Annual Report 2012 - Head and Neck - FINAL · 11-2I-148 Joint Treatment Planning for TYAs p20 p15...

University Hospitals Bristol NHS Foundation Trust

Royal United Hospital Bath NHS Trust

Annual Report Head and Neck MDT

2 Annual Report - Head and Neck MDT

Agreement and Approval

Head and Neck MDT Lead Clinician Ceri Hughes

Date 28/09/2012 Signature (agreed via email)

Review Date

Annual Report Review Date: 01/07/13

Versions

Version Date Reason Sign Off

1.0 11/07/10 Draft revision for 2011 Peer Review

2.0 May 2012 2012 report produced 28/09/2012

Annual Report - Head and Neck MDT 3

1 Measure Checklist

Core MDT Measures

Measure Number

Measure Operational Policy

Annual Report

Work Plan

Supporting Information

11-2I-101 Single named lead clinician and core team membership

p11, p15

11-2I-102 Named Restorative Dentist Core Team Member

p11

11-2I-103 Level 2 practitioners for Psychological Support

p23 p12

11-2I 104 Support for level 2 practitioners p23 p12 p5

11-2I-105 Team attendance at NSSG meetings p8

11-2I-106 Meet weekly and record core attendance & protocols for referral to next scheduled meeting

p17, p19

11-2I-107 MDT agreed cover arrangements for core member

p11

11-2I-108 Core member (or cover) present for 2/3 of meetings

p8-10

11-2I-109 Annual meeting to discuss operational policy p20 p6

11-2I-110 Policy for all new patients to be reviewed by MDT

p17

11-2I-111 Policy for communication of diagnosis to GP p21 p18

11-2I-112 Operational policy for named key worker p23 p18

11-2I-113 Operational policy for Principle Clinician p16

11-2I-114 Histopathology core members participating in EQA scheme

p26 p20 p7

11-2I-115 Core nurse member completed specialist study

p12-13

11-2I-116 Agreed responsibility for core nurse members p15

11-2I-117 Attendance at national advanced communication skills training programme

p12

11-2I-118 Operational Policy specifying discharge criteria

p24

11-2I-119 Aftercare and Rehabilitation protocol p25

11-2I-120 Clinical follow up protocol p25

11-2I-121 Core Clinical team members spending 50% of care on UAT cancer

p12

11-2I-122 Agreed service specification for rescue of reconstructive surgical flap

p24 p8

11-2I-123 Agreed policy for patients to discuss treatment options

p19

11-2I-124 Extended membership of MDT p13-14

11-2I-125 Patient permanent consultation record p22 p9

11-2I-126 Patient experience exercise p26 p22 p8 p10-11


Core MDT Measures

Measure Number


Annual Report

Work Plan


11-2I-127 Provision of written patient information p22 p23-24

11-2I-128 Pre-treatment assessment sessions p19

11-2I-129 Agree and record individual patient treatment plans

p17 p11 p12-15

11-2I-130 MDT/network agreed referral guidelines between teams/diagnosis & assessment

p24

11-2I-131 Single named designated hospital for surgical procedures

p8

11-2I-132 MDT/network agreed imaging guidelines diagnosis/assessment

p24

11-2I-133 MDT/network agreed pathology guidelines diagnosis/assessment

p24

11-2I-134 MDT / Network agreed treatment clinical guidelines

p24

11-2I-135 MDT/network agreed collection of minimum dataset

p27

11-2I-136 MDT/NSSG agreed participation in network audit

p26 p18 p9

11-2I-137 MDT/NSSG agreed list of approved trials p26 p21 p10

11-2I-138 MDT to discuss at least 100 new cases per year

p14

11-2I-139 Named core team members for thyroid cancer

p11

11-2I-140 Extended membership for thyroid cancer p13

11-2I-141 MDT/network agreed imaging guidelines diagnosis/assessment for thyroid cancer

p24

11-2I-142 MDT/network agreed pathology guidelines diagnosis/assessment for thyroid cancer

p24

11-2I-143 MDT / Network agreed treatment clinical guidelines for thyroid cancer

p24

11-2I-144 Network Audit for thyroid cancer p26 p19 p9

11-2I-145 MDT/NSSG agreed list of approved trials for thyroid cancer

p26 p21 p10

11-2I-146 MDT Agreement to Network Surgeon Authorised to Perform Lymph Node Resections

