Background to the acute medical unit
Acute medicine is concerned with the immediate and early specialist management of adults presenting with a range of medical conditions. The acute medical unit (AMU) acts as a 24/7 hub for all emergency medical admissions to hospital and provides a gateway to medical specialties, including oncology.1 These unselected emergency admissions often include patients with known cancer presenting as a result of their underlying disease and/or treatment, as well as patients with suspected cancer. Unexpected admission to hospital of oncology patients is recognized to result in a longer stay and a poorer patient experience.2 Providing efficient and excellent care to this complex patient group in a busy AMU presents a challenge.
Acute oncological emergencies encountered in the AMU include those relating to complications of systemic anticancer therapy, such as neutropenic fever and immune-related toxicities, and those due to radiotherapy or the cancer itself, including metastatic spinal cord compression and hypercalcaemia of malignancy. Many patients with cancer also present with other non-cancer-related medical emergencies.
As a specialty still in its infancy, acute medicine faces many challenges associated with developing new ways of working. Acute medicine is working to ensure that the infrastructure is in place for future innovative, high-quality, collaborative and adaptive acute medical care that meets the needs of patients. The same priorities have driven the growth of acute oncology and the need for integrative working.
Challenges faced in managing oncology patients in the AMU
The lack of experience of general physicians in managing oncological treatments and their side effects, coupled with limited access to oncologists and poor communication between oncologists and admitting teams, are recognized barriers to optimal management of oncology inpatients.3
Patients with known cancer may be able to give only limited information about their disease, prognosis and treatment. They might have been previously managed elsewhere, with the result that more detailed information is not readily available to the AMU physicians when critical decisions need to be made. These factors may discourage AMU physicians from having important discussions on prognosis, resuscitation and preferred place of care.
Furthermore, the AMU is a busy ward with a high turnover of patients. Physicians may find it difficult to attend to the needs of oncology patients. Some patients may present with true oncological emergencies and require acute resuscitation and close monitoring, while others may need their complex diagnoses explaining or their medicines carefully titrating according to their symptoms.
Adapting the AMU for oncology patients
The development of the acute oncology service in 2009 was a major turning point in tackling the above issues.4 The service supports the admitting medical team in the care of unplanned admissions resulting from symptoms arising from known cancer (50%), cancer treatment (30%) (Table 4.1) and new undiagnosed cancer (20%).5 Acute oncology service ...