Annual Report Gynaecology MDT

Transcription

1 Annual Report Gynaecology MDT University Hospitals Bristol NHS Foundation Trust Royal United Hospital Bath NHS Trust

2 Agreement and Approval Gynaecology MDT Lead, UH Bristol John Murdoch Date 11/08/2012 Trust Cancer Lead Clinician, UH Bristol Steve Falk Date 09/08/2012 Trust Cancer Lead Clinician, RUH Bath Dorothy Goddard Date 13/08/2012 Review Date Annual Report Review Date: 01/07/13 Versions Version Date Reason Sign Off /05/10 Draft revision for 2010 Peer Review /07/11 Draft revision for 2011 Peer Review 3.0 July report produced 08/08/ Annual Report - Gynaecology MDT

3 1 Measure Checklist Measure Number 11-2E E-202 Measure Single named lead clinician and core team membership Level 2 practitioners for Psychological Support Operational Policy p11,12 Annual Report Work Plan Supporting information 11-2E-203 Support for level 2 practitioners p11 p5 11-2E-204 Team attendance at NSSG meetings p7 11-2E E-206 Meet weekly and record core attendance & protocols for referral to next scheduled meeting MDT agreed cover arrangements for core member 11-2E-207 Core member (or cover) present for 2/3 of meetings 11-2E E E-210 Annual meeting to discuss operational policy Policy for all new patients to be reviewed by MDT Policy for communication of diagnosis to GP p22 p16 p11 p11 p7-8 p18 p10 p6-8 p17 p21 p15 p8 11-2E-211 Operational policy for named key worker p22 p15 p8 11-2E-212 Operational policy for low risk endometrial cancer 11-2E-213 Histopathology core members participating in EQA scheme 11-2E E-215 Core nurse member completed specialist study Agreed responsibility for core nurse members 11-2E-216 Attendance at national advanced communication skills training programme n/a n/a n/a p24 p15 p9-12 p13-14 p E-217 Extended membership of MDT p E-218 Patient permanent consultation record p21 p E-219 Patient experience exercise p17 p7 11-2E-220 Provision of written patient information p22,27 p7 11-2E E-222 Agree and record individual patient treatment plans MDT/network agreed guidelines for the management of endometrial cancer p11 p10 p16 p15-17 p E-223 MDT/network agreed guidelines for the p23 Annual Report - Gynaecology MDT 3

4 Measure Number 11-2E E-225 Measure management of ovarian cancer MDT/network agreed guidelines for the management of cervical cancer MDT/network agreed guidelines for the management of vaginal and vulva cancer 11-2E-226 MDT/network agreed guidelines for gynaecology chemotherapy 11-2E-227 MDT/network agreed guidelines for the gynaecology cancer follow up Operational Policy p23 p23 Annual Report 11-2E-228 Agreed collection of minimum dataset p24 p12 p8 11-2E-229 Agreed network audit p24 p E-230 Agreed clinical trials list p24 p19 p9 p23 p23 Work Plan 11-2E-231 Joint treatment planning for TYAs p19-20 p10 p10 Supporting information 4 Annual Report - Gynaecology MDT

5 2 Contents 1 Measure Checklist Contents Introduction Key Achievements Key Challenges The MDT Meeting NSSG Meeting Attendance (11-2E-204) MDT Meeting Attendance (11-2E-207) Attendance by Role Attendance by Individual Workload of MDT / Cases discussed Number new diagnoses discussed by MDT New diagnoses by first treatment type Surgical caseload by operating surgeon Cancer Waiting Time Targets Treatment of TYAs (11-2E-231) Meetings to Discuss Operational Policies (11-2E-208) Training Advanced Communication Skills Training (11-2E-216) Level 2 Psychological Support Training and Clinical Supervision (11-2E-202,203) Data Collection and Clinical Lines of Enquiry Data Collection (11-2E-228) Clinical Lines of Enquiry Audit Local Audit Timeliness of Diagnosis Notification to GPs (11-2E-210) Documentation of the Key Worker Details (11-2E-211) Recent published audits Participation in the EQA (11-2E-213) National Audit Participation in Audit Network SSG (11-2E-229) Other audits Patient and Carer Feedback and Involvement (11-2E-219) Research Clinical trials (11-2E-230) Publications Annual Report - Gynaecology MDT 5

