Evolving Pathways
of Care
Nicola Glover, Project Manager LCA
Jan Morrison, Macmillan Lead Cancer Nurse
Survivorship- a definition
– “…cover[ing] the physical, psychosocial and economic issues of cancer, from diagnosis
until end of life. It focuses on the health and life of a person with cancer beyond the
diagnosis and treatment phases. Survivorship includes issues related to the ability to get
health care and follow-up treatment, late
effects of treatment, second cancer and quality of life. Family members, friends and
caregivers are also part of the survivorship experience.”
The National Picture
– Cancer Reform Strategy – 2 million reasons
– NCSI vision Document
– Improving outcomes: a strategy for cancer – NCSI Next steps
– IoG; Improving supportive and palliative care – NCAT rehabilitation pathways and workforce
mapping tool
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The National Picture
– Cancer Reform Strategy – 2 million reasons
– NCSI vision Document
– Improving outcomes: a strategy for cancer – NCSI Next steps
– IoG; Improving supportive and palliative care – NCAT rehabilitation pathways and workforce
mapping tool
NCSI Next steps
1. Support through primary treatment from the point of diagnosis
2. Promoting recovery 3. Sustaining recovery
4. Reducing the burden of consequences of treatment
5. Supporting patients with active and advanced disease – interfacing with end of life care
services
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Survivorship Group Fourm
Model of Care recommendations
– Reduce bed days – ERAS
“experience optimal pre- and post-op rehab” “a more integrated rehab approach”
“self-management programmes” “effective discharge planning”
“Pts should know what to expect [after]” “Informed about possible S&S , who to contact and clear access routes back” – AOS Services
London Cancer Alliance Survivorship Group Fourm
MoC (cont’)
– Follow up
“where clinical guidance exists that covers the follow-up care of cancer patients…this must be adhered to. There is no evidence that traditional follow-up…always provides the most effective care.”
“people are living longer…more survive… more people experience long-term side
effects…traditional follow-up services should be reviewed…and…replaced…based on…
Survivorship Group Fourm
MoC (cont’)
– Care plan
“level of risk assessed…Individual care plan then drawn up addressing the whole range of needs…with the aim of minimising the risks and supporting the patient to mange ongoing conditions.”
– NICE Supportive and Palliative Care IoG – National rehab pathways
– Rehab should be integrated
London Cancer Alliance Survivorship Group Fourm
Cross-cutting Issues
– Patient Experience – Palliative Care – Rehabilitation – User Involvement – Work force – EducationSurvivorship Group Fourm
Achievements (2012)and priorities (2013)
for the LCA Survivorship Group
– HNA (and care plan)
– Treatment summary (TS) – Metrics
– Set-up of under-pinning groups – Visiting
– Mapping of survivorship services
– Research and service redesign strategy – Consequences of cancer treatment
23 Hour discharge
– For breast surgical patients, the terminology adopted is ‘23 hour stay’. However this means different things – ranging from day case
surgery to admission in the morning of one
day and discharge sometime the following day. – There is no consensus on an LCA definition yet – Exclusion criteria are accepted as being those
having breast reconstruction
– Purpose of the audit was to determine if there are similar ways this is being implemented
23 hour discharge audit tool
– Excel spreadsheet completed by one of the breast care nurses (BCN) from each Trust – Data validated at LCA BCN meeting
– Questions included: – Date of implementation – Exclusions criteria
– Where 24 hour support is accessed
– Does the patient go home with drains?
– When and who provides the temporary prostheses – When and who does lymphoedema prevention
teaching
– When and who teaches post-operative exercises – Is there any short stay specific patient or GP
23 hour discharge audit results
Na m e of Trust Im ple m e nta tion
yes / no date started or date planned to start
Ex clusion Crite ria Code s 1 Ax clearance 2 Reconstruction - flap 3 Medical reasons 4 Social reasons 5 Other (specify) 24 hr support from ? 1 ward 2 A&E 3 MGPU 4 Site Practioner 5 other (specify)
Se nt hom e w ith dra ins
yes / no
If yes who removed drain 1 DN
2 Hospital Clinic 3 GP
Please list all
Com fie Provide d
1 pre-op 2 Post op BCN 3 Post op Ward Staff 4 Other (specify) Lym phoe de m a Pre ve ntion Ta ught
yes / no 1 BCN pre-op 2 BCN post-op 3 Ward staff post-op 4 Other (specify)
Post Op Ex e rcise s
Please specify by who and when
Com munica tion to Prim a ry Ca re
please specify by who and when method of communication Inform a tion Provide d 23 hour specific generic
please give details
RMH Sutton
yes 2,3,4, 1,4, 5 SHO on call Yes - ward for removal 3 yes 1
yes physio at pre-assessment
Discharge summary from surgical team
short stay specific info and BCC
RMH Fulham Rd
yes 2,3,4 1,4, CAU
Yes if necessary - unusual now ward or CAU for removal unless live a
long way away then DN 3 yes 1
yes - physio at pre-asessment
Discharge summary from surgical team
short stay specific info and BCC RMH Private Croydon University Hospital Yes 2, others not necessarily excluded from 23hr but may be excluded from discharge with drain. Individual assessment
(Only if discharge
with drain) 1,4 Yes - 1,2 1, 2 or 3 yes 1,2
BCN pre op for all and again Post op if ANC
DN referral by ward. Discharge letter from
ward to GP Discharge with drain specific, DCU specific. CUH handbook St George's Hospital
yes 2,3,4,5 1,2 Yes - 1,2 1,2 yes - 1,2 yes - pre op by BCN Ward Generic
Kingston Hospital inc Queen Mary's Roehampton
No -planned and
due start Nov 2012 2,3,4,5 pt choice 1,2 no
3
2, 4 pre-assessment staff
pre-assessment +
physio Discharge summary 23 hour specific leaflet Guys and
St Thomas' Hospital
inc Lewisham Yes - 2008
1, 2, 3, 4, +
mastectomy 1. On Call Surgeon yes. 2 2 yes 1 + 2 Physio - pre op Dscharge letter- SpR Generic from BCC
Kings
Yes - 2006 2,3,4 1 no drains 2 1 and physio pre-op
Physio - pre op and
post class discharge summary generic Queen Elizabeth
Hospital Woolwich
Yes approx 1 yr
ago 2,3,45,early disc team 1,2,5,EDT Yes1,EDT 1,2 yes1,2,leaflet BCN pre/post op
Daycare nurses by fax,post op,discharge letter DR's. Dressing advice
Queen Mary's Hosp
Sidcup yes 2 1 no 2 1,2 BCN pre/post
Discharge summary from ward to GP
Generic ? Unsure what you mean
PRUH
Bromley yes 2 1 yes
4 early discharge team 1,2 BCN/early discharge team post Discharge summary from ward to GP ???
