Excellent Practices

Acute Oncology – Acute Assessment Unit and Acute Emergency Ambulatory Cancer Care

Practice Category: Treatment

Centre: The Christie NHS Foundation Trust

Tim Cooksley

Consultant in Acute Medicine

tim.cooksley@nhs.net

Challenge addressed by the practice

Emergency care systems around the world frequently experience capacity, resource, and staffing constraints. This is epitomised in NHS urgent and emergency care (UEC) settings. Emergency Department overcrowding can lead to worse patient outcomes due to delays in therapy. Cancer patients seeking emergency care can be vulnerable in this setting and timely delivery of care is often aspirational rather than reality in many acute care systems.

The increased range of cancer therapies, such as immune checkpoint inhibitors, indications for their use and delivery in an increasingly co-morbid population means that acute cancer complications will continue to place a growing and significant burden on emergency and inpatient hospital services. This requires novel and innovative models of acute cancer delivery to facilitate safe and sustainable care.

Solution

Acute medicine is at the heart of finding opportunities to mitigate the current crisis and deliver future innovative, adaptive, high-quality, and sustainable urgent and emergency care. The fundamental components of the specialty—well-functioning, evidence-driven Acute Medical Units (AMUs) and Ambulatory Emergency Care—alongside enhanced care areas are essential for high-quality emergency care.

Ambulatory care delivers acute care to patients without the need for an inpatient bed. Its implementation is founded on the evidence that patients presenting with acute illnesses can be stratified as low risk for developing complications and therefore do not require traditional inpatient care. This schema can logically be extended to the emergency oncology setting. Ambulatory outpatient management of low-risk febrile neutropenia using the MASCC score exemplifies this approach. The Christie has developed an acute medical model with an AAU and AACU to adopt this approach to acute cancer care.

Impact

AAU and AACU services have delivered nationally and internationally leading personalised acute cancer care. The units are managing 70–100 acute cancer patients a day, reducing pressure on local EDs and meaning many cancer patients avoid the indignity and harm of corridor care.

The expertise of the model has facilitated improved outcomes in acute cancer presentations, particularly life-threatening toxicities such as immune checkpoint inhibitor-related myasthenia gravis and overlap syndrome, and haemophagocytic lymphohistiocytosis (HLH).

The service has already led the delivery and development of several acute ambulatory cancer pathways including immune checkpoint inhibitor related hypophysitis and hepatitis, platinum related acute kidney injury, incidental pulmonary embolism and led national work on low febrile neutropenia based on The Christie pathway. More nuanced risk stratification of currently perceived high-risk toxicities has afforded the opportunity to personalise acute management.

Acute cancer and toxicity research is widely published through the unit. These innovative approaches are increasingly used as national and international exemplar models.

Critical success factors

  • An organisational passion for the delivery of high-quality acute cancer care.
  • Centralisation of acute cancer care has facilitated the knowledge and expertise to develop novel models, enabled greater skills and knowledge in the management of toxicities, and translated that to the daily delivery of high-quality acute care for patients.
  • Adopting the principles of acute medicine to acute cancer care through the models of the AAU and AACU.
  • Training and developing a highly skilled acute oncology workforce, including acute oncology nurse practitioners, pharmacists, physiotherapists, occupational therapists, dieticians, nurses, and doctors.
  • Using quality improvement and research to drive innovative models to deliver acute cancer care.
  • Collaborative working with oncology and specialty colleagues.
  • Multiple peer-reviewed publications, poster presentations and invited lectures to showcase achievements and facilitate further innovation and learning to develop services.

Next steps

  • As cancer therapies continue to evolve, the service will continue to innovate to deliver modern and novel models for the management of their toxicities to ensure continued improved outcomes.
  • Continue to lead and participate in acute cancer research work to drive both acute cancer outcomes and personalised toxicity management.
  • Begin delivering acute cancer care in the patient’s home, utilising digital technologies and patient-reported measures, supported by diagnostic interventions at the bedside, with point-of-care intravenous treatments and blood tests, and point-of-care ultrasound with administration of intravenous therapies. This will also offer the opportunity to integrate with palliative and supportive care at home when required.