6 3 Introduction This report relates to year 1 April 2011 to 31 March November 2011 saw the first meeting of the single specialist MDT across University Hospitals Bristol (UH Bristol) and the Royal United Hospital (RUH) Bath. 3.1 Key Achievements Successful introduction of single MDT between UH Bristol and RUH Bath. Reappointed two medical oncologists, clinical psychologist and a second radiologist Good clinical outcomes Developing research portfolio with good recruitment Provide a gynaecology oncology course and national gynaecology brachytherapy course Good achievement of waiting time targets Established and expanding CNS clinics with holistic approach Access to homeopathic oncology Palliative care input at MDT Patient input at SSG and Cancer Board Access to chemotherapy in the home for some patients where appropriate Redevelopment at UH Bristol of Cancer Information Centre and outpatient areas to improve patient experience 3.2 Key Challenges Maintaining and developing the service in a time of financial constraint Developing MDT covering 4 Trusts Enhancing research portfolio Full implementation of enhanced recovery programme Developing CNS led holistic needs assessment as part of management of follow up 6 Annual Report - Gynaecology MDT

7 4 The MDT Meeting 4.1 NSSG Meeting Attendance (11-2E-204) The Gynaecology NSSG has had the following meetings during April 2011-March 2012, with the MDT represented as follows. Meeting Date Name Job Title 13 th May 2011 Nick Johnson Rebecca Bowen Hoda al Booz Paul Cornes Russ Luker Pauline Humphrey Pinias Mukonoweshuro Tracie Miles 9 th December 2011 Hoda al Booz Axel Walther Pauline Humphrey Overall % Attendance 100 Surgeon (RUH) Oncologist (RUH) Oncologist (UHB) Oncologist (UHB) Surgeon (RUH) Radiographer (brachytherapy) Pathologist (RUH) CNS (RUH) Oncologist (UHB) Oncologist (UHB) Radiographer (brachytherapy) For further details of the meetings please see the Network Annual Report 4.2 MDT Meeting Attendance (11-2E-207) As noted in the operational policy the MDT meets weekly on a Wednesday morning with attendance recorded on the Somerset Cancer Register. Between 1 April 2011 and 31 March 2012 there were 52 meetings held of the UH Bristol MDT. RUH Bath members who did not attend the UH Bristol MDT prior to November 2011 have had attendance at the RUH MDT taken into account to provide an accurate picture of their MDT attendance Attendance by Role Role Lead Clinician for MDT 85% Surgical Gynaecology Oncologists (at least two at each meeting) 100% Oncologist 100% Histopathologist 98% Imaging Specialist 81% Clinical Nurse Specialist 94% MDT Coordinator 98% Attendance by Individual % Attendance Name Role % Attendance John Murdoch Surgical Gynaecology Oncologist 85% Russell Luker Colposcopy Lead Gynaecologist RUH 68% Annual Report - Gynaecology MDT 7

