Dr Tim Cooksley, Acute Physician, The Christie Hospital

1. Integration of Acute Medical and
Acute Oncology Services
Tim Cooksley
Consultant in Acute Medicine, UHSM
and Honorary Consultant, The Christie
@acutemed2

2. Overview
• The development of Acute Medicine
• The delivery of Acute Oncology
• Acute Medicine at a tertiary cancer hospital
• How should the unwell cancer be managed?
• Future Directions

3. “Every system is perfectly designed to
achieve the results it obtains”
• Medicine has 3 key tenets:-
• Understanding disease biology
• Discovering effective therapies
• Ensuring those therapies delivered effectively
• Delivery of medicine has traditionally been
viewed as an art form rather than a science
• Many factors – system determines
performance and need to change its pieces

4. What is Acute Medicine?
• Immediate and early specialist management
of adult patients with acute internal medicine
presentations
• Delivered by specialist team on Acute Medical
Units (AMUs)
• First UK AMUs developed in 1990s
• Model adapted in Ireland, Netherlands,
Australia, Singapore
• Society for Acute Medicine founded in 2000

5. Role of Acute Medicine
• Initial assessment by a competent clinician
• Early review by a senior clinician (Consultant)
• Diagnosis, with early access to diagnostics
• Assessment of physiological stability
• Ability to resuscitate patients
• Care delivered in AMUs with specialist MDT
teams

6. • RCP Acute Medicine task force
recommendations published 2007
• Blueprint for development
of acute medical services
Acute Medical Care

10. R. Conway et al. QJM 2014;107:43-49

11. R. Conway et al. QJM 2014;107:43-49

12. • 15.3% of patients had a history of cancer
• Increased length of stay
• (8.8 vs 7.2 days p<0.01)
• Need for Acute Onc/Acute Med collaboration
to ensure high quality and safe patient care

13. Distribution of cancer patients
presenting to AMUs
Berger et al. Clinical medicine 2013

14. Challenges of acute cancer care
• Cancer increasingly specialized and advances
in therapy treating multi co-morbid patients
• Diagnosis and treatment of emerging toxicities
• Increasingly patients suitable for critical care
admission

15. Presentations related to
systemic anti-cancer
therapy
Presentations related to
radiotherapy
Presentations related
directly to cancer
Neutropenic sepsis
Chemo-induced
nausea/vomiting
Acute kidney injury (AKI)
Electrolyte disturbances
Diarrhoea
Mucositis
Indwelling line infections
Hypersensitivity reactions
Extravasation injuries
Immune-mediated
presentations (colitis,
hypophysitis, dermatitis,
hepatitis, pneumonitis
etc…)
Arrhythmias
Skin reactions
Diarrhoea
Mucositis
Nausea/vomiting
Dehydration/AKI
Stridor/airway
compromise
Pneumonitis
Malignant spinal cord
compression
Seizures
Pleural effusion
Pericardial effusion
Ascites
Lymphoedema
Superior vena cava
obstruction
Bronchial
obstruction/stridor
Lymphangitis
Bowel obstruction
Acute pain
Hypercalcaemia
Tumour lysis syndrome
Carcinoid crisis

16. Acute/Emergency Oncology Delivery
• Many cancer centres in the world but only a
few provide specialized emergency/acute care
• Development of specialist admission units
increasing worldwide
• Hindered by the lack of data on both the
utilization of general EDs for cancer related
care and the impact of emergency cancer
facilities on patient outcomes

17. Standalone Cancer Hospitals
CENTRE FACILITIES/SERVICES ON SITE
HDU ITU Mgmt of
Acute
Leukaemia
Mgmt of
High Grade
Lymphoma
Mgmt of
Refractory/
Relapsed
Lymphoma
Bone
Marrow
Transplants
Specialist
TYA
Facilities
Phase I
Trials
Osteo-
sarcoma &
Ewings
Germ Cell
Tumours
Beatson WoSCC, Glasgow
The Christie Hospital, Manchester
The Royal Marsden Hospital –
Chelsea
Soft Tissue
Only
The Royal Marsden Hospital –
Surrey
Soft Tissue
Only
Barts Cancer Centre, London
Mount Vernon Cancer Centre/
East and North Herts NHS Trust
Only Low
Risk
South West Wales (Singleton)
Cancer Centre, Swansea
Velindre Cancer Centre, Cardiff Certain
Types Only
Clatterbridge Cancer Centre,
Wirral

21. Challenges of Acute Oncology Services
• Service evolved along differing models
dependent on local resources and design
• Logistical and financial problems
• Of the 183 services, only 50% fulfilling
national standards
• Evidence of reduced length of stay and
efficiency savings with AOS

