Welcome to The 4 th Annual Chemotherapy Conference Friday 18th March , Foresight Centre, Liverpool

1. 2011 Welcome to The 4th Annual Chemotherapy Conference Friday 18th March , Foresight Centre, Liverpool A Conference Hosted by Merseyside and Cheshire Cancer Network Sponsored by: Amgen, Astra Zeneca, Bristol-Myers Squib, Celgene, GlaxoSmithKline, Janssen-Cilag, Lilly, Napp, Novartis, Shire

2. Merseyside & Merseyside Cancer Network Acute Oncology Update 2011 Ernie Marshall Macmillan Consultant in Medical Oncology

3. The Cancer Journey Significant progress in elective cancer care Diagnosis Treatment Follow up New Cancers (UKP) 23% Complications of Cancer Complications of treatment • Lack of focus on emergency Inpatient Care: Prolonged stay, poorly coordinated, poor pt experience • Inpt cancer care ~12% acute inpt beds, • Admissions up 25% in 8yrs, • 40% inpatient cancer is emergency, • 60% managed by GIM • 60% chemotherapy 2002-06

4. Aspects of AO Transforming Inpatient Care www.improvement.nhs/cancer Management of inpatients Aim is to incorporate oncology input early in the inpatient journey rather than near the end New cancers (UKP) – not on established pathway Complications of chemo (radiotherapy) Complications of cancer (recurrence)

5. Chemotherapy Services in England: Ensuring quality and safety: NCAG Aug 2009 • Key Recommendations: • Chemotherapy pathway measures • Acute Oncology: All hospitals with emergency depts should establish AO Teams • MCCN Recommendation (Oct 2009) • 12month funding pump primed via CQUIN with cash releasing efficiency in 2011/12 • Aim to recruit AO team 01/04/10 • (NCAG- Aim for AOTs by 2011)

6. Estimated savings from AOT Cost per AO team 131K =915K across network

7. AO Peer Review 2011 • SA to be completed August 2011 Key Measures for Network, CCO and Units • Establishment of • AO Teams • Patient Flagging system (Alerts) • 24/7 Advice Line and Consultant Oncology On-Call • Pathways, protocols, training • MSCC pathway • Acute Oncology Fast Track Clinics • FN: 1hr target (‘door to needle time’)

8. MCCN AO Teams 6 Medical Oncologists appointed at CCO 2010/11 Major job plan review completed (>15 consultants) 5 sessions Oncology 1 wte CNS Admin Support (office) Established in: RLUH(3) Aintree (3) STHK (2) S&O (2) APH (2) Pathways Protocols Awareness MDTs Audit Minimum dataset 5 sessions Oncology released for: NCH (3) COCH (1)

9. Network AO Structure Network AO Group (NSO CNG) CUP CNG CCO ‘TSG’ CCO CUP TSG RLUH Aintree APH STHK S&O NCH COCH AO Team Steering Grp

10. Flagging System: Alerts New Chemo Episode Hospital PAS Admission A&E attendance Email alert to CNS Early review Or FU StHK: Well established (1/3 of referrals) roll out to Haem, palliative care, trials APH: rolling out via CCO Data Warehouse Network solution: central alert system linked to CCO IM& T strategy (TPoulter)

11. MCCN AO Activity Median LOS by type Type I (new cancer) =14days Type II (treatment complication) = 4days Type III (cancer complication) = 6days Estimated numbers per year: StHK 536 ( vs 359NatCatSat)

12. Referral and Review NCAG: Hospitals should aim to provide expert Oncological assessment within 24hours at least 5 days per week

13. 2011 Challenges • Peer Review • Alerts: optimise efficiency and develop local IT solution for all AO patients • 24/7 Triage: definition, funding, links to CCO Oncology on call • Protocols (overlap with Triage/Pall Care) • Clinic capacity (‘fast track’) • Registration: ownership and funding • Outcome measures: ?LOS, resource use, quality measures • Funding: 1year funding to be replaced by efficiency savings

14. Febrile Neutropenia • Key aspect of NCAG and NCEPOD Reports • Evidence for Fragmented care and delayed antibiotics despite FN protocols • 24 hour triage • FN pathway, • 1 hour door to needle time • No defined code for FN -

