Evolving Pathways of Care

Evolving Pathways of Care Nicola Glover, Project Manager LCA Jan Morrison, Macmillan Lead Cancer Nurse Charmaine Case. Breast Care Nurse. St George s Hospital

33 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. National Cancer Institute,

34 The National Picture Change Presentation title and date in Footer dd.mm.yyyy 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

35 The National Picture Change Presentation title and date in Footer dd.mm.yyyy 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

36 NCSI Next steps Change Presentation title and date in Footer dd.mm.yyyy 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

37 Model of Care recommendations London Cancer Alliance Survivorship Group Fourm 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

38 MoC (cont ) London Cancer Alliance Survivorship Group Fourm 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 NCSI

39 MoC (cont ) London Cancer Alliance Survivorship Group Fourm 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 HNA embedded in the patient pathway

40 Cross-cutting Issues London Cancer Alliance Survivorship Group Fourm Patient Experience Palliative Care Rehabilitation User Involvement Work force Education

41 London Cancer Alliance Survivorship 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 Health and Well-being clinics

42 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 across the LCA

43 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 information

44 Name of Trust RMH Sutton 23 hour discharge audit results Implementation yes / no date started or date planned to start Exclusion Criteria Codes 1 Ax clearance 2 Reconstruction - flap 3 Medical reasons 4 Social reasons 5 Other (specify) LCA breast pathway 23 hour discharge benchmarking results 24 hr support from? 1 ward 2 A&E 3 MGPU 4 Site Practioner 5 other (specify) Sent home with drains yes / no If yes who removed drain 1 DN 2 Hospital Clinic 3 GP Please list all Comfie Provided 1 pre-op 2 Post op BCN 3 Post op Ward Staff 4 Other (specify) yes 2,3,4, 1,4, 5 SHO on call Yes - ward for removal 3 yes 1 Lymphoedema Prevention Taught yes / no 1 BCN pre-op 2 BCN post-op 3 Ward staff post-op 4 Other (specify) Post Op Exercises Please specify by who and when yes physio at preassessment Communication to Primary Care please specify by who and when method of communication Discharge summary from surgical team Information Provided 23 hour specific generic please give details short stay specific info and BCC RMH Fulham Rd RMH Private 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 preasessment Discharge summary from surgical team short stay specific info and BCC Croydon University Hospital St George's Hospital Kingston Hospital inc Queen Mary's Roehampton 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 yes 2,3,4,5 1,2 Yes - 1,2 1,2 yes - 1,2 yes - pre op by BCN Ward Generic 3 No -planned and 2, 4 pre-assessment pre-assessment + due start Nov 2012 2,3,4,5 pt choice 1,2 no staff 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 Queen Mary's Hosp Sidcup yes 2 1 no 2 1,2 BCN pre/post Daycare nurses by fax,post op,discharge letter DR's. Dressing advice 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 Hillingdon West Middlesex Northwick Park 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 Yes Jan 12 2,3,4 1 No 1,2 Yes 1,2 BCN in clinic pre and post op, also ward staff Trust leaflet on discharge with drains, Breast Cancer care Your operation and recovery, exercise sheet and reducing the risk of lymphoedema Nil Post op physio or ward staff if Friday op Nil specific Nil specific Yes 2,3 1 Yes 2 2 Yes 1,2 Yes BCN pre op discharge summary Discharge summary no reconstruction on BCN pre op. physio and recorded in patient Yes - 2009 site,4 1,EDT Yes, EDT or clinic BCN pre-op BCN pre op if req post op diary Short stay specific and discharge with drain 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 Code: BCN = Breast Care Nurse, BCC= Breast Cancer Care, EDT = Early discharge team, CAU = clinical assessment unit, SHO and HO = junior doctors

45 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

46 23 Hour discharge Source: NHS Improvement (2011) Delivering major breast surgery as a day case or one night stay

47 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)

48 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 specific.

49 Change Presentation title and date in Footer dd.mm.yyyy 23 Hour Discharge Implementation in Practice Charmaine Case. Breast Care Nurse. St George s Hospital

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.

Who was involved? 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.

What were the key issues? 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 problems.

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.

Recipe for success? 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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