Supportive Care Audit Mercy Hospital for Women - Heidelberg

Transcription

1 Supportive Care Audit Mercy Hospital for Women - Heidelberg Melissa Shand Service Improvement Facilitator NEMICS July 2015

2 Acknowledgments Mandy Byrne NEMICS Cancer and Data Information Analyst Catherine Corrick Service Improvement Facilitator: Mercy Hospital for Women Page 2 of 24

3 Table of Contents 1. Executive summary Background Aim Methodology Results and findings Population Supportive care screening at MHW Distress score Problems identified Screening outcomes Information provided Referrals Discussion Overview of results Recommendations List of graphs Graph 1 Screening location by tumour type Graph 2 Screening clinician by screening location Graph 3 Distress score: Percentage of total screens Graph 4 Distress score by Graph 5 All problems identified: highest to lowest Graph 6 Percentage of screens provided written information Page 3 of 24

4 List of tables Table 1 Number of screens completed... 9 Table 2 Age at time of screen... 9 Table 3 Screens declined... 9 Table 4 Screening location by tumour type Table 5 Screening clinician by screening location Table 6 Distress score: Percentage of total screens Table 7 Distress score by Table 8 All problems identified by domain Table 9 Problems identified: highest to lowest (1 in 5 people identify problem) Table 10 Problems identified by : Fatigue Table 11 Problems identified by : Worry Table 12 Problems identified by : Sadness Table 13 Problems identified by : Fears Table 14 Problems identified by : Nervousness Table 15 Problems identified by : Sleep Table 16 Problems identified by : Pain Table 17 Problems identified by : Tingling in hands/feet Table 18 Problems identified by : Memory / concentration Table 19 Problems identified by : Constipation Table 20 Problems identified by : Family health issues Table 21 Problems identified by : Loss of interest in usual activities Table 22 Percentage of screens provided written information Table 23 Referrals offered Table 24 Offered & made Table 25 Offered & declined Page 4 of 24

5 Supportive Care Audit Mercy Hospital for Women 1. Executive summary The NEMICS regional supportive care audit was initiated by the NEMICS supportive care project officers. This is the first time an audit has been undertaken to identify the supportive care needs of the NEMICS cancer population. From the audit data collected, individual health service information was extracted and evaluated to provide information on the supportive care needs of their cancer population. Using the NCCN Distress Thermometer and Problem Checklist, Mercy Hospital for Women (MHW) audited total of 88 screens on 87 individual patients over an 18 month period, 1 January 2013 to 30 June Due to the oncology services provided at MHW, patients who were screened most commonly were those with gynaecological cancers (92%) and breast (3); most screens were completed by Pastoral care (36%) and nurse and specialist nurse combined (35%). Screening was undertaken within day oncology, specialist clinic and the lymphoedema clinic with the highest number of screens (59%) being completed by specialist clinic. In relation to distress scores recorded, over half of the people screened recorded a score of less than 4 and 40% recorded a score of 4 or above. Broken down by, 36% of screens within the day oncology unit recorded a score of 4 or more, and 42% of screens within the specialist clinic recorded a score of 4 or more. Whilst the precise meaning of distress scores is debated, knowledge that patients attending these services may report greater distress could assist services to monitor patients and provide self-management support or early interventions to reduce the impact of distress. Of the 88 supportive care screens recorded, there were a total of 531 problems identified across all problem domains. Considered by domain, problems were recorded as follows: practical domain 6%; family domain 6.4%; emotional domain 31%; and physical domain 57%. Different numbers of problems are listed in each domain and this needs to be taken into account when interpreting these figures. Emotional and physical domain problems featured with fatigue and worry being identified by just under half of the people screened. Problems with sadness, fears, nervousness, sleep, and pain were also commonly reported. Despite key commonly identified problems; supportive care problems reported by individual patients varied greatly, supporting the use of a checklist to efficiently enable individual patients to flag specific problems. Checklists enable patients to be active in identifying their problems and educates them that experiencing problems is common, and to ask for help. Building patient health literacy to actively recognise and report supportive care problems is important in the setting of great variance in problems reported, increasing numbers of cancer patients and limited resources. At the system-level, opportunities exist to scope existing/develop new evidence-based information resources, interventions and services to more systematically address commonly reported problems. Given the prevalence of fatigue and worry, thought could be given to systematically providing at risk patients early on with evidence-based resources to aid patient health literacy and self-management of these problems. Breaking down the problems identified by could provide opportunities for cancer services to addressing patient needs. Understanding the problems most commonly reported by could assist cancer services and units to take a systematic approach to providing targeted strategies, information and referrals/services early. Page 5 of 24

