LCA Head and Neck/Thyroid Clinical Forum. 15 th July 2015

Transcription

1 LCA Head and Neck/Thyroid Clinical Forum 15 th July 2015

2 Outcome measures for an LCA Head and Neck Enhanced Recovery programme Richard Oakley Head and Neck Surgical Oncology King's Health Partners ICC LCA Forum Wednesday july 15 th 2015

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4 Aims of ERAS (enhanced recovery after surgery) Ensures patients are in optimal condition for treatment, have the best possible care during the operation and experience optimal post operative rehabilitation Evidence based practice initiatives that when implemented together are bigger than the sum of all the parts Improve Medical outcomes Patient experience and satisfaction Efficiency Capacity MDT working Reputation (particularly as this has not be completed in H&N before) Reduce Complications Cost Length of stay Stress

5 Benefits for patients Helps people recover sooner so that life can return to normal as quickly as possible Gives peoples a better overall experience due to higher quality care and services It lets people chose what's best for them throughout the course of their treatment with help from their GP and the wider healthcare team (no decision about me without me). Many people that have had experience of Enhanced Recovery say that it makes a hospital stay much less stressful

6 Example of enhanced recovery after surgery elements Referral from Primary Care Optimised health / medical condition Informed decision making Pre operative health & risk assessment PT information and expectation managed DX planning (EDD) Pre-operative therapy instruction as appropriate Optimising pre operative haemoglobin levels Managing pre existing co morbidities e.g. diabetes Pre- Operative Admission Minimally invasive surgery Use of transverse incisions (abdominal) No NG tube (bowel surgery) Use of regional / LA with sedation Epidural management (inc thoracic) Optimised fluid management Individualised goal Admission on day Optimised Fluid Hydration CHO Loading Reduced starvation No / reduced oral bowel preparation ( bowel surgery) Intra- Operative DX when criteria met Therapy support (stoma, physio) 24hr telephone follow up Planned mobilisation Rapid hydration & nourishment Appropriate IV therapy No wound drains No NG (bowel surgery) Catheters removed early Regular oral analgesia Paracetamol and NSAIDS Avoidance of systemic opiate-based analgesia where possible or administered topically Post- Operative Follow Up 6

7 Incidence for the London Cancer Alliance region Head and Neck including thyroid Geographical areas 17.3 SEL: per 100K 252 per yr 16.2 SWL: NWL: 300 Alliance 16.8: 811 ENGLAND ENGLAND

8 Cancer Survival and Deaths Relative survival estimates Deaths per yr SEL: 79.6% 74 SWL: 86.2% 64 NWL: 83% 88 Alliance 82.9% 226 Total ENGLAND % Worse survival than the English average THE ONLY CANCER TYPE THAT IS SIGNIFICANTLY SIGNIFICANT WORSE THAN ENGLISH AVERAGE We need to save 2.37 lives to make us average!

9 DOH initiative apply ERP to improve ONCOLOGICAL OUTCOMES Page 9 1. Improving outcomes Benign v Malignant processes 2. Mortality and Morbidity 3. Multiple different treatment modalities 4. Head and neck cancer 15 different subsites 5. Biggest costs worst outcomes associated with salvage surgery 6. Modifiable risk factors: 74% of head and neck cancer associated with smoking and drinking or smoking alone. Treated patients who smoke do worse. 7. Smokers recur more often (double incidence of a second primary)

10 Head and Neck Enhanced Recovery programme FIRST Consultation NO CANCER Primary prevention Pre- Operative/ Diagnostic MDM Admission Intra- Operative Radiotherapy/Chemo RT with curative intent SURVEILLANCE Post- Operative D I S C H A R G E 5 YEARS 10

11 The project team Mr Richard Oakley Consultant Head and Neck Surgeon Catherine Collins/Lizzie Hunt Ward Sister, Blundell Ward Rachael Donnelly /Emma Gilbert Principal Head and Neck Dietitian Imelda Fleming/Hannah Samuels Head and Neck CNS Alice Jenner/Nicky Easton Cancer Programme Claire Twinn - SALT Alison Dinham Physiotherapist Dr Teresa Guerrero Urbano Consultant Oncologist Annabel Hooper Tracheostomy CNS Joanne Jefford / Samantha Tordesillas Community Head and Neck team Lorraine Love/Raj Sal ENT Service Manager Mr Andrew Lyons - Consultant Head and Neck Surgeon Jonathan Watkiss/ Imran Ahmad/Dianne Baresenne Consultant Anaesthetist

12 Enhanced Recovery starting point Clear scope Current state pathway map Future state pathway map Clear project plan Clinical engagement Management support Governance / running of the project Clinical leads Steering group Collaborative working Project plan PDSA cycles

