New approaches to acute oncology must build upon the experience of acute medicine
The challenge in providing a responsive service which meets the needs of acutely unwell patients admitted to hospital has been well studied within the arena of acute medicine. This chapter focuses on the key elements in acute hospital-based care in terms of facilities, policies, and how an acute oncology service (AOS) may complement pre-existing services to the benefit of patients.
Facilities: Background to the development of the acute medical unit
Traditionally, patients with a suspected medical illness requiring urgent hospital assessment would be directed to the ward of the general physician on call. They would expect to be cared for, regardless of medical condition, until their discharge or other outcome. However, over the past 25 years there has been considerable development in acute care in response to a variety of factors. These include an inexorable increase in acute admissions. Indeed emergency admissions via the emergency department (ED) or from primary care grew more rapidly in the UK than waiting list elective admissions between 2000 and 2001.1 Coincident with rising admissions is the reduction of the acute hospital bed base by approximately a third over the past 25 years in the UK. Furthermore, patients themselves are becoming older, with increasingly complex and multiple comorbidities. Patients aged 85 years and over accounted for 4.8% of first attendances to English EDs in 2008/9, 62% of which were admitted.2 Indeed, persons aged 85 years and above are almost 10 times more likely to be admitted to hospital than those aged 20–40 years.2 Consequently, there have been changes in both the design and location of receiving facilities, and in the staffing skill mix and training for those working at the 'sharp end' to meet these challenges.
Patients admitted on the unselected medical take will include those with known or suspected cancer. Currently, these patients are often managed initially by staff whose primary area of expertise is not oncology. Hence, opportunity exists in which an AOS can work either alongside or within the acute medical service with defined care pathways to improve outcomes and patient satisfaction.
The Royal College of Physicians (RCP) began to address the challenge of acute medical care provision in 2000 with their report, Acute Medicine: the physician's role.3 This encouraged the development of acute medical units (AMU) to focus admissions within a specific receiving area. This allowed the evolution of new models of consultant-led care delivery, development of nursing roles, and the establishment of professions with expertise working at the interface between community and hospital care. It is easy to see that, by applying improved care pathways in this area, patients can be directed to see 'the right person, in the right setting - first time', which was the title of the subsequent RCP report in 2007.4 Therein, the vision for the ...