A128
Improving the patient experience and reducing length of stay - a novel approach to managing inpatients presenting with previously undiagnosed cancer
Judy King, Pauline Leonard, Richard Jennings, Celia Ingham-Clark
Whittington Hospital NHS Trust, London, UK
Background
Patients who are diagnosed with cancer as inpatients tend to have a poorer prognosis. They are often subjected to multiple, often unnecessary investigations which can lead to prolonged hospital admissions. The National Chemotherapy Advisory Group report states that All hospitals with emergency departments should establish an acute oncology service to ensure the rapid and appropriate management of patients presenting with previously undiagnosed cancer. With increased MDT working it has become the practice for oncologists to become involved in the patient journey only after an established diagnosis of cancer has been made. Through an audit of local practice we sought to develop a novel inpatient pathway that would improve the patient experience and reduce length of stay for inpatients with previously undiagnosed cancer.
Method
All patients who were diagnosed with cancer at the Whittington Hospital NHS Trust in 2008, where their first point of contact was A&E, were identified via the ACCESS database. A retrospective review of notes was performed for these 54 patients. Surgical presentations of cancer were excluded (n=20), leaving 34 patients for the final analysis. Data was collected on age, gender, primary site of disease, number of investigations/blood tests, time to referral to oncology/palliative care, length of stay and eventual outcome. The results are being used to inform the development of an acute oncology system at our hospital.
Results
The age range of patients was from 41-97 years, with a peak in the 80s. The most common underlying malignancies were of upper GI (53%) and lower GI (25%) origin, followed by adenocarcinoma of unknown primary (9%), lung (6%) and breast cancer (3%). The median number of investigations (ultrasound, CT, MRI, nuclear medicine, biopsy and endoscopy) per patient was 3 (range: 1-9), the median number of blood tests was 42 (range: 6-215) and the median length of stay was 19 days (range: 4-97). The median delay to oncology referral from radiological evidence of cancer was 10 days compared to 1 day from histological evidence of cancer. Only 26% of patients were referred to the inpatient oncology team, whereas 100% were discussed at MDT. 1 patient was referred for surgery with curative intent, 4 were transferred to tertiary referral centres and the remainder were treated palliatively: 1 received endocrine therapy, 3 were offered palliative radiotherapy (10%), 7 were offered palliative chemotherapy (25%), and 12 received best supportive care (40%).
Conclusion
Earlier input from the oncology team, either as a clinical opinion or in an advisory capacity, could have identified patients who may never have been fit enough to benefit from treatments such as chemotherapy or radiotherapy, so saving the patient from unnecessary investigations. As a consequence patients might have been referred more promptly and appropriately to the palliative care team who would be better placed to manage symptom control and address any associated psychological issues. A pilot scheme has been launched for patients with a strong clinical index of suspicion or radiological evidence of (metastatic) cancer, incorporating both a rapid access clinic and guidelines for inpatient review, data from which will be presented at the meeting.