13 Outcome No 1: First Consultation prevention/optimisation Smoking cessation Smoking cessation all 2 week waits or head and neck cancer referrals Consultant lead consultation and smoking cessation referral made (95% compliance) Ming Wei Tang et al A Surgeon led smoking cessation intervention in a head and neck cancer centre. BMC Health Services (2014) 14:636 DOI /s

14 Outcome 2: First consultation patient information Page 14 Patient information relating to logistics of diagnostic pathway and timing of MDM discussion : My roles, my responsibilities : smoking cessation reinforcement : Getting better together : Timing and dates of scans : Optimising my dental health screening tool keying dental review : Nutritional screening tool keying dietitics consultation Consent for diagnostic procedures

15 Outcome 3: First consultation pre-assessment Page 15 Same day pre-assessment Referral for more formal detailed assessment in any patient with multiple comorbidities or issues with capacity to consent Formal report to be considered at MDM as part of decision making process Outcome 4: Documentation of comorbidities MOCA Charleson mortality index Get up and go

16 Panendoscopy Outcome 5 (SAME DAY ADMISSION) Page 16 Admit on day (90% compliance)

17 Diagnostic work up for patients undergoing panendoscopy and biopsy Page 17 Outcome 6 AIRWAY Airway alert system to formalise communication between anaesthetic and surgical team operating in shared airway Documentation to follow patient outlining issues and plan for management in case of airway embarrassment Patients with difficult airway clearly signed Biannual multi-disciplinary training in Theatre/GCCU and head and neck ward to embed competences. Compliance >95% Evidence for measure NAP4, Nourai et al Tracheostomy independent risk factor

18 MDM Page 18 Diagnosis and treatment plan SURGICAL PATHWAY PART 2

19 Outcome 7: Post MDM patient information Page 19 Patient information relating to treatment modality, morbidities and expectations : My roles, my responsibilities : smoking cessation reinforcement : Getting better together : Timing and dates of surgery : Optimising my dental health screening tool keying dental review : Nutritional screening tool keying dietitics consultation Consent for diagnostic procedures

20 Nutritional bundle for major Head and Neck Surgery Page 20 OUTCOME 8 CARBOHYDRATE LOADING 95% Compliance Pre op drink 21:00 hrs night before surgery Pre op drink 2 cartons 400mls at 5:00 am OUTCOME 9 Documentation of incidence of Malnourishment and dehydration Two days pre op One bottle of fortisip tds One day pre op One bottle of fortisip tds

21 Panendoscopy Outcome 10 (SAME DAY ADMISSION) Page 21 Admit on day (90% compliance)

22 Diagnostic work up for patients undergoing panendoscopy and biopsy Page 22 Outcome 11 AIRWAY Airway alert system to formalise communication between anaesthetic and surgical team operating in shared airway Documentation to follow patient outlining issues and plan for management in case of airway embarrassment Patients with difficult airway clearly signed Biannual multi-disciplinary training in Theatre/GCCU and head and neck ward to embed competences. Compliance >95% Evidence for measure NAP4, Nourai et al Tracheostomy independent risk factor

23 OUTCOME 12 Anti infection bundle Page 23 Wash on day of surgery Antibiotic prophylactic protocol (95%)

24 OUTCOME 13: MAJOR SURGERY ANAESTHETIC BUNDLE Page 24 Anaesthetic protocol (95% compliance) Intra-operative Temperature monitoring/ Rectal temperature Goal directed Fluid therapy (Lidco monitoring) Site an arterial line +/- Central venous catheter: Contralateral to site of likely free flap harvest Urinary catheter BIS monitoring

25 OUTCOME 14: Post operative early rehabilitation Page 25 Wake up on day of surgery (50%) Early return to head and neck ward : Same day (50%) Post operative check list: Handover ITU or Ward (95%) Critical care airway alert system (95% compliance) Enteric feeding commenced within 8hrs (25%) within 24hrs (95%) (Weimann et al 2006 ESPEN Guidelines on enteral nutrition Clinical Nutrition 25: ) Documentation of pain scores Documentation of PONV VTE prophylaxisis (95% compliance)