8 Bob Anderson Surgical Gynaecology Oncologist 65% Jo Bailey Surgical Gynaecology Oncologist 83% Nick Johnson Surgical Gynaecology Oncologist 75% Joya Pawade Histopathologist / Cytologist 87% Pinias Mukonoweshuro Histopathologist / Cytologist 67% Sarah Johnson Histopathologist Mat leave Hoda Booz Oncologist 73% Paul Cornes Oncologist 81% Hugh Newman Oncologist 67% (joined Nov 2011) Axel Walther Oncologist 91% (joined Oct 2011) Rebecca Bowen Oncologist 82% (from Nov 2011) John Hughes Radiologist 79% Simon Malthouse Radiologist 52% Katy Horton Fawkes CNS 79% Jayne Alexander CNS 81% Sally Keates Porter CNS 73% Tracie Miles CNS 84% Jane O Mahoney CNS 70% Sally Hawkins MDT Coordinator 83% Doreen Quibbell MDT Coordinator 84% Juliet Duffy Ward specialist nurse 85% 4.3 Workload of MDT / Cases discussed Meetings were held weekly on a Wednesday within the Board Room at St Michael s Hospital UH Bristol, with RUH Bath members participating via video-link. The MDT uses the Somerset Cancer Register to record and capture outcomes of MDT discussions. The table below demonstrates referrals between April 2011 and March Number new diagnoses discussed by MDT Cancer type Primary Recurrence Metastasis Vulval Vaginal Cervix Uterus and endometrium Ovary and fallopian tube Peritoneum Other Total Annual Report - Gynaecology MDT

9 4.3.2 New diagnoses by first treatment type Please note this shows the first treatment only. Patients may have gone on to have subsequent treatments of other types. First treatment type Number Active monitoring 4 Anti-cancer drug 79 Brachytherapy 7 Chemoradiotherapy 21 Specialist Palliative Care 9 Surgery 333 Teletherapy 32 Other/not stated* 21 * These are patients who have declined treatment, not yet started treatment, died before treatment, went elsewhere for treatment, or had already been treated outside of the Network prior to referral Surgical caseload by operating surgeon Includes all types of surgery, including biopsies, debulking and cervical procedures. Figures will not tally with those above as will include patients who have had more than one operation, patients where surgery was given as a subsequent treatment, surgeries that did not count as a definitive treatment, or patients diagnosed and discussed in the previous period. Name Number John Murdoch 111 Jo Bailey 87 Robert Anderson 67 Nick Johnson 149 Russ Luker Cancer Waiting Time Targets Performance against the CWT targets by Trust, 2011/12. Both Trusts achieved all standards. Metric Target UH Bristol RUH Bath Two week wait (first appointment) 93% 97.4% 95.1% 31 day first definitive treatment 96% 98.4% 99.3% 31 day subsequent - surgery 94% 98.7% 100% 31 day subsequent - drug 98% 100% 100% 31 day subsequent - radiotherapy 94% 99.5% 100% 62 day referral to treatment GP 85% 92% 98.1% 62 day referral to treatment screening 90% 100% 100% Annual Report - Gynaecology MDT 9

10 4.3.5 Treatment of TYAs (11-2E-231) One patient in the TYA age group (15-24) was treated by the MDT in the review period. The patient did not have a joint treatment planning decision with the TYA MDaT. The MDT now has a policy to ensure referral of TYAs and the TYA MDaT is developing reports that will enable it to identify patients who have not been referred. 4.4 Meetings to Discuss Operational Policies (11-2E-208) The Gynaecology team has a well-structured process for meeting to review both operational and strategic developments: Operational Meetings: Occur every 6 weeks following on from MDT (all members invited) the team meet to discuss current issues and agree work streams as required. The meetings allow for issues to be discussed and addressed as they arise. Annual General Meeting: The most recent Annual General Meeting took place on 14 th May Minutes are available in the Supporting Information on pages Annual Report - Gynaecology MDT