6 Building capacity in terms of triage and referrals following screening is a work in progress at MHW. Due to variations in the quality of the information relating to this recorded in the medical record, limited conclusions can be drawn from the available data. Of the screens that recorded this information (88), 10% recorded that information had been provided, 86% recorded that no information was provided and a further 4% did not record whether information was provided. Of the 49 referrals recorded as offered, 30 (61%) were made. Referrals audited included only first tier referrals as a result of the supportive care screen; additional referrals made following assessment by the clinician/service referred to were not audited. Most referrals (90%) were made to services provided by MHW. Of these, the services most referred to were: social work (36.6%), GP/doctor (23.3%) and nursing (16.6%). Only 2 of the 30 (6.6%) referrals made were for community services; 1 to a GP and one to Cancer Council Victoria. Data was not collected on why referrals were made to individual services; however given the high number of screens identifying problems in the emotional domain, the higher number of referrals to services to assist with these issues: social work, pastoral care, and counselling (14 referrals or 46.6%) would be expected. In relation to the problems identified in the physical domain, there were 13 referrals or 43.3% made to GP/Dr, physiotherapy, nursing, and dietetics. Given the high prevalence of fatigue amongst the audit sample, the relatively low rates of referral to physiotherapy/occupational therapy/group fatigue management interventions or community rehabilitation services seem unusual and may warrant further enquiry. These audit findings provide an opportunity for MHW oncology services to review a sample of needs identified to consider whether the right supports are in place to address identified needs. The majority of referrals made following screening were to services offered by MHW. Building relationships with cancer-related non-government organisations and community health and rehabilitation services could assist oncology staff to understand the services available, increase access to a broad range of varied services and provide cancer patients with a choice to receive their support services within their local community. NEMICS has commenced initial work to strengthen these relationships and referral pathways. Page 6 of 24

7 2. Background A key priority of the cancer reform agenda is the identification and management of supportive care needs in the cancer population. A priority underpinned by the 2009 policy: Providing optimal cancer care supportive care policy for Victoria. This policy outlines the following strategic directions for supportive care provision: identifying the supportive care needs of people affected by cancer capacity building for optimal supportive care implementing supportive care screening into routine practice addressing supportive care needs referral and linkages. Supportive care (SC) screening using the NCCN Distress Thermometer (DT) and Problem Checklist commenced across the north eastern region of Melbourne in 2010 via a grants program funded by NEMICS. Participating health services included: Austin Health, Eastern Health, Mercy Hospital for Women and Northern Health. Project officers have been located in each of the health services to raise awareness of the supportive care needs of cancer patients, drive implementation and build capacity to address supportive care needs through education and resource development. In 2013, in collaboration with SC project officers, NEMICS developed a supportive care screening database to assist health services to monitor and report on the supportive care issues affecting our cancer population. The database was based on the items within the 2013 NCCN DT and Problem Checklist. 3. Aim The detailed audit described in this report is a selection of the screened population at Mercy Hospital for Women to explore their supportive care needs profile. Analysis of the data includes profiles of population demographics, tumour streams, distress levels, problems identified and referrals made. 4. Methodology All supportive care screens undertaken at Mercy Hospital for Women (MHW) between 1 January 2013 and 30 June 2014 were identified and audited. MHW is a state-wide service providing specialist surgical oncology services for women with gynaecological cancers. Supportive care screening at MHW is undertaken with newly diagnosed cancer patients except for those screened within the Lymphoedema clinic (up to 2 years from diagnosis). The following data was collected for all screens, including those that were declined: Tumour type Age at time of screen Location of screening Treatment at the time of the screen Designation of clinician who undertook the screen. The following additional data was collected on screens with completed Distress Thermometer and Problem Checklist. Distress Score Problems identified on the problem checklist Intervention that occurred at completion of the screen: Page 7 of 24

8 - Did a discussion take place to address the need/s identified? - Was information provided? - Was a referral made? - Service/s referred to. This data provides a snapshot of screening at MHW. Page 8 of 24