p24

11-2I-147 Provision of Written Patient Information for Thyroid Cancer

p22 p23-24

11-2I-148 Joint Treatment Planning for TYAs p20 p15

Locality Measures

11-1D-101i Named Members of the Local Support Team p14

11-1D-102i Provision of Neck Lump Clinics p19

11-1D-103i Provision of thyroid clinics p19

11-1D-104i Designated Clinicians p12


Core MDT Measures

Measure Number


Annual Report

Work Plan


11-1D-105i HDU and ITU on site p8

11-1D-106i Written Policy for a Named Specialist Head and Neck Ward

p8

11-1D-107i Registered Nurse Staffing p8

11-1D-108i Named Speech and Language Therapist p8

11-1D-109i Named Dietician p8


2 Contents

1 Measure Checklist ......................................................................................................................... 3

2 Contents ........................................................................................................................................ 6

3 Introduction .................................................................................................................................... 7 3.1 Key Achievements ................................................................................................................ 7 3.2 Key Challenges ..................................................................................................................... 7

4 Meetings Attendance ..................................................................................................................... 8 4.1 MDT team attendance at the NSSG Meetings ....................................................................... 8 4.2 Core MDT Meeting Attendance ............................................................................................. 8

5 Operational and Developmental Meetings ................................................................................... 11

6 Training ....................................................................................................................................... 12 6.1 Advanced Communication Skills Training ............................................................................ 12 6.2 Level 2 Psychological Support Training ............................................................................... 12 6.3 Donna Graham - Qualifications and Courses ...................................................................... 12

6.3.1 Qualifications: .................................................................................................................. 12 6.3.2 Courses ........................................................................................................................... 13

6.4 Claire Coogan - Qualifications and Courses ........................................................................ 13 6.4.1 Qualifications: .................................................................................................................. 13 6.4.2 Courses ........................................................................................................................... 13

6.5 Courses ............................................................................................................................... 13

7 Data Collection and Clinical Lines of Enquiry ............................................................................... 14 7.1 Workload of MDT ................................................................................................................ 14

7.1.1 New diagnoses of cancer discussed by the MDT ............................................................ 14 7.1.2 New diagnoses (including recurrence/metastasis) by treatment type ............................... 15 7.1.3 Surgical cases by responsible consultant ........................................................................ 15

7.2 TYA patients ....................................................................................................................... 15 7.3 Clinical Lines of Enquiry ...................................................................................................... 16

8 Audit and Local Audit ................................................................................................................... 18 8.1 GP Notification within 24hours – Audit of Compliance ......................................................... 18 8.2 Key Worker Policy – Audit ................................................................................................... 18 8.3 Network Agreed Audits ........................................................................................................ 18 8.4 Other Audits ........................................................................................................................ 18 8.5 Audit in relation to Thyroid Cancer ...................................................................................... 19 8.6 EQA Audit ........................................................................................................................... 20

9 Research and Clinical Trials ........................................................................................................ 21

10 Patient and Carer Feedback and Involvement .................................................................. 22

Appendix 1 Patient Information ..................................................................................................... 23 1.1 Macmillan / Cancer Backup materials for People affected by cancer. .................................. 23 1.2 Other resource Leaflets ....................................................................................................... 23


3 Introduction

This report relates to the operational period April 2011 to March 2012. This period has seen a number of issues, challenges and successes as outlined below.

The focus of effort for the head and neck team has been the achievement of agreement to a merged Service across the greater Bristol conurbation, whilst maintaining excellence in the service.

An integrated Head and Neck service for Bristol and the ASWCS region has been achieved, with a single MDT serving the region. RUH Bath joined this single MDT from April 2012 and no longer holds a local meeting. Therefore documentation is being submitted by UH Bristol as host of this multi-organisational MDT.

The second tranche and arguably more difficult is the physical and policy integration of Head and Neck services in Bristol on one site. This complex piece of work continues to dominate the development work the MDT, at least for the first part of the year. Currently the centralisation is planned to take effect from autumn 2012, with a staff consultation due to begin in mid-May.

Additional key achievements and challenges are outlined below.

