated haematological problems areroutine in haematology practice. Laboratory-focusedmeetings with biomedical and clinical scientists alsotake place.Working with other specialtiesHaematologists work in joint clinics with clinicaloncologists, orthopaedic surgeons, obstetricians andpaediatricians depending on the relevant patient groupand may consult physicians from a number ofdisciplines when treating patients with complexhaematological disease. Close liaison with primary carespares many patients hospital visits and allowsmanagement in the community.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality service is dependent on evidence-basedmanagement, appropriate staffing and access toadequate facilities.Specialised facilitiesThe facilities required are dependent on the clinicalservice provided. For hospitals that care for patientswith haematological cancers, facilities should beorganised as set out in the document Improvingoutcomes in haematological cancers. 3 Specialist unitsmay require facilities for therapeutic apheresis andcytopheresis. Hospitals that deliver intrathecalchemotherapy must have a designated clinical area inwhichthisisperformed. 6OutpatientsFacilities should guarantee a rapid turnaround of bloodresults and should have an appropriate environment inwhich to deliver sensitive information to patients andtheir families.Day careHaematology day-care areas are crucial for patientreview and the delivery of blood products, certainchemotherapy regimens and infusional treatments(bisphosphonates, intravenous iron, immunoglobulin,coagulation factors and monoclonal antibodies). Goodday-care facilities greatly relieve pressure on inpatientbeds and are more acceptable to patients.InpatientsThe number of dedicated beds and isolation roomsneeded and the requirement for filtered air and positivepressure rooms depends on the level of inpatient careoffered, particularly the predicted length of neutropeniaand the degree of immunosuppression. Facilities shouldbe appropriate for the age of the patients as outlined byNICE. 7Units that provide a specialist service for patients withinherited bleeding disorders and haemoglobinopathiesshould have adequate day-care facilities for review andtreatment of patients and access to appropriateinpatient facilities.Workforce requirements: clinical and support staffThe haematology team of a district general hospital(DGH) should have the following members. It should include at least three whole-timeequivalent (WTE) consultant haematologists; theseshould work as part of a team that may cover morethan one site. There will be either a nurse consultant or a numberof clinical nurse specialists that may havesubspecialist expertise in areas of blood transfusion,haemoglobinopathies, venous thromboembolicdisease, haemophilia or bone-marrowtransplantation. Outpatient facilities and staffing and inpatientstaffing should be as outlined in Table 2. The service should also include access to apharmacist with a special interest in chemotherapy,a data manager, specialist palliative care, a dieticianand physiotherapists.Service developments to deliver improvedpatient careHaematologists maintain and improve quality of carefor their patients and the laboratory duties for which130 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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