9 5. Results and findings 5.1 Population There were 95 supportive care screens using the NCCN Distress Thermometer and Problem Checklist offered at MHW over the 18 month period, 17 were declined resulting in 88 completed screens on 87 patients. Table 1 Number of screens completed Tumour Type Number of screens offered Number of screens declined Number of screens completed Breast Gynaecological Other / not recorded 4 4 Total Age: The majority of women (55%) were 50 to 69 years of age when they undertook the screen followed by those that were less than 50 years (27%) and those that were 70 years or more (18%) Table 2 Age at time of screen Tumour Type Less than 50 years years 70 or more years Total Breast Gynaecological Other / not recorded Total 24 (27%) 48 (55%) 16 (18%) 88 (100%) Declined screens In total there were 105 screens offered at MHW during the audit period with 17 of these screens declined. Table 3 shows the screens declined by. Table 3 Screens declined Screening unit Tumour type Number of screens declined Lymphoedema clinic Breast 8 Day Oncology Gynaecological 3 Surgical Ward Gynaecological 3 Not recorded Gynaecological 3 Total 17 Page 9 of 24

10 5.2 Supportive care screening at MHW Oncology patients receiving active treatment at MHW are likely to receive their treatment within 3 services, the surgical unit, the day oncology unit and specialist clinic (gynaecological oncology outpatient clinic). Graph 1 and table 4 show that at MHW the majority of screening occurred within the specialist clinic followed by day oncology and the lymphoedema clinic. Although 2 screens were offered on the surgical ward, these were declined; therefore no screening occurred on the surgical unit during the audit period. Screening for the 3 breast cancer patients occurred within the lymphoedema clinic. Tumour type by screening location n = 88 1% 59% 32% 8% Day oncology Lymphoedema clinic Specialist clinic Not recorded Graph 1 Screening location by tumour type Table 4 Screening location by tumour type Tumour Type Day oncology Lymphoedema clinic Specialist clinic Not recorded Total Breast 3 3 Gynaecological Other / not recorded Total 28 (32%) 7 (8%) 52 (59%) 1 (1%) 88 (100%) Page 10 of 24

11 Graph 2 and table 5 show that the majority of screening at MHW is undertaken by Pastoral care (36%) and nursing staff (35% - nurses and specialist nurses combined). There is variation in clinicians who undertake the screen by screening location: in day oncology pastoral care undertakes the majority of screening and in the specialist clinic the majority of screening is undertaken by nursing staff. There are a large number of screens (26%) which did not record who completed the screen. Screening clinician by screening location n = 88 Number of screens Allied health Nurse Pastoral care Project officer Specialist nurse Unable to determine Graph 2 Screening clinician by screening location Table 5 Screening Clinician Screening clinician by screening location Day oncology Lymphoedema clinic Specialist clinic Not recorded Total Total % Pastoral care % Unable to determine % Specialist nurse % Nurse % Allied health 2 2 2% Project officer 1 1 1% Grand Total % Page 11 of 24

12 5.3 Distress score Graph 3 and table 6 shows that of the 88 screens that recorded a distress score, almost 60% of patients self-reported a score of less than 4. A score of 4 or above on the Distress Thermometer are generally interpreted as suggestive of higher levels of distress. Approximately 40% of patients at MHW self-reported a score of 4 or above. Distress score Percentage of total screen n = % 2.3% 30.7% 58.0% Less than 4 Between 4 and 8 8 or more Missing Graph 3 Distress score: Percentage of total screens Table 6 Distress score: Percentage of total screens Less than 4 Between 4 & 8 8 or more Missing Total Total number Percentage total 58.0% 30.7% 9.1% 2.3% 100% Page 12 of 24

13 At MHW, Graph 4 and table 7 show a similar spread of self-reported distress levels across s. Percentage of screens 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Distress score by Day oncology Lymphoedema clinic Specialist clinic Missing 8 or more Between 4 and 8 Less than 4 Graph 4 Distress score by Table 7 Distress score by Day oncology Lymphoedema clinic Specialist clinic Not recorded Total Less than Between 4 and or more Missing Total Page 13 of 24