3.1 Key Achievements

Maintaining clinical engagement in centralisation process

Introducing teleconferencing

Advertised for new additional head and neck pathologist

Obtained outline approval for refurbishment of MDT clinic area to a purpose built functional and patient centred environment

Agreement of theatre plans for new centralised surgical service

Work progressing towards enhanced recovery and day-of-surgery admission

Established ‘Head and Neck 5000’ NICR research project (over 600 recruited nationally, 80 in Bristol)

Significant improvements to recruitment to other trials

3.2 Key Challenges

Implementation of centralisation

Improve the quality of patient experience with regard to dental screening, rehabilitation and ongoing care

To continuously improve the data capture and submission of information to the DAHNO audit, gaining a better understanding of the technical factors that affect upload of information into the national database and finding mechanisms to better monitor the quality of data throughout the year


4 Meetings Attendance

4.1 MDT team attendance at the NSSG Meetings (11-2I-105)

The Head and Neck NSSG held the following meetings during April 2011-March 2012, with the MDT represented as follows.

Meeting Date Name Job Title

17th

June 2011 Ceri Hughes John Waldron Phil Guest Graham Porter Emma de Winton Hoda al Booz Rebecca Davies Miranda Pring

Surgeon and MDT Lead Surgeon (RUH) Surgeon (UHB) Surgeon (UHB) Oncologist (UHB) Oncologist (UHB) Radiologist (UHB) Pathologist (UHB)

2nd

December 2011 Ceri Hughes John Waldron Matthew Beasley Phil Guest Graham Porter Steve Thomas Darren Pinder Antonio Orlando Paul Tierney Hoda al Booz Susan Armstrong Mandy Williams Rebecca Davies Caroline Calder Morwenna White-Thompson Jane Beckinsale Michelle Taylor Caroline McGill

Surgeon and MDT Lead Surgeon (RUH) Oncologist (UHB) Surgeon (UHB) Surgeon (UHB) Surgeon (UHB) Surgeon (RUH) Surgeon (NBT) Surgeon (NBT) Oncologist (UHB) Radiologist (NBT) Radiologist (UHB) Radiologist (UHB) Pathologist (UHB) SaLT SaLT SaLT SaLT

Overall % Attendance 100

For further details of the meetings please see the Network Annual Report

4.2 Core MDT Meeting Attendance (11-2I-108)

During April 2011-March 2012 the MDT held 51 meetings, with one cancellation due to a national holiday. The cancellation was carefully planned to ensure patient pathways were not unduly delayed as a result.

Role % attendance 11/12

Lead Clinician for MDT 80%

3 Surgeons 96% (98% 2 or more)

2 Oncologists (inc nuclear medicine) 62% (92% with 1 or more)

Histopathologist 96%

Imaging Specialist 96%

Nurse Specialist 92%

MDT Coordinator 96%


Ward Nurse* 0%

Speech and Language Therapist 88%

Dietician 53%

Restorative Dentist 78%

Endocrinologist** 0%

Nuclear medicine specialist 92%

* There is not a ward nurse member for the MDT due to lack of availability **An endocrinologist does not routinely attend the MDT, as this was not felt to be beneficial. A full breakdown of MDT meeting attendance for core MDT members for period 1 April 2011 to 31 March 2012 is as follows. Changes to the job plans for two surgeons in the second half of the year saw good attendance by all surgeons in the second half of the year.

Name Role % attendance

Ceri Hughes Lead Clinician for MDT, Surgeon 80%

Phil Guest Surgeon 75%

Steve Thomas Surgeon 49% (72% after job plan change)

Graham Porter Surgeon 73%

David Baldwin Surgeon 75%

Paul Tierney Surgeon 55% (72% after job plan change)

John Waldron Surgeon 75%

Hoda Booz Clinical Oncologist 77%

Matt Beasley Clinical Oncologist 78%

Mandy Williams Radiologist 43%

Julian Kabala Radiologist 45%

Sue Armstrong Radiologist 75%

Miranda Pring Histopathologist 84%

Paul Wilson Restorative Dentist 61%

Donna Graham CNS 69%

Claire Coogan (started March 2011) CNS 78%

Nikki Turner MDT Co-ordinator 82%

Laura Black Dietitian 53%

Jane Beckinsdale Speech and Language Therapist 73%

Karin Bradley Endocrinologist 0%

The RUH Bath held separate MDTs during the review period and therefore the attendance for these meetings is reported separately.

Name Role % attendance

John Waldron Lead Clinician for MDT, Surgeon 78%

Darren Pinder Surgeon 71%

Emma de Winton Oncologist 72%

Stewart Redman Radiologist 61%

Caroline Styles Radiologist 65%


Simon Rose Histopathologist 80%

Fiona Mackay CNS 80%

Carol Cook CNS 7%

Rachael Goble MDT Co-ordinator 85%

Nick Bergin Dietician 59%

Michelle Tayler Speech and Language Therapist 80%

Thomas Tylee Research Nurse 2%


5 Operational and Developmental Meetings

As the MDT members are also core members of the SSG, in order to avoid duplication and make best use of time, the SSG meetings are used to discuss operational issues and updating of the operational policy.

