Eliyaz Ahmed, Macmillan Consultant in Medical Oncology Clatterbridge Cancer Centre NHS foundation Trust

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Delivering Acute Oncology Service Remotely Using Virtual Multidisciplinary Team
Eliyaz Ahmed1, V. Balakrishnan2, Brian Brough2, Theresa Grainger,2 Jackie Readshaw2 & Ben Harris3
1.The Clatterbridge Cancer Centre NHS foundation Trust 2. Nobles Hospital, Isle of Man 3. Hospice, Isle of Man
Background
Provision of an Acute Oncology Service (AOS) is a
key requirement for all acute trusts in the United
Kingdom, aimed at improving the care of cancer
patients through early oncology input. Various AOS
models exist across the United Kingdom, led by a
consultant oncologist or an AO clinical specialist
nurse (CNS), or a combination of the two. Nobles
hospital in Isle of Man serves a population of around
87,000 and majority of patients receive systemic
anticancer therapy locally under the supervision of
visiting oncologists from Clatterbridge Cancer Centre
(CCC). Nobles Hospital has a busy Accident and
Emergency department with 40,000 attendances a
year. There is however currently no AOS at Nobles
hospital and we piloted delivery of AOS remotely
from CCC using virtual MDT. We present here the
model and the results of pilot of remote acute
oncology service (RAOAS).
Aim/Objective
A
B
The Model
The RAOAS MDT model set-up is shown in figure 1.
All unplanned oncology admissions at Nobles hospital
were reported to the MDT coordinator by fax using the
RAOAS referral form. The MDT coordinator collated
the referrals and prepared a list that was e-mailed to
the oncologist at CCC, each day at least 30 minutes
before the meeting. The MDT meetings were held on
week days at lunch time via video or teleconferencing.
The meetings were typically attended by a member of
palliative care team from the Hospice in isle of Man, a
member of the medical team responsible for the care
of the patient at Nobles hospital, CNS from
chemotherapy unit at Nobles Hospital and the MDT
co-coordinator at Nobles. The medical oncologist
visiting Nobles hospital chaired and conducted the
proceedings of the MDT from CCC.
Results
The pilot ran over six month period. A total of 66
patients were discussed over 41 RAOAS MDT
meetings. Cases were presented mostly by trainees
attached to the patients’ named consultant and
occasionally by the Consultants or Associate
Specialists.
a) RAAOS referrals by tumour groups: The
RAOAS referrals covered a wide range of tumour
sites as shown in figure 2.
b) RAOAS referrals by admission type : The
problems/diagnoses covered a wide range of usual
acute oncology presentations as shown in figure
3. Seven (11%) referrals were for miscellaneous
reasons such as vague symptoms, sepsis
unrelated to malignancy or treatment, opioid
toxicity etc.
Limitations of the RAOAS model
3 .How did the RAOAS advice impact on management ?
Earlier discharge (15%), Length of stay (12%), Choice
of investigations (30%),Choice of medication (13%)
and Further referrals (15 %).
4. Did the advice from RAOAS fulfil your referral
expectations?
65 % respondents felt the service met their
expectations either completely or mostly.
5.How would you rate the overall service?
74 % rated the service as good to excellent.
6. Do you think the RAOAS has educational value/benefit
to the non-oncology staff?
Yes (78% ), No (4%)
Feedback from RAOAS service users
Following the completion of the pilot a survey was
conducted among service users. The responses and
selected comments are shown.
1. How did you find the RAOAS format (Video
Conferencing MDT)?
60 % liked the current format, 12 % preferred face-to face
meeting and 12 % favoured direct- patient review by the
oncology team.
2. Was your referral answered in a timely manner?
Majority of users ( 60%) felt felt that the referral was dealt in a
timely manner.
Next Steps: Developing the virtual RAOAS
Conclusions
Contact Information
Based on the results and lessons learnt from the pilot
we have made recommendations for the trust to
develop the AOS locally adopting the virtual MDT
model. We favour AOS model led by (preferably) an
Acute physician with interest in AO or AO CNS with
virtual rounds linked to oncologist at CCC.
The pilot shows that the AOS can be delivered
remotely from the cancer center working along with
the local acute teams. This model with additional
support and modifications can provide a cost-effective
viable alternative to the current models. Based on the
the experience of the current pilot, we propose a
RAOAS model for this hospital led by either a
physician with interest in acute oncology or an AO
CNS with support from oncologists at the cancer
Centre.
To assess the feasibility of a novel pilot project aimed
at providing AOS at Nobles hospital, remotely from
the CCC.
Nobles Hospital
Eliyaz Ahmed
Macmillan Consultant in Medical Oncology
Clatterbridge Cancer Centre NHS foundation NHS Trust
Bebington, CH63 4JY
e.ahmed@nhs.net
the only source of a needed photo or graphic is the Web,
scaling must be applied with caution. Scaling an image more
A member of the admitting team presented the case
highlighting the acute problems and results of any
investigations. After discussion of each case, the
oncologist advised a treatment plan that was recorded
on the RAOAS form. The MDT coordinator filed the
completed RAOAS MDT outcome in the health care
record, and a copy was sent to the patient’s GP and
to the patient’s oncologist and any other appropriate
health care professional involved in the patient’s care.
A survey was conducted among the service users to
asses the quality and benefit of the RAOAS.
Figure 1: The RAOAS virtual MDT model set-up
The uptake of the RAOAS was rather poor initially
and the work load during the pilot was less than
anticipated considering the number of cancer related
unplanned admissions. The uptake from surgical
specialities was almost nil. The oncologist did not
have time allocated in the job plan for RAOAS
sessions during the pilot .Lack of dedicated local AO
staff to oversee day to day functioning of the RAOAS
and the timing of the MDTs might be the factors for
the limited uptake.
12%
15%
11%
3%
26%5%
3%
8%
9%
8%
Lung
Breast
Urology
Skin
GI and HPB
Haematology
Unknown Primary
Gynaecological
Head and Neck and Brain
Sarcoma
27%
21%
41%
11%
Type 1 Type 2 Type 3 Miscellaneous
Figure 2. RAOAS referrals by tumor groups
Figure 3. RAOAS referrals by admission type
Type 1- New cancers, Type, 2 - Complications of cancer treatment and
Type 3 – Complications of malignancy
"I like the current format, but in an ideal world I
would prefer direct patient review by the
Oncology team."
“ RAOAS in the current format is suitable for IOM
due to lack of on-site specialists “
“ I am impressed with the ease of the referral and
much needed timely advice. The Oncologist is also
quite approachable”
"I was very pleased with the oncology service I
received for my two patients yesterday. Both were
young patients with newly diagnosed cancer with
(understandably) anxious families. We were able to
discuss the cases with the oncologist and get a plan
of management. It is a real boost to the acute cancer
services for Nobles."
“ It would be a great shame to stop it."