14 5.4 Problems identified Analysis of the problems identified on the problem checklist will not include a comparison with the distress score identified as this relates to a global distress level rather than to individual problems identified by the patient on the problem checklist. Of the 88 supportive care screens completed, there were 531 problems identified across all problem checklist domains. Analysis of problem checklist data found the following: A mean of 6.03 problems A median of 5 problems A range of 0 to 24 problems A standard deviation of Table 8 lists the problems identified by domain and breaks these down to show the percentage each problem contributes to the domain, the total number of problems and total number of screens. Table 8 All problems identified by domain Problems Total ticks % of domain % of total problems % of total screens Number of screens 88 PRACTICAL 32 Child care 1 3.1% 0.2% 1.1% Housing % 0.8% 4.5% Insurance / financial % 1.7% 10.2% Transportation % 0.8% 4.5% Work / school % 1.7% 10.2% Treatment decisions % 0.9% 5.7% FAMILY 34 Dealing with children % 0.9% 5.7% Dealing with partner % 1.5% 9.1% Ability to have children 3 8.8% 0.6% 3.4% Family health issues % 3.4% 20.5% EMOTIONAL 162 Depression % 2.8% 17.0% Fears % 5.3% 31.8% Nervousness % 5.3% 31.8% Sadness % 6.0% 36.4% Worry % 7.9% 47.7% Loss of interest in usual activities % 3.2% 19.3% PHYSICAL 302 Appearance % 2.8% 17.0% Bathing / dressing 2 0.7% 0.4% 2.3% Breathing 6 2.0% 1.1% 6.8% Changes in urination % 2.8% 17.0% Constipation % 3.8% 22.7% Diarrhoea 9 3.0% 1.7% 10.2% Eating 6 2.0% 1.1% 6.8% Fatigue % 8.1% 48.9% Feeling swollen % 2.4% 14.8% Fevers 1 0.3% 0.2% 1.1% Getting around 8 2.6% 1.5% 9.1% Indigestion % 2.4% 14.8% Memory / concentration % 4.3% 26.1% Mouth sores 9 3.0% 1.7% 10.2% Nausea 8 2.6% 1.5% 9.1% Page 14 of 24

15 Problems Total ticks % of domain % of total problems % of total screens Nose dry / congested 9 3.0% 1.7% 10.2% Pain % 4.7% 28.4% Sexual % 1.9% 11.4% Skin dry / itchy % 2.8% 17.0% Sleep % 5.3% 31.8% Substance abuse 0 0.0% 0.0% 0.0% Tingling in hand / feet % 4.5% 27.3% SPIRITUAL 1 Spiritual concerns 1 0.2% 1.1% Total 531 Practical domain: Of the 531 ticks recorded in all domains of the problem checklist, 32 or 6.0% were recorded in the practical domain. There are six problems included in this domain. Overall the greatest proportion of responses related to insurance / financial and work / school. Family domain: Of the 531 ticks recorded in all domains of the problem checklist, 34 or 6.4% were recorded in the family domain. There are 4 problems included within this domain. Overall the greatest proportion of responses related to family health issues and dealing with partner. Emotional domain: Of the 531 ticks recorded in all domains of the problem checklist, 162 or 31% of all ticks were recorded in the emotional domain. There are 6 problems included in this domain with each screen recording at least 2 problems in this domain. Overall the greatest proportion of responses related to: worry, sadness, nervousness and fears. Physical domain: Of the 531 ticks recorded in all domains of the problem checklist, 302 or 57% of all ticks were recorded in the physical domain. There are 22 problems included in this domain with each screen recording at least 3.5 problems within this domain. Overall the greatest proportion of responses related to: fatigue, sleep, pain, and tingling in hands / feet. Page 15 of 24

16 Irrespective of domain, this graph 5 illustrates the problems identified within the problem checklist from those identified most often to least often. People are identifying a range of problems regardless of tumour type following their cancer diagnosis. 60.0% Percentage of problems: Highest to lowest 50.0% Percentage of screens 40.0% 30.0% 20.0% 10.0% 0.0% Graph 5 All problems identified: highest to lowest Practical Family Emotional Physical Spiritual Page 16 of 24

