SELF ASSESSMENT REPORT (MULTI-DISCIPLINARY TEAM)

Transcription

1 SELF ASSESSMENT REPORT (MULTI-DISCIPLINARY TEAM) Network Trust MDT MDT Lead Clinician CSCCN PORTSMOUTH HOSPITALS Portsmouth Colorectal MDT (11-2D-1) /12 Daniel OLeary Compliance Self Assessment COLORECTAL MDT COLORECTAL LOCALITY MEASURES 87.8% (36/41) Self Assessment 100.0% (2/2) Key Themes Structure and function of the service The Portsmouth Colorectal MDT has been running since 1999 and meets weekly at 8-10 a.m. in the Seminar Room, ITU, Queen Alexandra Hospital, Cosham, Portsmouth. There are facilities for displaying and reviewing radiology but not histopathology. Anal MDT shared with Chichester meets alternate Tuesday mornings at in the Oncology Centre Seminar Room, with similar facilities (one surgeon and clinical oncologist from the larger colorectal MDT start in the Anal MDT on these occasions). Chichester take part by video-link. An attendance record is taken. The most recent Business Meeting of the MDT was on when this document was approved. The Colorectal and Anal MDT includes all of the required core members including Clinical Nurse Specialist support. The number of CNSs is approximately 2 FTE for a catchment population of 550,000 with approximately 310 newly diagnoses patients per year. New patients diagnosed July June 2011 A total of 312 patients received a new diagnosis of colorectal cancer in this year. -The total number of CT scans was 379, some patients requiring more than one CT scan -97 MRI scans were carried out among 110 patients diagnosed with rectal cancer ( patients with obviously extensive disease on CT or who were deemed unfit for operation often had CT scans only. Compliance with waiting time standards July June 2011: SELF ASSESSMENT REPORT for Portsmouth - Colorectal MDT (published: 30th September 2011) Page: 1/6

2 2 Week Wait Clinics: 1574 patients were referred to the 2WW colorectal clinics by their doctors with suspected colorectal cancer. The proportion seen within target time was 92%. Compliance with treatment time standards (FDT= First decision to treat):. Among 62 day standard patients -99 had surgery as their first treatment. 44% had their operation within 62 days. -60 had oncological treatment as their first treatment. 53% had treatment within 62 days Among 31 day standard patients -112 had surgery as first treatment. 97% had their operation within 31 days*. -38 had oncological treatment as first treatment. 100% had treatment within 31 days* *All 62 day patients have to meet the 31 day target as well with regard to timely treatment within 31 days of decision re treatment. The percentages include these 62 day patients. Comment: The 31 day figures indicate that delays to treatment are infrequent once the MDT has decided treatment, whether by surgery (97% within target time) or oncological treatments (100% within target time). In contrast, a relatively high number of patients breached the 62 day treatment standard (56% where surgery first treatment, 47% where it was oncological). Investigation of the cause has highlighted the difficulty in getting patients with possible or actual colorectal cancer through the diagnostic phase in a timely manner. This was also a feature of the internal peer review carried out in In particular, the capacity for CT pneumocolons and ability to report them in a timely manner remain unresolved. Approximately 50% of patients with colorectal cancer in Portsmouth will require a further test after staging. These include MRI after CT has shown liver metastases, colonoscopy to confirm an equivocal radiological finding or perhaps attempt polypectomy, endorectal ultrasound where a cancer might be T1. These additional tests add to delay, making it imperative that the earlier workup happens faster so the patient can have a management decision with enough time remaining to implement it without breaching. Working in times of economic difficulty it is hard for the hospital to provide the variability in diagnostic capacity and reporting that is required to match the variability in demand. Radiology and endoscopy sessions run at near full capacity. The likely solution will be to provide dedicated sessions (isolated from other clinical demand) for cancer evaluation and management within these services. Coordination of care/patient pathways The colorectal and anal MDT in Portsmouth has been largely responsible for writing the CSCCN Network Guidance and Pathway of care documents. It adheres to this guidance. Once diagnosed, details are sent to the patient's GP by fax within 24 hours. This works well in SELF ASSESSMENT REPORT for Portsmouth - Colorectal MDT (published: 30th September 2011) Page: 2/6

3 clinic and is being worked on following emergency admission when we strive to provide the same service. Communication with patients utilizes nationally available booklets and a local booklet which describes the care, processes and personnel in Portsmouth. All patients are assigned a Key Worker and details of how to contact the Clinical Nurse Specialists and MDT Office as well as other agencies within the hospital and nationally. Patients are given a brief handwritten summary of their diagnosis and investigation plan after diagnosis and a copy of the typewritten letter detailing their agreed management after MDT meeting and discussion with the patient. This serves as an individualized patient-focused management plan detailing diagnosis, stage, treatment options and rationale for treatment chosen. After surgery, Follow-Up is protocolized and standardized. Many patients now enter a virtual follow up clinic run by our CNS Sister. Follow up after rectal cancer resection continues in surgical consultant --led clinics. Patient care is at times generic or pooled so as to speed it up, especially with regard to operations. This approach is a direct response to DoH requirements. In this setting the role of the MDT Coordinator and Clinical Nurse Specialists is crucial in ensuring that patients are kept informed of events and kept "on target". Patient experience National Patient Experience Survey Portsmouth Hospitals NHS Trust as a whole was in the lowest 20% of Trusts in this national survey. This was taken very seriously by the Trust and action plans were formulated to improve patient experience. The colorectal service fared below national average in 54/59 questions in the NPES. Much of the survey focuses on communication, attitudes and perceptions. These have been difficult to maintain at a high level in what has become a very generic service in Portsmouth with pooling of patients for diagnostics, counselling and treatment. A key issue may be the small number of CNSs in relation to clinical caseload (1 FTE / 160 patients). Since the survey was done, the colorectal service has made changes to our processes and service (e.g. patients now receive a letter summarizing the discussion they have had concerning their agreed treatment plan and its rationale; an in house local patient experience survey is underway) which should improve our patients experience of their care. Clinical outcomes/indicators (Please note that the time period for this data set is April March 2011 so slightly different from the data in the first part of this document). Among 337 patients diagnosed with colorectal cancer 247 underwent surgery (elective or emergency). -The major resection rate was 68% of all patients with colorectal cancer (231 /337) and 93.5% among those undergoing operation (231/247). -27% did not undergo operation due to extensive disease, comorbidity / frailty / patient wishes SELF ASSESSMENT REPORT for Portsmouth - Colorectal MDT (published: 30th September 2011) Page: 3/6