26 Enhanced Recovery Programme Head and Neck Thyroid Surgery Pathway Ward (circle): BLUNDELL ESTHER Patient Label: AFFIX PATIENT LABEL HERE Admission date (dd/mm) Planned discharge date (dd/mm) Consultant Initials Nurse Led Discharge (circle) Admitted through SAL (circle) Patient swabbed for MRSA at pre-assessment Patient special dietary requirements (circle)? If yes, state here Patient BMI Air mattress used (circle) Diabetic Management Required Patient has had previous chemo radiation therapy Radioiodine Tx Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Day 1 (dd/mm) Named day nurse (+PIN) Named night nurse (+PIN) NURSING Observations Staple remover kept beside bed Observe for haematoma Hourly check of wound Hourly check of drains Post op MRSA swabs Post op cardiovascular observations Monitor fluid balance Diagnostics Calcium level (state) Nutrition Follow a normal diet. Encourage fluid intake if IVAD removed FY1 Indwelling devices Assess if IVAD and drains are safe to remove. Remove IVAD if eating and drinking normally. Ted stockings Medication Review Drug Chart Ensure Prescription Complete Write TTOs Regular paracetamol 1g QDS and PRN analgesia prescribed Thyroxine replacement prescribed Ward round Ward round summary completed in blue notes pages MDT Discharge Planning Send section 2 if required Practice nurse support arranged if needed Mobilisation Patient out of bed Patient for facial nerve rehab / physio Activities of Daily Living Assessment Pain Score Initial Record variance None Mild Moderate Severe If >=1, REVIEW ANALGESIA AFFIX PATIENT LABEL HERE Haematoma Patients with haematoma may have swelling, oozing, pain, bleeding or inflammation Management of surgical drains Check drains hourly. Seek to remove according to protocol Review colour of discharge. Is discharge Red Clear Creamy Review amount of discharge (over 8 hours) Has patient had previous chemoradiation therapy? Yes 0-30ml >30ml No 0-10ml >10ml Has the drain been vacced? Yes No If you trigger a red alert the nurse in charge and doctor Wound management These patients can be susceptible to wound infection. Maintain regular monitoring and ensure urgent medical review if infection detected. Hypocalceamia Patients with Hypocalcaemia may display symptoms such as neuromuscular irritability, muscle cramps, twitching, tingling sensation in fingers and toes, numbness, depression, confusion and / or disorientation. An abnormal reading is <1.8 and should be reported to the nurse in charge and the doctor. 4 DAYS Ward round led by Mr (please circle) SpR (name) Lyons Jeannon Simo Hussain McGurk Patient on track for discharge? 3 DAYS If no, state reason Sign off - Named day nurse Sign off - Named night nurse YES NO

27 OUTCOME 15: BESPOKE CARE PATHWAYS (95%) Page 27 Ward based care pathways specific to operation Laryngectomy +/- free flap Free flap +/- neck disection Neck dissection alone parotidectony Thyroidectomy

28 OUTCOME 16:Mortality morbidity data collection Page 28 Post operative morbidity poms uclh Clavien-Dindo audit at 7 days and 14 days Length of stay (fit for discharge) Post operative morbidity survey at 7-14 days

29 Enhance your recovery: Wallet sized Five year follow up plan

30 OUTCOME 16: SURVEILLANCE Page 30 Traffic light follow up PROTOCOL POST TREATMENT COMPLIANCE WITH PROTOCOL/DATABASE MANAGER POST TREATMENT ORN SURVEILLANCE AND EARLY MEDICAL INTERVENTION WITH DEDICATED FOLLOW UP CLINIC AND MDM POST TREATMENT SMOKING CESSATION INTERVENTION PROVISION

31 Head and Neck Enhanced Recovery programme FIRST Consultation NO CANCER Primary prevention Pre- Operative/ Diagnostic MDM Admission Intra- Operative Radiotherapy/Chemo RT with curative intent SURVEILLANCE Post- Operative D I S C H A R G E 5 YEARS 31

32 AGGREGATION OF MARGINAL GAINS OLD NEWS Everybody's doing it!!!!

33 Overview of Cancer Data Sources Head and Neck Cancers Stephen Scott, LCA senior analyst Please contact for information

34 Lymphoedema in Head and Neck Cancer Martine Huit Lymphoedema CNS, Guy s and St Thomas NHS Foundation Trust LCA Lymphoedema Community of Practice member

35 The London Cancer Alliance Lymphoedema CoP Set up to 2013 to provide expert clinical leadership about lymphoedema in the LCA Long acknowledged that lymphoedema is under-recognised in it s early stages, and that access to services is highly inequitable LCA CoP service mapping and education mapping demonstrated this is the case in the LCA Also known that lymphoedema services are cost effect and that early intervention improves quality of life, patient experience, and reduces GP attendance and need for antibiotics LCA pathway developed as a result

36 The London Cancer Alliance

37 The London Cancer Alliance Head and neck lymphoedema - Overview Following treatment for head and neck cancer patients are often left with persistent side-effects, which may include lymphoedema. Appropriate, early intervention to treat lymphoedema can reduce psychological distress and improve functional ability, improving long term outcomes for patients and reducing cost to the NHS. The DAHNO 2013 (13 th Annual report) acknowledged that co-morbidities impact on outcome for patients but lymphoedema was not included as a co-morbidity. With the introduction of the CHANT team at GSTT, provision of specialist lymphoedema care was not included in their pathway. The development of any future head and neck services within the LCA should consider what resources will be required and how patients will access a lymphoedema specialist.