17 Table 9 shows the problems identified irrespective of their domain for the problems most commonly identified. Of the 39 problems listed in the problem checklist a total of 12 were identified by at least 1 in 5 people, with fatigue and worry identified by approximately half the people who completed the problem checklist. All of 12 problems were from the emotional and physical domains with one exception, family health issues which is from the family domain. Table 9 Problems identified: highest to lowest (1 in 5 people identify problem) Problems % of total screens Fatigue 48.9% Worry 47.7% Sadness 36.4% Fears 31.8% Nervousness 31.8% Sleep 31.8% Pain 28.4% Tingling in hand / feet 27.3% Memory / concentration 26.1% Constipation 22.7% Family health issues 20.5% Loss of interest in usual activities 19.3% Tables 10 to 21 break down the most commonly identified problems by. There is potential for s and the MHW oncology service to use this information to address commonly identified problems. Investigating the causes for these problems may assist in implementing strategies to minimise their causes and impact. Table 10 Problems identified by : Fatigue Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Table 11 Problems identified by : Worry Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Table 12 Problems identified by : Sadness Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Page 17 of 24

18 Table 13 Problems identified by : Fears Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Table 14 Problems identified by : Nervousness Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Table 15 Problems identified by : Sleep Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Table 16 Problems identified by : Pain Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Table 17 Problems identified by : Tingling in hands/feet Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Table 18 Problems identified by : Memory / concentration Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Page 18 of 24

19 Table 19 Problems identified by : Constipation Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic Specialist clinic % Not recorded Table 20 Problems identified by : Family health issues Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Table 21 Problems identified by : Loss of interest in usual activities Screening Unit Number of ticks Total screens by % of total screens by Day Oncology % Lymphoedema clinic % Specialist clinic % Not recorded Page 19 of 24

20 6. Screening outcomes After patients complete the screening tool, a conversation with a health professional assists to clarify the patient s perception of identified problems and address needs through information provision, triage and referral. This conversation is a key component of the screening process recommended by the Victorian Department of Health and Human Services. The following data provides an insight into the outcomes of this discussion at MHW. 6.1 Information provided Graph 6 and Table 22 provide a picture of the level of information provided to patients following a screen. In total, 86 of the 88 screens completed recorded whether information had been provided. Of these, only 9 screens recorded providing written information. It is difficult to determine if this is an appropriate rate of information provision as there are a number of factors that may have influenced this figure, including: - Information provision was not always recorded on the supportive care medical record form - Information may have been offered but declined by the patient - Information may have been provided prior to the screening event % of screens provided written information 1.1% 2.3% 86.4% 10.2% Yes No Not applicable Unable to determine Graph 6 Percentage of screens provided written information Table 22 Percentage of screens provided written information Was written information provided? Yes No Not applicable Unable to determine Total % 86.4% 1.1% 2.3% 100.0% Page 20 of 24

21 6.2 Referrals Tables 23, 24 and 25 show the referrals that were offered, those that were made and those that were declined. Referrals were most commonly made to services provided by MHW and were made to social work services. Of the 9 referrals offered for psychology, none were made. Looking at commonly identified physical domain problems such as fatigue, sleep and pain, we notice very few referrals are being made to services that would potentially work to alleviate these problems. Referrals to community rehabilitation services are notably absent. However, this audit only included screens for newly diagnosed cancers which may explain the lack of referrals in this early stage of treatment. Given emerging evidence about the importance of exercise interventions for fatigue, further investigation is recommended in this area. Table 23 Referrals offered Referral services Total referrals offered Social work 13 Psychology 9 GP/ doctor 8 Nursing 5 Counselling 4 Look Good Feel Better Program 4 Other 2 Pastoral Care 2 Cancer Council Victoria 1 Dietetics 1 Grand Total 49 Table 24 Offered & made Referral services Health service Community Unspecified Grand Total Social work GP/ doctor Nursing 5 5 Pastoral Care 2 2 Cancer Council Victoria 1 1 Counselling 1 1 Dietetics 1 1 Look Good Feel Better Program 1 1 Other 1 1 Grand Total Table 25 Offered & declined Referral services Health service Community Unspecified Grand Total Psychology Counselling 2 2 Social work 2 2 Look Good Feel Better Program 1 1 Other 1 1 Grand Total Page 21 of 24