11 5 Training 5.1 Advanced Communication Skills Training (11-2E-216) The following core members with direct clinical patient contact have attended the National Advanced Communication Skills training: John Murdoch attended on 9-11 December 2011 Nick Johnson attended on November 2010 Russ Luker attended on November 2010 Tracie Miles attended on 4-6 March 2009 Jayne Alexander attended on March 2011 Katy Horton Fawkes attended on March 2011 Hoda Al-Booz attended on March 2011 Paul Cornes attended on November 2010 Sally Keates Porter attended on 9 April-1 May 2009 These members have booked to attend courses in the future: John Hughes is booked for October 2012 Jo Bailey is booked for 18 th and 19 th September 2012 The remaining members are keen to undertake the course and are awaiting further dates to become available. 5.2 Level 2 Psychological Support Training and Clinical Supervision (11-2E-202,203) The following staff have undertaken the Network approved training to provide level 2 psychological support to cancer patients and their families: Jayne Alexander (13 th and 14 th December 2011) Katy Horton-Fawkes (3 rd and 4 th January 2012) Jane O Mahoney (2001) Tracie Miles (booked for autumn 2012) Support for Level 2 Practitioners is provided by regular supervision by level 4 psychologists. An example timetable showing support sessions is available in the Supporting Information on page 5. Annual Report - Gynaecology MDT 11

12 6 Data Collection and Clinical Lines of Enquiry 6.1 Data Collection (11-2E-228) The MDT endeavors to collect the ASWCS Minimum Dataset, recording information on the Somerset Cancer Register (SCR). The MDT also contributes data to the national cervical audit. The Trust is working to improve the completeness of data on the cancer register. A recent audit of certain key fields on the SCR for patients given first treatment at UH Bristol for gynae cancer in quarter 4 showed that: 100% had a diagnosis code, diagnosis date, cancer status, and MDT discussion recorded 100% had a stage recorded (TNM or FIGO) 77% had a SNOMED code (83% those treated with surgery) 70% had a pathology report entered (86% those treated with surgery) 56% had a CNS contact recorded (this figure is lower because CNS contacts for patients from outside the Bristol area will be recorded on the relevant local record). 100% had a treatment intent recorded These results are amongst the best in the Trust and show a significant improvement from previous quarters. The MDT continues to work proactively to improving data collection. An additional staff member has been seconded to this role at UHB. At RUH Bath the SWPHO staging project dashboards show 90% gynae cancers had a stage submitted to the register for January-May This puts them as one of the top Trusts in the South West for getting this information to SWPHO promptly. There is currently a problem with submission of Gynae staging data to SWPHO as FIGO staging from the SCR does not get included in the registry dataset, despite it being an acceptable staging format for the registry. The SCR should address this in the next release. 6.2 Clinical Lines of Enquiry Clinical Lines of Enquiry are detailed below, with comments where the MDT differs significantly from the expected or average. Metric 1: Surgical Caseload (ovarian) Measure of the number of ovarian cancer surgeries performed in a year by surgeon. The aim is that each surgeon should perform at least 15 cases. Data is from the Trent Cancer Registry based on diagnoses in 2008 and is not supplied in detail to enable investigation of individual cases or identification of the surgeons concerned. UH Bristol had 3 surgeons with under 15 cases (one of whom had 14 cases), and two nominated subspecialists with over 15 cases. Two surgeons with under 15 cases had performed one operation only. These are due to either data error (patients wrongly coded as having cancer an issue which we know affects registry data from recent staging project work) or incidental findings (cancer was not suspected at time of surgery for other condition). The surgeon who had performed 14 operations did so before temporary retirement resulted in a change of job plan in year. 12 Annual Report - Gynaecology MDT