23. The Christie
• Largest cancer hospital in the UK
• Treats approximately 44000 patients a year
• 21 bedded MAU
• Ambulatory unit which can house 6 patients
• 160 Inpatient beds
• 7 Critical Care beds

24. Christie OAU
• Patients admitted through 3 main routes:-
• Hotline
• Inpatient clinics/Chemotherapy
• Emergency referrals from other hospitals

25. Acute Medicine at The Christie
A Consultant led and delivered service
Daily OAU ward round of all patients
Working collaboratively with oncologists
Seeing ward patients with acute and general
medical problems
Developing services
Education of trainee doctors and nurses in
acute medical care

26. Collaborative working
• Cardiology in-reach and ECHO
• Rapid access to ERCP and emergency
endoscopy
• Infectious disease in-reach
• Acute kidney injury
• Supervision and assessment of junior doctors

27. Achievements
• Reduced number of patients admitted to
other hospitals
• Improved patient flow
• Reduction in inpatient mortality
• Increased collaboration with Oncologists
• Closer supervision and training of trainee doctors
• Improved patient pathways/journeys
• Collaboration in research projects
• 1st ward in hospital – “Gold award”

30. Time to first dose IVABx in sepsis
0
50
100
150
200
250
300
350
0-15 15-30 30-45 45-60 Greater than 60
NUmberofPatients
Time from Presentation to Antibiotic (mins)
Time to 1st Dose Intravenous Antibiotics in Patients with Suspected Sepsis post
Chemotherapy
Mattison G et al. Journal of Supportive Care in Cancer, 2016.

31. Future Directions
• Expand service to 7 day working
• Further specialty support
• Develop audit/research in acute cancer care
• Collaboration with international colleagues
• Develop ambulatory services
• Low risk febrile neutropenia
• Enhanced Supportive Care (ESC) II

32. Enhanced Supportive Care II
• ESC promotes better access and earlier
integration to Supportive Care in Oncology
• ESC II – Acute and Supportive Care
Ambulatory Unit
• Fresh and modern approach to cancer care
• First model of its kind in Europe
• Facilitates ambulatory management of low
risk febrile neutropenia

33. • Safe and effective
• Benefits include
• admission avoidance
• reduced risk of nosocomial infections
• cost savings
• possible improved patient experience and satisfaction
• improved access to specialist care
Ambulatory care of low risk febrile
neutropenia

34. • Low risk
• Acceptance by Physician and Patient
• Adequate monitoring – access to Helpline
• Compliance with instructions
• Tolerance of oral regimen
• Only 30% of patients eligible for ambulatory
care received it due to logistical problems
Requirements of Ambulatory service

37. • 54 year old male
• Metastatic melanoma
• Completed 3 cycles of Ipilimumab
• 4 day history of generalized headache,
extreme fatigue and nausea
• Seen 2 days earlier at local University hospital
• CT brain – NAD
• Diagnosed migraine and discharged
Case History

38. • Alert
• BP = 100/60mmHg. Pulse = 90bpm
• Chest clear
• No focal neurology
• BM = 2.1mmols
Examination

39. • Cortisol < 50
• TSH = 0.03
• LH < 1
• FSH < 2
• ACTH = 10
• Prolactin = 150
Pituitary Profile

40. MRI Pituitary

41. Courtesy of Professor V Shannon, MD Anderson, Houston, TX

45. “In what has become a near-weekly ritual, one of us
receives an emotionally laden call about the plight of a
loved one, colleague or acquaintance with cancer who
needs our help to navigate the labyrinth of emergency
care. The patient may receive care at our
comprehensive cancer center but become “stranded” in
an ED outside the often rigid borders between our
center and other healthcare systems….
These exercises often end with the caller’s tremendous
expression of gratitude, thanking us for being “miracle
workers”. However, it shouldn’t take a miracle to
communicate and deliver high quality patient-centered
care in the ED.”

47. MD Anderson Emergency Room
• Largest cancer hospital in the world
• Opened cancer ER in 2010
• 1 Chair and 18 Associate Professors
• Approximately 70 attendances a day

48. “Every system is perfectly designed to
achieve the results it obtains”
• Standalone Cancer Hospitals
• Varying access to services/specialty support on site
• Large University Teaching Hospitals
• Various approaches to deliver acute cancer care
• Small District General Hospitals
• Varying support of Acute Oncology Services
• Is it possible to develop standards that each can
achieve to deliver high quality acute cancer care?

49. Conclusion
• Varying models of delivery of acute cancer
care
• Standalone units for foreseeable future
• Research needed into optimal strategy and
pathways
• Need for Oncology/Acute Medicine and other
Specialty collaboration to ensure safe and high
quality acute cancer care