Attendance is high at the SSGs and thus all members have the opportunity to feed into discussions.

A synopsis of themes:

Centralization

Increasing workload and no additional clinical time

Data capture – specifically electronic proforma for referral to MDT and use of Somerset Cancer Register

Provision of Radiotherapy Taunton

Thyroid Cancer – Local Guidelines

In addition to the above there is a weekly departmental meeting which discusses operational issues.

The most recent SSG and operational meeting was held on 15th May 2012 and minutes are available in the supporting information on page 6. There followed a presentation on the Somerset Cancer Register, discussion about data quality, and clinical lines of enquiry.


6 Training

6.1 Advanced Communication Skills Training (11-2I-117)

The following core members of the MDT with direct clinical patient contact have attended the National Advanced Communication Skills training:

Ceri Hughes, 28th-29th February 2012

John Waldron 22nd-24th March 2011

Graham Porter, 23rd-26th June 2010

Hoda Booz, 22nd-24th March 2010

Matt Beasley, 23rd-26th June 2010

Clare Coogan 15th-17th June 2011

Donna Graham, 11-13th October 2011

Jane Beckinsale, 7th-9th December 2011 The following members have booked to attend future courses:

Paul Tierney The remaining members of the MDT intend to attend the training as more courses become available.

6.2 Level 2 Psychological Support Training (11-2I-103,104)

Donna Graham has undertaken the Trust’s Network approved training to provide level 2 psychological support for patients and carers. She undertook the course on 24th and 25th May 2012.

She undergoes monthly clinical supervision with a level 4 clinical psychologist for one hour per month. A copy of the timetable is available in the supporting information on page 5.

Claire Coogan has undertaken a communication module as part of her Masters in Cancer Care course.

She undergoes monthly clinical supervision via the following methods:

Individual meetings with Lead Cancer Nurse at NBT

Access to group supervision run by clinical psychologists

6.3 Donna Graham - Qualifications and Courses (11-2I-115)

6.3.1 Qualifications:

BSC (Hons) Nursing with RGN Certificate , University of the West of England, Third class, 1999

Assessor and Mentor Course with Distance Learning, University of the West of England, Pass, 2000

Aural Care for E.N.T and Community Nurses, Addenbrookes N.H.S Trust, Pass, 2000

E.N.B Specialist Facio Maxillary Module - NURA 370, E.N.B University of Plymouth, , Pass, 2000

E.N.B Acute Care Specialist Practice, University of Plymouth, Pass, 2002

Masterclasses in Head and Neck Cancer - MSC Level 20 credit Module, University of the West of England, Pass, 2009/10


6.3.2 Courses

Surgical Voice Restoration Course Intermediate level, Macmillan, 2 days, 2003

Care of the critically Ill Patient through Simulation, UBHT, 1 day, 2001

Managing Complications in Surgical Voice Restoration. Macmillan, 1 day, 2005

UHB - Bereavement Support, Breaking bad news and Difficult conversations Level 3, UHB, 5days, 2005

Surgical Voice Restoration - Advanced Level, Macmillan, 1 day, 2006

Palliative Care Training - Pain Management, Symptom Management,Holistic Care., 3 days, UHB, 2006

6.4 Claire Coogan - Qualifications and Courses

6.4.1 Qualifications:

BSC (Hons) Nursing , Open University, currently being undertaken

6.4.2 Courses

Head and Neck Master Class, level 3, 2010

6.5 Courses

Involvement in the education of staff, patients and families continues to remain a crucial element to the role of the CNS, aiming to raise standards of care and awareness of head and neck cancer. The following information lists the courses that they regularly teach on.

Course Provider

ENB 237 Oncology course UWE

Understanding the cancer journey North Bristol Trust

Cancer and its management (for HCA's) North Bristol Trust

Symptom management North Bristol Trust

Mouth care North Bristol Trust

The role of the Macmillan head and neck nurse North Bristol Trust

Back to Nursing Course North Bristol Trust

Tracheostomy study day North Bristol Trust

Complementary therapies St Peter’s hospice


7 Data Collection and Clinical Lines of Enquiry (11-2I-135)

The Cancer Register is the system of choice for the collection of data and information to support the Head and Neck Team.