Imperial Yes at CHX since
2010
1, 2, 3, 4,
5-mastectomy 1, 2, 5-HO, BCN Yes 2
No daycare used for mastectomy Yes 1, 2
BCN in clinic pre and post op, also
ward staff Nil
Trust leaflet on discharge with drains, Breast Cancer care Your operation and recovery, exercise sheet and reducing the risk of lymphoedema Hillingdon
Yes Jan 12 2,3,4 1 No 1,2 Yes 1,2
Post op physio or ward staff if Friday
op Nil specific Nil specific
West Middlesex
Yes 2,3 1 Yes 2 2 Yes 1,2 Yes BCN pre op discharge summary
Short stay specific and discharge with drain
Northwick Park
Yes - 2009
no reconstruction on
site,4 1,EDT Yes, EDT or clinic BCN pre-op BCN pre op
BCN pre op. physio if req post op
Discharge summary and recorded in patient diary
Drain management and info provided by EDT
Ealing
Yes June 2011 2,3,4 1,5BCN Yes BCN 2 Yes-2
BCN and illustrated
info leaflet from BCC Not required
Booklet on drain education
LCA breast pathway 23 hour discharge benchmarking results
23 hour discharge points for discussion
– Exclusion criteria – Imperial and Guy’s Hospitals exclude patients having axillary clearance, while others do not
– Some exclude all patients having mastectomy while others only exclude those having a
reconstruction
– 4 Trusts rarely or never send patients home with
drains. Others routinely do so. Those that do use a variety of processes for drain management and
removal including returning to the hospital.
– Should we be looking to bring all Trusts more in line or are we happy to continue the variation in practice
23 Hour discharge
23 hour discharge points for discussion
– Postoperative exercise teaching shows great variation although all teach something (NB
national standard is that all patients should be seen by physiotherapist)
23 hour discharge points for discussion
– Risk stratification for physiotherapy referral based on type of axillary surgery?
– Discuss further within the breakout group
– Variety of patient information provided –some 23 hour specific, some drain management
Charmaine Case. Breast Care Nurse. St George’s Hospital
23 Hour Discharge
Implementation in Practice
How did we go about it?
e set up a project team with clinical representation from everyone involved in the patient journey – consultant surgeons, anaesthetists, physios, BCNs, ward staff, patient representative and a project
manager from the SW London Cancer Network.
he project launched in early September and a project plan, key milestones and timescales were agreed.
merging issues and risks were reviewed and an action plan developed covering the core activities that needed to be completed.
ore activities were assigned to project team members according to their particular specialism.
egular project meetings were held to ensure momentum was maintained.
e set up a project team of specialist staff to drive forward the programme. It was important to
have clinical representation on the team from everyone involved in the patient journey.
ur project team comprised: consultant surgeons, anaesthetists, physiotherapists, breast care
nurses, pre-admissions and ward staff, a patient representative and a project manager from the SW London Cancer.
What were the key activities?
Mapping the patient pathway
Collecting baseline data on patient volumes and length of stay
Assessing suitability of wards, pre-admission environments and theatre capacity and making such adjustments as were needed for model
Developing anaesthetic and early discharge protocols.
Reviewing ward staff roles and responsibilities in line with the new model.
Introducing nurse-led pre-assessment and discharge.
Developing patient information for the new model
Addressing anaesthetist and physiotherapy cover issues to enable 23-hour model implementation.
Physiotherapy cover (resolved by giving patients DVD of essential arm/shoulder exercises & BCN
teaching these at pre-admission stage)
Baseline data - HES data inaccurate. (resolved by
conducting retrospective audit to identify volumes and average LoS)
Friday operations list – potential to delay next
day discharge due to lack of weekend cover (resolved by introducing nurse-led discharge)
Discharge with or without drains – Decided to
discharge patients with drains in situ, but with good backup support in place for them in the event of
What has been achieved?
– Model was implemented on 1 December 2010 for all breast surgery patients who met the clinical criteria.
– Since then 52 patients have been treated under the 23-model. This is 83% of all eligible breast surgery patients.
– As a result, average length of stay for all breast patients has reduced from 5 days to 2 days.
– Good communication – make sure your stakeholders are engaged from the start and ensure your clinical team are involved and new joiners are trained in the model. We used posters, newsletters and process maps in the wards etc.
– Strong project management with regular project meetings and clear action planning.
– Leadership and enthusiasm from the top. This is critical to the success of the project. We were lucky to have the General Manager for Surgery sitting on the project team alongside our breast care nurses and ward sisters.
– Involve patients from the start. We had a patient representative on our project team, who helped ensure the patient was at the heart of everything we did.
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