Trust in collaboration establishes a care unit for patients with cancer requiring complex symptom control, facilitating rapid discharge to their preferred place of care

Outline:

The Oncology Symptom Control Unit at University College London Hospital is an 11 bedded unit led by two palliative care consultants and a palliative clinical nurse specialist, with the aim of managing and reviewing oncology patients whose main issues are symptomatic.

This arose from a review of oncology admissions to UCLH showing 60% of patients who presented had a symptom such as pain, nausea or breathless as their presenting complaint. The challenge has been to meet the needs of these patients in a timely way, jointly optimising their condition with the oncology teams and helping with both communication and advance care decision making.

To meet the needs of these complex patients we have a daily consultant and CNS ward round and robust discharge arrangements. Given the complexity arising in these patients’ medical conditions and in the symptom control management, we have alongside our clinical work developed educational programs for nurses and junior doctors

We collect data on every patient regarding outcomes based on length of stay, symptom control measures, distress, family experience, discharge destination and Electronic Palliative Co-ordination systems. We are working jointly across the trust to share expertise, especially the pain team and have regular governance and safety meetings.

Challenges:

The Oncology Symptom Control Unit developed from a review of patients presenting to the oncology inpatient service at UCLH, where an audit revealed 60% of patients had symptomatic issues as their primary presenting problem.

The complexity of cancer care and advanced symptom control, with difficulties in communication across transition points of care in the community and hospital, led to the novel development of this model.

The Oncology Symptom Control Unit has therefore focussed on these outcomes for improvement:

- Timely senior review by a palliative care consultant (to ensure appropriate key issues, medications and advance care discussion plans have been had).

- Saving money by reducing the length of stay

- Saving money by helping to avoid unnecessary re-admissions

- Novel symptom control methods to enhance the patient experience and improve the quality of life for palliative cancer patients.

- Develop staff skills and experience of complex symptom control in this context, through education and development.

Outcomes:

Timely senior review:

- This has been achieved by having a daily consultant and CNS ward rounds enabling open conversations within 24 hours of admission.

- Documented decisions and plans for discharge. Saving money by reducing the length of stay

- Monitoring median and modal length of stay for our patients and reviewing discharge destination for all patients, showing we are rapidly discharging to their preferred place of care. Saving money by helping to avoid unnecessary re-admissions - We liaise with discharge coordinators, community teams and GPs both through phone, paper and the use of Co-ordinate my care (an electronic palliative care record), to ensure all parties are aware of key conversations and decisions regarding future issues.

Novel symptom control methods

- The use of patient control analgesia for cancer pain and developing protocols to rapidly improve pain for patients.

- Developing pathways and procedures for managing complex pain patients with implantable intrathecal pumps. Develop staff skills and experience of complex symptom control in this context, through education and development

- Regular junior doctor and nursing sessions as well as on the ward teaching in advanced symptom control, which are reviewed and fed back

Spread:

Symptom control or palliative care units are not generally available within most hospital organisations as traditionally such patients were managed either through a liaison team or discharged to a hospice.

We have identified that there are patients who present to hospital where their symptomatic problems are their main issue and a symptom control team taking the lead on their care improves outcomes for the patient.

Our service currently is for oncology patients, those with a solid tumour, however, we feel our approach and model could easily be extended to other cancer groups e.g. haematology of teenage-young adult patients and non-malignant patients.

Our unit’s focus on clear communication and discharge planning has enabled complex patients to be discharged to their preferred place of care effectively, feedback from community teams and hospices has identified outstanding communication and satisfaction from patients and families.

Value:

We are collating evidence at the moment with regards to length of stay, this is showing improved median and modal length of stay for patients admitted our care. This has financial value by ensuring patients are discharged and flow through the service as commissioned.

Patient experience data has demonstrated a positive improvement in patient care, with symptoms and experience measure as being significantly improved following admission to our unit.

Involvement:

The project has been commissioned to achieve the aims as set above following reviews of the presenting complaints and complexity of oncology patients admitted as inpatients at UCLH.

This was reviewed by the oncology directorate who are in support of this model, the ward staff who have seen it as an opportunity to develop their skill mix in palliative medicine and by junior doctors rotating through the unit who gain experience in advance symptom control.

We have collected staff feedback on teaching sessions, all so far are outstanding with people changing shifts so they can attend. Junior doctor feedback has been universally excellent with doctors asking to rotate onto the unit citing the educational benefit and the support they receive.