Work remains ongoing to improve data quality and understand the best way to use the cancer register to capture and submit data as appropriate.

In 2011/12 an audit of certain key data items for Head and Neck patients receiving a first definitive treatment showed:

100% had a treatment start date, four-digit diagnosis code, diagnosis date, tumour status

97% had treatment intent recorded (100% quarter 4)

97% had MDT discussion recorded

48% had a CNS contact recorded (71% quarter 4)

91% of those having surgery had pathology recorded on the cancer register and a SNOMED code (100% quarter 4)

91% of those having surgery had a procedure code recorded (note not all procedure codes are available on cancer register)

71% had TNM staging recorded (94% quarter 4)

The improvements seen in quarter 4 were due to data quality improvement exercises that took place in this period and on an ongoing basis.

7.1 Workload of MDT

The MDT met 51 times during the period. On average, there are around 23 discussions per meeting.

The below tables give a breakdown of data from 1 April 2011 to 31 March 2012.

It excludes benign and borderline tumours.

7.1.1 New diagnoses of cancer discussed by the MDT

Source: Somerset Cancer Register, ‘local download’ patients with diagnosis date 01/04/2011-31/03/2012 inclusive, site ‘head and neck’. Excludes patient with status ‘no cancer diagnosis’, tumour status ‘benign’ ‘borderline’ or ‘no cancer’, or diagnosis ‘benign neoplasm of…’

The number far exceeds the 100 new cases per year recommended as a minimum for such an MDT (11-2I-138)

Organisation of diagnosis

Number primaries

Number recurrence/metastasis

Bristol 232 20

RUH 72 4

Total 304 24


7.1.2 New diagnoses (including recurrence/metastasis) by treatment type

Treatment Number patients

Active monitoring 10

Anti Cancer Drug 10

Brachytherapy 2

Chemoradiotherapy 28

Non-specialist palliative care 2

Specialist palliative care 12

Surgery 176

Teletherapy 48

Not stated/Other* 40

Grand Total 328

*These are patients who declined treatment, chose to go elsewhere for treatment, had not started treatment in the period, died before treatment or had been treated elsewhere prior to referral to the Network

7.1.3 Surgical cases by responsible consultant

Data source is Somerset Cancer Register. Includes only those given surgery as a first treatment (see comments above for 7.1.1. Surgeon is as recorded on treatment record.

Surgeon Number cases

Baldwin DLB 35

Hughes CWH 28

Tierney PAT 20

Porter GP 16

Guest GXG 13

Morgan JXM 11

Thomas SJT 11

Waldron J 18

Schnetler J 6

Pinder D 5

Maddox P 8

Other (incidental findings) 5

Grand Total 181

7.2 TYA patients (11-2I-148)

The MDT discussed one patient in the TYA age range (15-24) during the review period, however this was a patient with a pre-existing diagnosis where treatment was already ongoing. The patient was referred to the TYA MDaT, but there was no joint treatment planning as treatment had started. Should any further treatment be required, joint planning would be undertaken as appropriate.


7.3 Clinical Lines of Enquiry

Peer review stipulates that clinical lines of enquiry data should come from the 2010 DAHNO audit. Figures from this audit are recorded below as required, however due to the age of this data and serious data quality problems from that year, more recent and reliable figures are also included as a more accurate indication of current practice.

Percentage of new cases of head and neck cancer discussed at MDT

2010 DAHNO audit – 61% (UH Bristol) 66.7% (RUH Bath)

2011/12 from Somerset Cancer Register for UH Bristol – 96.5% (with ‘undiscussed’ cases being investigated)

The MDT intends to discuss every new case of head and neck cancer. The 2010 audit figure is due to data quality issues and is in no way an accurate reflection of practice then. On an ongoing basis, any cases identified which do not appear to have been discussed are investigated and the record corrected where appropriate.

Percentage of new cases of head and neck cancer discussed at MDT* where recorded T, N, M staging category is evident

2010 DAHNO audit – 39% (UH Bristol) and 46% (RUH Bath) Q4 2011/12 (all Head and Neck cases, UH Bristol) – 94% (either pre-treatment or final integrated stage recorded on diagnosis screen of SCR), and (all Head and Neck cases, RUH Bath) 100% (reported to SWPHO) Recording of staging is a key aim of the MDT and the SWPHO staging project shows the MDT to be one of the best in the Trust. The MDT has also shown good practice in developing use of the staging boxes on the MDT outcome form, enabling capture and checking of staging live in the meeting. The current DAHNO extract takes TNM information from a part of the register where this information is not regularly captured, which would explain the poor result in 2010. When the new DAHNO extract tool has been completed, existing staging information will be moved if necessary to ensure that it reaches the DAHNO database.