38 The London Cancer Alliance GSTT Lymphoedema Service In 2014 total number of patients with head and neck lymphoedema = 247 which is equivalent to 35% of the caseload 35% 30% 25% 20% 15% 10% % 0% % Head and Neck Referrals at GSTT from

39 The London Cancer Alliance Development of Pathway Current Pathway Pt seem within 6 weeks of referral Assessed and treatment plan created Discharge when goals achieved; if goals not achieved need to determine underlying cause/s with appropriate referral to members of the MDT Average time registered with clinic = 9 months (other tumour groups 2 20 years) Current ideas under development Pre-assessment education; piloted & discontinued due to: High cancellation rate Low attendance numbers limited opportunity for individuals to share their experience Clinical presentations often complex and not as conducive to group sessions as upper and lower limb lymphoedema Teaching slot in Head and Neck Wellbeing Event Written information on lymphoedema included in GSTT booklets Investigate what support other HCP need to provide basic lymphoedema information to at risk patients Investigate where additional specialist involvement at key points is needed?

40 The London Cancer Alliance Impact of changes to lymphoedema practice Number of MLD appointments reduced from 108 in 2010 to 16 in Average length of time registered with service reduced from 3 years to 9 months for this group of patients Cost effective collar 15 Course of MLD 2300 (10 sessions) Patient reported benefits: Reduced number of visits to the hospital Effectiveness of self management using the collar Improvement in swallowing and voice quality

41 The London Cancer Alliance What next for the head and Neck Pathway Group? What has caused the rise in referrals? GSTT, 2 patients 2007 to 249 in 2014/15) What percentage of patients treated for head and neck cancer go on to develop lymphoedema? Which treatment pathway leads to the highest number of patients developing lymphoedema? Are you providing the right information to at risk patients? Are you putting it in the treatment summaries? Are you referring people with early signs to your local services? How can you take the LCA pathway and the learning from GSTT forward? What else do you need from the CoP?

42 SURGEONS ATTITUDES TOWARDS ADVISING THEIR PATIENTS ABOUT SMOKING CESSATION Francesca Kum Richard Oakley MEd. in Surgical Education Student, Imperial College London ENT SHO, Guy s LCA July 2015

43 BACKGROUND 22% of patients seen in H+N clinic are smokers 73% of upper aero-digestive tract cancers are attributable to smoking and alcohol Known impacts on outcomes Previous research - teachable moment Tang, M., Oakley, R., Dale, C., Purushotham, A., MÃ ller, H. & Gallagher, J. (2014) A surgeon led smoking cessation intervention in a head and neck cancer centre. BMC Health Services Research. 14 (1), 1-8.

44 QUESTIONS & DISCUSSION POINTS 1) Do consultants believe smoking cessation is a priority for their patients? 2) Is the teachable moment, at first point of contact with H+N cancer services used for discussing smoking cessation? 3) What are the barriers or obstacles in discussing smoking and referring patients to cessation services? 4) Are there mechanisms in place for ensuring that a smoking cessation referral is made and acted upon?

45 METHODS Online survey of H+N/MaxFax consultants distribution via the LCA Questionnaires for qualitative component (for MEd. project) mokingadvice

46 RESULTS n=11 H+N = 9 MaxFax = 2

47 RESULTS Who do you think should discuss smoking? [ ] The GP who referred the patient [ ] The Surgeon who first sees them [ ] The Surgeon who gives them the cancer diagnosis [ ] The Surgeon who plans/will perform the surgery [ ] The Oncologist [ ] The cancer specialist nurse

48 RESULTS Who should make the smoking cessation referral? [ ] The GP who referred the patient [ ] The Surgeon who first sees them [ ] The Surgeon who gives them the cancer diagnosis [ ] The Surgeon who plans/will perform the surgery [ ] The Oncologist [ ] The cancer specialist nurse

49 c) Formally referred to smoking cessation services b) Verbally advised to stop smoking a) Verbally discussed their smoking habits All smokers >80% 50-80% 20-50% <20% Did not answer All smokers >80% 50-80% 20-50% <20% Did not answer All smokers >80% 50-80% 20-50% <20% Did not answer RESULTS In the last 6months, estimate the proportion of patients that you have

50 RESULTS Do you know how to refer a patient to smoking cessation services at your trust? No 45% Yes 55%

51 RESULTS Factors preventing/discouraging a smoking cessation discussion: None Consultation time (n=2) Patient s likely engagement (n=2) Obstacles to making a referral: Availability of cessation services Knowledge or referral pathway Resources

52 CONCLUSIONS & PLANS Smoking is discussed BUT a small proportion of patients are formally referred by the surgeon Only 6/11 know how to refer a patient for smoking cessation Recognition of team work required pathway GP H+N service CNS Trust specific model and action plan required

53 THANK YOU