13 At RUH Bath, the sub specialty surgeon in Bath performed more than 15 ovarian cancer operations. Another surgeon in Bath performed less than 15 (one) but this case was to remove a pelvic mass with a low malignancy index and the finding of ovarian cancer was unexpected. Metric 2: Gynaecological Oncology Staging All patients with gynaecological cancer should be assigned a FIGO stage, plus nodes status for cervical cancer. The Network was above average for staging completeness in 2008 and 2009, with 88% and 85% cases staged. As mentioned above, locally recording of stage has reached 100% in This may translate to a slightly lower figure in the national registry due to differences in attribution and the possibility of post-mortem cases. Metric 3: Surgical Enhanced Recovery / Length of stay Enhanced recovery is important in reducing length of stay and improving patient experience after surgery. Both UH Bristol and RUH Bath had a lower than average number of patients with length of stay greater than the median, following major resection for uterine cancer in Both Trusts had median length of stay of 3 days, compared to the national average of 4 days. 81% RUH patients and 78% UH Bristol patients stayed for less than 4 days, whilst 10% UH Bristol and 12% RUH patients stayed for over 6 days. These are very positive results. Metric 4: Survival Survival figures are given by Network and not broken down by Trust. The Avon, Somerset and Wiltshire Cancer Network survival was average or better for most types and time periods. The Network showed significantly higher 2-year and 5-year survival for patients with cervical cancer. These results are positive and reflect the good practice of the MDT. Metric 5: Clinical Nurse Specialists The National Cancer Patient Experience Survey 2010 showed 100% patients at UH Bristol and RUH Bath were given the name of a CNS. Both Trusts were in the top 20% Trusts nationally with this score. 68% UH Bristol and 73% RUH Bath patients said they found it easy to contact their CNS, which is average compared to other Trusts. 95.7% patients at RUH Bath said their last CNS contact was about the right length of time. 86.7% UH Bristol patients said their last CNS contact was about the right length of time, which is low compared to other Trusts nationally although in itself is still a high proportion of patients. The CNS team always endeavor to spend as much time with each patient as that patient needs, although this has to be balanced against the other requirements of the role. Gynaecology is one of the national pilot sites for the Macmillan 1:1 support project which is piloting roles that can support cancer patients and CNS teams. Annual Report - Gynaecology MDT 13

14 7 Audit 7.1 Local Audit The team have participated in audit over the period of this report including: Local audit of high risk endometrial cancer Audit of laparoscopically assisted vaginal hysterectomy Audit of laparoscopic radical hysterectomy Audit of laparoscopic radical trachelectomy Audit of how patients are given their initial diagnosis 62 day cancer breach and near miss breach audit. Audit of MDT recommendations against outcome Vaginal stenosis rates Radiotherapy toxicity Theatre utilisation time Surgical morbidity and mortality rates Colposcopy QAT Wait times for surgery 2ww compliance Consent audit Cancer registry staging Surgical excision rates Medica independent sector reporting of CT scans MRSA audit Clostridia audit DVT audit Heparin audit CNS 24hour fax back audit 1 and 2 Named Key worker Wait times for cat A radiotherapy 14 Annual Report - Gynaecology MDT

15 7.1.1 Timeliness of Diagnosis Notification to GPs (11-2E-210) As outlined in the operational policy once a patient has been diagnosed with a Gynaecological cancer, the GP is notified by either telephone or by letter via CDS. An audit against the standard has been conducted in February-March 2012 using 20 sets of notes selected at random at both UHB and RUH. Audit outcomes: RUH 100% GPs notified within 24 hours. UHB 95% GPs notified within 24 hours. Actions: The UHB rate is a function of job plan availability of consultants to sign off letters. This has been addressed by electronic sign off for each consultant to ensure letters are on CDS within 24 hours Documentation of the Key Worker Details (11-2E-211) As outlined in the operational policy, the MDT Lead nominates a key worker for each patient at the time of MDT discussion. The key worker s name is clearly and prominently recorded on the MDT outcome proforma, which is filed in the patient s case notes. An audit against the standard in February-March 2012 has been conducted using 20 sets of notes selected at random at both UHB and RUH. Audit outcomes: RUH 100% key worker details documented in notes. UHB 85% key worker details documented in notes. Actions: The UHB key worker is identified as a mandatory function along with stage and agreement of treatment plan at the end of each discussion at MDT 7.2 Recent published audits Measuring the time from onset of symptoms to treatment of endometrial cancer See report in the British Journal of Cancer 104(12): PMB audit (SS) See abstract from the RCOG international meeting, Egypt 7.3 Participation in the EQA (11-2E-213) The core histopathologists participate in EQA and this has been confirmed. Evidence of participation is available in the supporting information on pages 9-12 or in hard copy. 7.4 National Audit Cervical cancer national audit 7.5 Participation in Audit Network SSG (11-2E-229) The Trust has agreed to participate in the current Network audit, on enhanced recovery following laparotomy. This audit is underway at the time of writing. The previous NSSG audit, on pelvic stress fractures following radiotherapy, was stopped due to the very low numbers of patients involved which meant meaningful conclusions could not be drawn. Annual Report - Gynaecology MDT 15