22 7. Discussion 7.1 Overview of results Population: Age at which screening occurred at MHW reflects the age at which cancer is diagnosed for gynaecological cancers across the state. The audit provided a clear picture of where screening occurs at MHW and allows some comparison between s. For future audits it would be beneficial to collect specific cancer type rather than generally grouping cancer diagnoses into gynaecological cancers. This would enable analysis of selfreported distress and problems identified by specific cancer type providing opportunities for identifying issues and interventions specific to patient s needs. Distress score: Overall, recorded distress scores followed the expected pattern with most people identifying a score of less than 4, fewer people identifying a score of between 4 and 8 and fewer still identifying a score of 8 or more. This pattern was consistent across tumour type and. Problem checklist: This study demonstrated that there are many (531) problems identified by cancer patients at MHW. Some problems such as fatigue and worry were identified by approximately 50% of screens. Variability in problems identified reinforces the value of using a problem checklist to assist patients to actively identify their individual needs. Worry, sadness, fears and nervousness were the most commonly identified emotional domain problems. Increasing awareness of the high prevalence of these problems and implementing strategies early to assist people to manage the impact of these could assist in the early identification and management of these problems. Fatigue, sleep and pain remain the most commonly identified physical domain problems. Problems with fatigue and sleep can often be addressed in group sessions and through referral to allied health professionals working within community health/rehabilitation centres who specialise in these areas. Opportunities and collaborations should be investigated to support greater understanding of community-based services and strengthened linkages between services. NEMICS is currently undertaking work in this area and should be consulted in relation to this work. The Problem Checklist assists people to actively identify problems specific to them from a list of 39 across 5 domains. Additional benefits of the checklist are to educate individuals that these problems are common, it is OK to ask for help and there is help available. We need to ensure that after a supportive care screen is completed, a discussion with a skilled health professional takes place and actions/referrals are agreed upon and completed. Of 9 referrals offered to psychological services, none were made. Given that problems within the emotional domain were commonly identified, further work is required to investigate the issues and barriers in relation referrals for psychological support. Page 22 of 24

23 Screening outcomes: At present screening outcomes are recorded on the supportive care screening medical record form and the quality of data collected depends on the accuracy of what is recorded. The data collected reflects first tier referral data only and does not record further referrals made by the clinician to which the original referral is made. The number of referrals made to address problems did not necessarily reflect the number of times a problem was identified. Of the 49 referrals offered to address identified problems only 30 were actually made. The importance of the conversation that accompanies screening cannot be underestimated in assisting the patient to determine how best to address their needs. It is difficult to evaluate whether the type and amount of information and referrals offered are appropriate from the information recorded by clinicians. Further work is required to investigate this issue. Knowledge of psychosocial services (health service & community), referral pathways, and the availability of acute and community allied health and psychosocial clinicians to refer to may impact on referrals offered. 8. Recommendations Methodology: All supportive care screens for the time period were audited providing a picture of the supportive care needs of the cancer population at MHW. Modifying the supportive care medical record form to collect data on specific cancer type, for example, ovarian, uterine and endometrial, may assist MHW to target interventions to specific patients to better address their needs. Distress score: Further investigation into causes of distress to provide guidance for strategies to support patients during this time is required. This audit has identified different rates of self-reported distress according to tumour type and unit in which the screening occurs. Problem Checklist: This is the first time an audit has been undertaken to identify the supportive care needs of a large sample of the MHW cancer population. It provides a unique opportunity to use these findings and to collaborate with consumers to identify the issues patients are experiencing by tumour type and by screening location. The audit also provides an opportunity for individual services to develop strategies to address commonly reported needs. Results from the audit provide an opportunity for MHW, in collaboration with other NEMICS region oncology services, to take a region-wide approach to address gaps in service. This audit identified the most commonly recorded problems across all domains in the Problem Checklist. Problems within the emotional and physical domain were identified most often. In addition, patients identified fatigue as a problem approximately 50% of the time. Consideration could be given to interventions to assist patients to manage fatigue early in their care. Page 23 of 24

24 Screening outcomes: Further work is required to determine the best method of capturing more detailed triage and referral data. There is an opportunity to better understand the relationship between reported distress, problems identified, what occurs during the discussion and the actions and referrals taken. Understanding these relationships may assist in planning services to address supportive care needs and to build relationships with cancer NGOs and community services to best support patient needs. This audit focused only on information recorded on the supportive care screening tool medical record form. To capture and understand second tier referrals a more detailed medical record audit is required. Further research into the local patient experience of screening to determine whether the subsequent discussion, information provision and referrals made met individual patient needs is recommended. Since undertaking this audit, a dedicated psychiatry clinic has commenced within the service. As there were no referrals accepted for psychology during the timeframe of the audit, repeating the audit following the implementation of this clinic may provide some interesting data on the impact of this clinic for patients. Page 24 of 24