Percentage of cases of head and neck cancer* where the interval from biopsy to reporting is less than 10 days 2010 DAHNO audit – no data available (UH Bristol); 100% based on 2 cases, rest unknown (RUH Bath) 2011/12 – 84 pathology records with both a date of request and date of reporting were found on the SCR for patients diagnosed at UH Bristol between 01/04/2011 and 31/03/2012. Of these 50% were reported within 10 days. However it should be noted that this will include excision specimens as well as biopsies. Of those that waited over 10 days, only 4 were biopsy samples (11%). It is difficult to extract these data from SCR at present, which is presumably why the 2010 audit showed a null return for UH Bristol and unrealistically low numbers for RUH Bath. It is hoped that the system will eventually be modified to help capture this information more easily. The system records investigation details separately from histology reports and cannot link the two. Histology reports will record interval from sample being received in the lab to the date of reporting. In the majority of cases date of receipt will equal date of sample being taken. Therefore this is the figure we have used above as an estimate. We intend to validate with further audit.


Percentage of new cases of head and neck cancer where confirmed seen by a clinical nurse specialist prior to the commencement of treatment

2010 DAHNO audit – 17.4% (UH Bristol), 20.8% (RUH Bath)

2011/12 – UH Bristol Cancer Register suggests 51% saw a CNS at any point in their pathway to date. The register dates suggest around 50% of those seen were seen prior to treatment, although the data quality of this cannot be confirmed. RUH Cancer Register shows 68% having seen a CNS prior to treatment.

This percentage is not an accurate reflection, with many more patients than this seen by a CNS, including pre-treatment. The figure is due to inconsistent data collection, which the MDT is working on. All patients should be seen by a CNS. At RUH, the gap in data collection is due to a CNS being on unexpected leave, and recording is now confirmed to be back to 100%.

Percentage of new cases of head and neck cancer* confirmed as having any pre-operative/ pre-treatment (includes radio and chemo-therapy) dietetic assessment

2010 DAHNO audit – 0% (both Trusts)

2011/12 – (UH Bristol) no patients on the register had a contact with a dietician recorded, however this is due to data recording issues because at least some will see a dietician

The measure specifies that it refers to patients having seen a dietician. It should be noted that the percentage having any pre-treatment dietetic assessment i.e. conducted by a non-dietician e.g. CNS, pre-operative assessment nurse etc. is much higher.

When the new DAHNO dataset is published the MDT will be able to work on capturing this information more reliably in the right place.

Percentage of cases of head and neck cancer* confirmed as having any pre-operative/pre-treatment dental assessment

2010 DAHNO audit – (UH Bristol) 60% (excluding major salivary glands, for which figure is 0%) It is unclear how this figure was obtained and if it is correct. (RUH Bath) 23% (excluding major salivary glands, where there is no data)

2011/12 – 35 patients diagnosed in 2011/12 had a contact with a dentist recorded on the register. That equates to 16% patients given surgery or an oncological treatment.

We know the contacts with dentists and other professionals aren’t reliably captured on the register so this is likely to be an underestimate. When the new DAHNO dataset is published the MDT will be able to work on capturing this information more reliably in the right place. An internal audit on dental screening has recently been undertaken which will provide better information about the true picture of dental assessment services at UH Bristol.

At RUH Bath a pathway has been put in place that ensures all patients receive dental screening prior to treatment and this is documented in the paper notes. There is no mechanism to electronically capture the data and therefore it is difficult to provide specific statistics. The RUH team are confident that in practice 100% receive this service.


8 Audit and Local Audit

8.1 GP Notification within 24hours – Audit of Compliance (11-2I-111)

The records of 20 patients diagnosed in the review period at the Trust were audited electronically. 30% had evidence the GP was notified within 24 hours of the patient being given their diagnosis. Delays were usually due to the time taken to type the letter. The MDT is considering alternative ways to notify GPs, including the possibility of using notification faxes, which works well in some other MDTs. The key challenge is identifying a system that works well across all of the different clinical teams involved in the care of patients with Head and Neck cancer.

