Draft:Ambulatory care (United Kingdom)

In the United Kingdom, Ambulatory Care refers to the hospital-led coordination and delivery of cancer treatment on an outpatient basis that would traditionally require an inpatient stay. Coordinated by a hospital team and with daily visits to a treatment centre, ambulatory care patients stay at home or in accommodation close to the hospital overnight.

Ambulatory Care is a safe alternative to inpatient cancer care. By enabling people undergoing treatment for cancer to continue aspects of their everyday lives, it can support people's autonomy and contribute to a more positive experience.

Definition
In general terms, ambulatory care is medical care provided on an outpatient basis. In the United States, it encompasses a broad scope of clinical specialties and treatments.

In the United Kingdom, Ambulatory Care (AC) is a term that has become synonymous with the cancer specialty. While many National Health Service (NHS) settings have ambulatory care units, these are typically day case surgery or outpatient departments. In the UK cancer clinical setting, Ambulatory Care typically refers to the provision of systemic anti-cancer therapies on an outpatient basis that would have traditionally required an inpatient stay.

Ambulatory Care facilitates the delivery of intravenous therapy and chemotherapy when the cancer protocol involves a continuous or intermittent infusion over several days. Some chemotherapy regimens can be given entirely on an AC basis. Other treatments, for example an allogeneic haematopoietic (stem cell) transplant, can have a pre-determined time when patients are admitted to an inpatient ward.

In Ambulatory Care, patients stay in a residential setting overnight, returning to an AC unit each day for clinical review, infusion change or treatment. Overnight accommodation could be their usual home, a hospital hotel/apartment, or a commercial hotel. When determining suitability for AC, patients need to be clinically stable and able to engage in aspects of self-monitoring, for example recording their body temperature, measuring their urine output and/or keeping a fluid balance chart. Although not a requirement, most patients choose to be accompanied by a family member or friend overnight. Although AC patients receive their daily clinical review and/or treatment in a day care or outpatient setting they are, for all intents and purposes, considered inpatients by their medical and nursing team and require vigilant, pre-emptive care.

History
Ambulatory Cancer care was conceived in the US in the 1980s and reflected a shift towards more individualised, person-centred care. Foremost, however, it mirrored increasing rates of cancer and associated healthcare demand which had begun to challenge inpatient bed capacity, and delivery of on-time cancer treatment.

Technological progress helped pave the way for AC internationally. The development of portable infusion pumps, haematopoietic growth factors and better antiemetics (anti-nausea medication) contributed to the feasibility of Ambulatory Care of people with cancer. By the 1990s in the US, significant progress had been made in transitioning inpatient cancer treatment to ambulatory pathways.

In the UK, the development of Ambulatory Care was influenced by the concepts of self-care, where people with illness are seen as active partners. Whereas in the US, AC's development was driven by cost savings and fiscal benefits, it was the opportunity to increase NHS cancer treatment capacity together with the potential for enhanced patient experience that provided the impetus for AC in the UK. Here, the first NHS Ambulatory Care service was modelled on USA cancer services, especially the practice at Memorial Sloan Kettering Cancer Center (MSKCC) in New York. A field visit to MSKCC by a team from University College London Hospitals NHS Foundation Trust in the early 2000s, led to their initial piloting of AC in 2003 with the administration of high-dose methotrexate. The team also ran a pilot exploring adult patients’ experience of receiving a BEAM (carmustine, etoposide, cytarabine, melphalan) haematopoietic stem cell transplant on an ambulatory basis at UCLH. Between 2005 and 2011, an additional 1443 adults with cancer were treated via Ambulatory Care. Adult Ambulatory Care is now a mainstay of the UCLH NHS Foundation Trust's cancer services.

Other NHS cancer treatment centres have since developed adult cancer AC services, notably at the Leeds Teaching Hospitals NHS Trust, the Sheffield Teaching Hospitals NHS Foundation Trust and The Christie NHS Foundation Trust. In young people's cancer services, the first NHS Teenage and Young Adult AC service was established in 2012 at UCLH, to coincide with the opening of its UCH Macmillan Cancer Centre.

With growing interest and an emerging evidence base reporting how the pathway positively contributes to young people's experiences of cancer treatment, in autumn 2022 a national Special Interest Group hosted by the Children's Cancer and Leukaemia Group (CCLG) in collaboration with Teenage and Young Adult Cancer (TYAC) was formed, bringing together healthcare professionals committed to the development of children and young people's AC in across the UK.

Nursing in Ambulatory Care
Ambulatory Care is a nurse-led service. The nursing team based in AC is integral to the development and running of the AC services. Nursing teams within AC are responsible for patient clinical care, patient education as well as service management and development. Experienced nurses lead in assessing patient suitability to ambulate, closely monitor symptoms and toxicities from treatments, and are the patient's main point of contact throughout their stay.

As many aspects of monitoring are managed by a patient in AC (often together with their carer), education is delivered by nurses to ensure safe and effective care. Education typically covers the treatment protocol, supportive care, self-monitoring, potential toxicities to be aware of, medication administration, management and troubleshooting of Computerised Ambulatory Delivery Devices (CADD pumps). Following education, both patient and nurse sign a contract agreeing to the conditions of the AC stay.

Local operational processes and procedures vary between centres, but all need to be robust and clear. Senior AC nurses draw on their knowledge and expertise, playing a key role in service development and care pathway improvement.

Safety
The safety of Ambulatory Care has been demonstrated within different international settings from the perspective of not having increased mortality, infection or toxicities, building confidence in the safety and feasibility of the service. Responsibility for safety is seen as shared in AC between the patient and the healthcare team, together with an accompanying family member or friend.

A clinical safety net is now understood to be key in assuring both clinical safety and confidence in AC. This includes a 24-hour telephone advice line; staying in proximity to the hospital; ensuring access to the full complement of the multi-disciplinary team; and appropriate patient education to confidently engage in self-monitoring and self-surveillance.

Patient experience
Ambulatory Care is widely understood to contribute positively to people's experiences of cancer treatment. This derives from people of all ages being able to make and exercise choices about how time is passed; experience freedom from the hospital environment; feel empowered and independent.

Within young people's services, AC supports the delivery of age-appropriate care. This is enabled by a greater opportunity to offer individualised, person-centred care through AC, in comparison with inpatient care. Ambulatory Care helps retain aspects of life that are important to young people; anchoring them in aspects of their usual life and relationships.