4 Among 231 patients undergoing elective or emergency resection: -Overall mortality rate was 2.6% (0.5% elective, 11.9% emergency) -5% returned to theatre. -13% were readmitted (14% after elective operation, 7% after emergency operation) Among the 189 elective surgical resections -77% were completed laparoscopically. -mortality rate was 0.5% at 30 days viz: 0% after laparoscopic, 2% after open resection In national terms this is a very high rate of laparoscopic resection with a very low mortality rate. Readmission rates are relatively high. In part, this reflects the move to earlier discharge and enhanced recovery. Patients are counselled before discharge regarding features that should prompt readmission. Patients having open or emergency operations stay longer and readmission rates are lower. Trial Recruitment 88 patients recruited to national colorectal oncology trials Apr 2010-March 2011 Key Audit Projects: Investigation patterns of patients following staging of colorectal cancer: Fully 50% of patients who had been staged and brought to the MDT meeting required an additional investigation before a management plan could be advised. Mortality after emergency surgical procedures for colorectal cancer: The colorectal unit undertook an audit in 2010 because the mortality rate in this group was >15%. The unit reported this to the MD and CEO. Although the percentage was high the actual number of patients involved is small (5 in a year). Audit of deaths suggested that greater attempts need to be made to avoid surgery in patients not likely to benefit (but these are often difficult to define with confidence), greater use of stenting with referral to other centres at times when stenting may not be available in Portsmouth and greater availability of CT scanning after emergency admission. The mortality rate in this group in the past year dropped to 11.9%. NBOCAP: Portsmouth contributes data on all of its patients with colorectal cancer to the National Bowel cancer Audit Project and has done so since its inception. Network Audit of Laparoscopic Colorectal cancer Resection This project, adopted by the CSCCN, was set up by Portsmouth and documents the evolution of laparoscopic cancer resection in 7 hospitals covering a population in excess of 2 million. 57% of resections were completed laparoscopically with shortened hospital stay and no compromise of oncological markers of quality. Good Practice Good Practice/Significant Achievements -"One stop" 2WW clinics offering flexible sigmoidoscopy SELF ASSESSMENT REPORT for Portsmouth - Colorectal MDT (published: 30th September 2011) Page: 4/6

5 -Nurse led MDT clinic to discuss MDT advice with patients -Letters to patients detailing agreement to MDT treatment plan and its rationale as a personalized patient-focused record. -National Training Centre in Laparoscopic Colorectal Cancer Resection (Lapco) -> 75 % of elective resections achieved laparoscopically. -Enhanced recovery programme -Surgical High Care Unit for greater safety in recovery -Nurse-led virtual follow up clinics -Significant record of initiating and leading local and Network audits -Replacement 5th substantive consultant colorectal consultant post to be filled 2011 Concerns Immediate Risks Serious Concerns Failure to meet 62 day target Current difficulty in meeting 62 day target largely due to delay in the diagnostic / staging phase of patients journey. Potential solutions identified. Additional designated staging scan slots (ring fenced) being negotiated with radiology. IT infrastructure being put in place to enable outsourcing of CT reports via PACS, to support capacity at periods of annual leave. Colonoscopy capacity being expanded. Concerns No reliable funding for data collection / audit Data collection for NBOCAP and other outcomes reliant on highly skilled and dedicated research coordinator who receives no funding from the hospital and whose income is dependent on unpredictable "soft" money from varying sources on a 6-12 monthly basis. Need for more Clinical Nurse Specialists Our ratio of newly diagnosed patients to CNSs is the highest in the Network by a large margin. It is likely that the limited time that they have for interaction with the patients is detrimental to SELF ASSESSMENT REPORT for Portsmouth - Colorectal MDT (published: 30th September 2011) Page: 5/6

6 communication, understanding, confidence and ultimately patient satisfaction as reflected in the NPES. General Comments The clinicians in the Colorectal MDT in Portsmouth work well as a team. Many, both medical and nursing, are committed and talented individuals. This is evidenced by excellent clinical outcomes and successful adoption of advancing technologies such as laparoscopic resection. However, our processes need to be speeded up to ensure treatment within target times and our patients need to receive and perceive a better experience as evidenced in the national survey. Organisational Statement I, Daniel OLeary (Lead Clinician) on behalf of PORTSMOUTH HOSPITALS agree this is an honest and accurate assessment of the Colorectal MDT. SELF ASSESSMENT REPORT for Portsmouth - Colorectal MDT (published: 30th September 2011) Page: 6/6