8.2 Key Worker Policy – Audit (11-2I-112)

The records of 20 patients diagnosed in the review period at the Trust were audited electronically. 15% had both a key worker name and contact number clearly recorded. 25% had the CNSs’ names and contact details recorded but did not explicitly state which was the keyworker. 20% recorded the name of the keyworker but not the contact details, although some did state these had been given to the patient. 40% did not record a name or contact details.

The MDT is investigating alternative methods of ensuring this information is recorded, and whether it is possible to combine this with the GP notification. On the positive side, there was evidence in a majority of cases that the dictator/typist had remembered the importance of recording keyworker information. The next step is to ensure that all the necessary information is recorded and that this is maintained consistently.

8.3 Network Agreed Audits (11-2I-136)

The Network agreed audit for 2012 is on dental rehabilitation. The MDT is participating in the audit. The last Network audit was on ‘Quality of Life and Swallowing’ and was presented at the October 2011 study meeting of the SSG.

8.4 Other Audits

Clinical effectiveness of the Head and Neck MDT

Measured: Treatment given against MDT treatment plan, communication of decisions to GP

Conclusion: 84% cases had complete concordance, which is in line with other similar studies. Adjuvant treatment was concordant in 100% cases. Reasons for variation were due to intra-operative findings, worsening of co-morbidities or problems identified during pre-operative work up. 80% GPs had been sent a letter outlining the MDT decision.

Actions: Improve documentation of decisions in notes and notification of GP – policies and monitoring in place as part of peer review

Post-operative complications of thyroid surgery

Measured: Incidence of complications following thyroid surgery undertaken by Ceri Hughes between 2006 and 2010. Numbers of patients undergoing pre- and post-operative nasendoscopy and pre-operative fine needle aspiration.

Conclusion: Incidence of most complications was below the threshold set for the audit. Short term recurrent laryngeal nerve injury incidence was higher than the threshold (9.88%, threshold 8.7%). Result should be considered in light of low numbers affecting significance levels and some questions around reliablilty of voice changes as a measure for RLNI. Pre-operative and post-operative


nasendoscopies were not carried out in sufficient numbers of cases (43% and 77%, target 100%) and fine needle aspiration was carried out in 89% cases, target 100%.

Actions:

Future audit to establish if visualisation of laryngeal nerve during surgery reduces risk of RNLI.

More patients should undergo FNAC

More patients should undergo preoperative and postoperative nasendoscopy with more reliable record keeping (partly in place electronically). Possibly audited.

A more comprehensive and easier system to record nasendoscopy findings. Possibly through use of a sticker or form.

More reliable record keeping of parathyroid glands seen in operation

Patients who undergo total thyroidectomy should have calcium levels checked at 24 hours postoperatively regardless of previous normal blood calcium levels and be educated on symptoms of hypocalcaemia.

Consider use of a Vocal Performance Questionnaire in addition to nasendoscopy Mandibulectomies in the SouthWest

Measured: Personnel performing reconstructions, failure rate of free-flaps, and hospital acquired infections in donor sites.

Conclusions: All standards were met in Bristol.

Actions (across all three sites):

Use of a proforma to record operation notes for patients undergoing head and neck cancer reconstruction, including flap ischaemic time.

Microvascular reconstruction of mandibulectomies should involve two consultant head and neck surgeons working simultaneously.

Legible recording of post-operative flap observations on a specifically designed chart.

Doppler probes should be available for examination of pedicle blood flow where clinical examination of the flap is equivocal or not possible.

Consideration should be given to the clinical efficacy and cost-effectiveness of monitoring equipment such as internal Doppler probes.

Electronic coding of operative procedures should be the responsibility of a designated senior member of the surgical team. Hospital discharge summaries should replicate this verbatim.

The data from this audit should be updated prospectively to monitor osseous free-flap failure rates in head and neck reconstruction.

BCC excision margins

Measured: Quality of recording of margins at time of excision and measurement of margins.

This audit has been recently completed.

Record keeping audit

Planned for late 2012/2013, looking at recording of keyworker and MDT outcomes in all sets of hard copy notes.

8.5 Audit in relation to Thyroid Cancer (11-2I-144)

A Network audit in relation to thyroid cancer has not been agreed. The NSSG plans to discuss this at their next meeting. The MDT would be keen to participate in such an audit. Matthew Beasley recently conducted a local study on thyroid cancer and presented a poster to the BAHNO conference.


