It may be worth revising management of oncology emergencies and prescribing in palliative care, however the support from seniors and specialist nurses for is excellent.

The home ward is D9, there are often outliers having radioiodine treatment in dedicated rooms on A5. Clinics take place in oncology outpatients. Most consultants’ offices are in the R block (out past the stroke/rehab wards). Handover takes place in the D9 office.

There should be a minimum of two SHOs (ideally 3 or 4) and one ward registrar on the ward on weekdays. There is a duty consultant for the week. There is an on call registrar every 24 hours, who covers referrals during the daytime. Specialist teams also conduct their own ward rounds of their patients on a weekly basis as per the timetable on D9.

There is a 1:8 night on call rota, with lieu days an annual leave spread in the rotation – there is not one long block of annual leave as on other jobs. Nights and weekday evenings are split with haematology, other than Friday evenings when there is separate cover. Oncology weekends on long days are typically 1:6. It usually OK to get weekday study leave, as long as there is minimum cover on the ward or a swap can be arranged.

1. Daily MDT / board round in the doctors’ office on D9 at 8:30 2. Radiology meeting on Tuesday mornings at 8:30in the Berridge room on Level 5 3. Palliative care teaching may occur on Monday lunchtimes depending on the time of year

If there is spare capacity in SHOs it is worth attending outpatient clinics to gain experience, the timetable is in the D9 office – arrange with other SHOs/ward SpR to spend half a day.

There is also a mentoring scheme for SHOs – each is assigned to one consultant and SpR.

• Day starts at 8:30 in the doctors office on D9 with hand-over from the night person
• MDT / paper ward round with consultant, SpR, SHO's, nurses, physios, and OT's after handover, normally lasts until 9:30 - 10:00
• Post take ward round of new patients by consultant, SpR and SHO
• The remaining SHO's starts seeing the ward patients and outliers
• All patients under oncology needs to be seen every day
• At 17:30 you hand over to the evening SHO
• At 20:30 you hand over to the night SHO

Patients may be admitted from:

1) A&E – they may have telephoned the oncology out of hours red phone and been triaged by a sister, in which case they are seen directly by us. In some cases on call you will be asked to telephone patients back where the nurse would like a further opinion. These conversations must be documented on the triage form and on EPIC under encounters.

For patients arriving at A&E with neutropenic sepsis, remember they need antibiotics within one hour (or 30 mins for haematology). These can be prescribed remotely via EPIC if clinically appropriate (ask about penicillin allergy). Any patient who has had chemotherapy within the last 30 days should be considered at risk of neutropenic sepsis. Refer to the oncolnet protocol for antibiotic choices & key investigations.

2) Cancer assessment unit (‘CAU’) during the day - seen by the on call registrar

3) Elective admissions for chemotherapy/radioiodine

4) Clinic

5) Transfers from DGH

There are EPIC smart phrases for oncology admission and oncology discharges – ask the current SHOs to share them with you. ‘.onchist’ gives a summary of their oncology history from clinic.

Be aware that some patients are on oral chemotherapy or take home chemotherapy pumps. These must be discussed with a registrar or consultant at admission. SHOs should not prescribe chemotherapy, do not be caught out by newer oral agents – if in doubt, check.

For patients on chemotherapy, take care to reconcile their ‘take home’ medications for chemo at discharge as these may not be on the inpatient EPIC chart. Check weaning instructions for dexamethasone.

Consultants

Acute take patients on ward - under ward consultant for that week (consultant rotates weekly). For management decisions day-to-day

Patients then get reviewed by specialist oncology teams (each cancer has its own team). Specialist teams will give input regarding further oncological treatment options and when to start/restart chemotherapy.

Handovers

0830 - Morning handover. Often need to chase Haem. 1730 - hand over to evening SHO. Mon-Thurs cross-cover haematology, Friday and weekend have separate Haem & Onc SHOs. 2030 - hand over to night team. One SHO and one on-site Haem SpR. Oncology registrar is off site, but can be called if emergency to come in. Generally, SpRs will escalate to consultant overnight if required. Friday afternoon - handover between ward consultants prior to weekend.

Dr Gregory is the consultant in charge of the rota. In practice, swaps on the rota are generally managed between the SHOs on a reciprocal arrangement. Be mindful when swapping with any of the haematology team to clarify if you will be covering haematology or oncology that day.

The key resource is Oncolnet. This is the intranet for Oncology & Haematology. Contains guidelines for emergency management (e.g. neutropenic sepsis) Also, importantly, this is where you can find trial information. If a patient who is on a trial phones the advice line out of hours, you must refer to the trial protocol. This can often give you signs of toxicity and management options.

British Columbia Cancer Agency website has a useful cancer drug manual to look up common side effects etc when on-call.

The palliative care handbook (copy in D9 office) and the website pallcare.info has useful information on converting opiate doses and preparation of syringe drivers

There are specialist nurses for the different cancers, they are a good point of contact for advice about particular patients management/follow up if the particular consultant/SpR is unavailable.