15. CCO Triage for Suspected FNAudit findings ( Ford, 2009) • 3 month Triage calls (164 calls) • 73 attended CCO: majority low risk • 66 ‘other’: hospital, GP, community nurse • 50% of cases not neutropenic • Average Time from triage call to arrival 4 hours (range - 13hours) • Low risk LOS = 2.7days, High risk LOS = 7days • Examples of dislocated care at DGH

16. DGH: Case I • Cancer Centre Triage call 16.30 • Advised to attend local A&E 18.30 • ‘Low risk’ : • CCO informed and advice sought • Patient commenced oral antibiotics at 22.00 • On call pharmacy input with switch to Imipenem and G-CSF • Patient continued capecitabine further 24hrs • Hospital LOS : 9days

17. MCCN FN Audit • Methods • 3 month retrospective audit (feb-Apr10) • Weaknesses: Data incomplete, retrospective • 97 Patient episodes (91pts ) • 67 Oncology; 32 Haematology • 5 Trusts • Aintree (20) • CCO (39) • COCH (17) • Southport (7) • St H&K (14)

18. Summary I • Multiple routes of admission • 48% admitted via A&E. (55-85% for units) • 60% via Triage (except CCO) • Median Neutrophil count = 0.3 • MEWS = 87.6% (44/85= 0-2) • MASCC= 12.4%

19. Summary II • Time to Abs: • 0-1hr -23%, • 0-2hr 45% • 0-4hr 60% • Median inpatient stay = 6days (1-43) • Haem :Acute Leuk=12d, others=8d • Solid : 5days • Intravenous Ab = 6d, oral Ab (24) = 4d • Deaths =9 (10%)

20. Next Steps • Small numbers and patchy data • Requires more analysis • Multiple pathways but A&E critical • 1hr target not achieved (not realistic?) • Scope for risk stratification ? • 10% Mortality – relate to risk • Need for prospective audit • (capecitabine toxicity)

21. Conclusions • AO evolving rapidly across MCCN • Evidence for Increasing activity and awareness • Evidence for speedy review • Improved communication • Reduce admission rate ? • Yes but difficult to quantify • Reduce LOS ? • Probably, but little impact on hospital bed base • Improve quality and safety ? • Yes, intuitively but needs Qualitative R&D, • AO ‘major benefit’ 50% cases (St H&K) • Save Money ? • Not easily realised but good value ?

22. National Cancer Peer Review Programme Millie Forde – Assistant Quality Manager - North Zone

23. Aims of Today

24. The New Healthcare Environment

26. What is Cancer Peer Review? • A quality assurance process for cancer services • An integral part of Improving Outcomes – A Strategy for Cancer • Assesses compliance against IOG for NHS patients in England • A driver for service development and quality improvement • Supported by a set of measures

27. Measures Development • Developed by an expert group • Aimed to measure areas detailed in the national documentation e.g. NICE Improving Outcomes Guidance and national reports such as NCAG and NRAG reports. • Three month consultation on new measures

28. New Measures

29. Aims of Cancer Peer Review

30. The Peer Review Programme

31. The National Schedule

32. Outcomes of Peer Review

33. The Process

34. Self Assessment Report

35. Self Assessment Report – Key Themes

36. Self Assessment Report • Will be a public document • Will form basis of Annual Peer Review Report for those teams not subject to internal validation • Handbook contains guidance on identifying Immediate Risks, Serious Concerns and Concerns

37. Chemotherapy Service- Evidence Documents (only required every other year)

38. Demonstrating Agreement • Where agreement to guidelines and policies is required there should be a statement on the front cover of the document indicating the groups and individuals that have agreed the document and the date of agreement. • Evidence Guides will indicate the groups and individuals that need to be documented as agreeing the key evidence documents.

39. Evidence Guides

40. Internal Validation – the purpose

41. Who is responsible for internal validation?

42. Internal Validation – what we expect

43. Internal Validation – suggested approaches

44. Internal Validation – the process

45. The Internal Validation Report • Will be a public document • Will form basis of Annual Peer Review Report for those teams not subject to external review • Handbook contains guidance on identifying Immediate Risks, Serious Concerns and Concerns

46. Using CQuINS V4 Available via the web site at: www.cquins.nhs.uk Secure web based database supporting each stage of the cancer peer review process Records assessments, compliance with the measures and reports Provides information for national analysis and reporting

47. Completing the Self Assessment • Upload Key Documents - (Alternate years only) • Enter Compliance on CQuINS • Complete Team Report

48. Completing the Self Assessment 1 2

49. 1 Upload Key Documents 1 2 3

50. Enter Compliance