8.6 EQA Audit (11-2I-114)

Miranda Pring participates in the National Head and Neck EQA, a copy of her certificate is available in the supporting information on page 7. Simon Rose participates in the regional general histopathology EQA, which includes head and neck specimens. His participation has been confirmed by the RUH team.


9 Research and Clinical Trials (112I-137,145)

Extract from report to SSG summarising MDT clinical trials activity and actions. The list includes thyroid cancer trials.

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’.

SSG endorsed NCRN trials:

PET -NECK Study 8 15 Open 10 No actions required

NCRN trial recruitment:

ART DECO - 0 Open 2 No actions required

COSTAR 2 2 Open 2 No actions required

Head and neck 5000 - 64 Open 150 No actions required

IoN - - In set up 8 No actions required

TCUK IN 30 23 Closed 0 No actions required

TITAN - - In set up 4 No actions required

DeEscalate - - In set up 10 No actions required

MDT actions - to be completed at MDT meeting:

No actions required

The above actions were agreed by the MDT on 17th April 2012 in the presence of Mr J Waldron (MDT chair) and

Dr M Beasley (H & N SSG Research Lead)


10 Patient and Carer Feedback and Involvement (11-2I-126)

The results of the 2011/12 national cancer patient experience survey were received shortly before the self-assessment. Fuller results, including countrywide comparisons and patient comments, are expected in the near future and will enable a better analysis and actions to be drawn up.

41 patients with head and neck cancer responded to the survey. 80% rated their overall care as excellent or very good.

Seven results were more than 10% higher than the national average. These were:

- Staff gave a complete explanation of what would be done [during surgery]

- Always/nearly always enough ward nurses on duty

- Patient did not think they were deliberately misinformed

- Patients were able to discuss worries and fears with staff during visits

- Family definitely given all the information they needed to care for patient at home

- Staff definitely did everything to help control pain

- Patient given the right amount of information about condition and treatment

Eight results were more than 10% lower than the national average, and these are areas we will be targeting to improve. The questions in this group were:

- Patients given written information about the type of cancer they had (although a high percentage went on to say they were given the right amount of information about their condition and its treatment)

- Patients given information on support groups

- Patients were told they could get free prescriptions

- Hospital staff gave information on getting financial help

- Patient given written information about operation (see first bullet point above)

- Nurses did not talk about the patient as if they were not there

- Always given enough privacy when discussing condition or treatment

- Offered a written assessment and care plan

Actions completed as a result of the last patient experience survey included improving the information available to patients about benefits advice and financial help, appointment of a cancer patient user representative to Cancer Board, installation of Macmillan ‘info points’ staffed by volunteers around the Trust, establishment of a new acute oncology service for patients with emergency presentations or complications of oncology treatment, establishment of a CNS and AHP forum, and physical improvements to the BHOC environment and outpatient area.


Appendix 1 Patient Information (11-2I-127,147)

1.1 Macmillan / Cancer Backup materials for People affected by cancer.

Web: be.macmillan.org.uk

Tel: 0800 500800

Material Code

Understanding Cancer of the Head and Neck MAC 11652

Understanding Cancer of the Voice Box MAC 12101

Understanding Thyroid Cancer MAC 11655

Understanding Radiotherapy MAC 11640

Understanding Chemotherapy MAC 11619

Understanding Lyphoedema MAC 11651

Talking to children when an adult has cancer MAC 5766

Talking about your Cancer MAC 11646

Lost for words – how to talk to someone with cancer MAC 11631

Cancer Backup Recipes MAC 11668

Diet and Cancer MAC 11625

Eating well after cancer treatment MAC 12516

Caring for someone with advanced Cancer MAC 11623

Controlling the symptoms of Cancer MAC 11670

Coping with Advanced Cancer MAC 11626

End of Life- The facts MAC 12149

Coping with Fatigue MAC 11664

Emotional Effects of Cancer MAC 11669

Work and Cancer

Money Worries, How can we help? MAC 4603

Help with the cost of Cancer MAC 4026.08

Living with Cancer is expensive MAC 4029.06

State Benefits and support MAC 11279_C

Getting Travel Insurance when you have been affected by cancer MAC 4056

Travel and Cancer MAC 11667

Giving up smoking MAC12514

1.2 Other resource Leaflets

Leaflet Source

What is the role of the Head and Neck Clinical Nurse Specialist

UHBristol Leaflet


Laryngectomy Information Pack The National Association of Laryngectomee Clubs

Radiotherapy – Head and Neck Cancer UHBristol Leaflet

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