16 7.6 Other audits The histopathology team has undertaken or are undertaking the following audits since the last annual report: Cervical cancer reporting for women under and above the age of 35 between 2007 and 2009 in UH Bristol - Completed 2011 High grade serous endometrial carcinoma in UH Bristol and Royal United Hospital Bath - Ongoing Histopathological reporting of Borderline Ovarian Tumour at UH Bristol NHS Trust - Completed 2010 Proposed audit: Vulval malignancy reporting and MDT discussion 16 Annual Report - Gynaecology MDT

17 8 Patient and Carer Feedback and Involvement (11-2E-219) The National Cancer Patients Experience survey results are reviewed by the MDT and actions identified as a result. Results from the 2011/12 exercise were expected in July 2012 but had not been received at the time of writing the report. From the 2010/11 exercise a number of issues were identified and actions were implemented as a result. These actions have now been completed and it is hoped that the new survey results will reflect this. Actions included: Installation of Macmillan information points around UH Bristol, including St Michael s Hospital, to increase the information available to patients outside of the BHOC Access to Macmillan Citizens Advice Bureau clinics to provide advice and support on financial matters and benefits available Patient representative on UH Bristol Cancer Board to ensure patient and user views are represented in strategic decision making relating to cancer Annual Report - Gynaecology MDT 17

18 9 Research 9.1 Clinical trials (11-2E-230) The Gynaecology MDT is actively involved in clinical trials and participates in NSSG agreed trials. The below is an excerpt from the annual Research report produced by the NSSG, detailing the MDT s recruitment to clinical trials and any actions arising. MDT estimate for recruitment (2011/12) Actual MDT recruitment (2011/12) Trial Status (April 12) MDT annual estimate of recruitment for 2012/2013 MDT actions and comments for 2012/13 (endorsed trials) If no actions required please state no actions required. NCRN trial recruitment 11/12: DNA Methylation Study 0 0 No longer open at UHB N/A N/A GROINSSV-II 8 2 Open 8 Continue (newly opened) ICON 6-2 Closed n/a No action required UBH 10-4 Open RUH 6 No action required ICON 8 WGH 4 NSECG - 25 Closed n/a No action required RT3VIN - 1 Open 1 No action required Desktop III 4 0 In set up 4 Trial not open yet MDT actions: The trial portfolio has been reviewed and discussed by the Oncologists and ICON8 opened at all sites. RB and AW have participated in the NCRN ovarian subgroup meeting held jointly with the Scottish Gynae Cancer trials Meeting this year and will continue to attend meetings to identify new and relevant trials to enhance our portfolio. A collaboration has been developed with the other Gynae Oncologists within the Network to ensure that large studies will be open across all sites and available to all patients and that small studies relevant to rare cancers or subsets will be opened in at least one site, accepting referrals from across the Network. Of note Expressions of Interest have been sent from the MDT for Interlace, PARAGON and Metro-BIBF. Members of the research team undergo the required GCP training updates. The above actions were agreed by the MDT on in the presence of Mr John Murdoch and Dr Rebecca Bowen (MDT Lead and MDT Research representative who will attend the network SSG). 18 Annual Report - Gynaecology MDT

19 9.2 Publications MDT members regularly publish the results of their research in journals. publications by the MDT is available in the supporting information. A full list of recent Annual Report - Gynaecology MDT 19