53
LCA Head and Neck/Thyroid Clinical Forum 15 th July 2015
LCA Head and Neck/Thyroid Clinical Forum 15th July 2015
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 15th 2015
• 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
Aims of ERAS (enhanced recovery after surgery)
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
Example of enhanced recovery after
surgery elements
6
Referral from
Primary Care
Pre-
Operative
Admission
Intra-
Operative
Post-
Operative
Follow
Up
• 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
• 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
directed fluid therapy
• 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
• Admission on day
• Optimised Fluid
Hydration
• CHO Loading
• Reduced starvation
• No / reduced oral
bowel preparation (
bowel surgery)
• DX when criteria met
• Therapy support
(stoma, physio)
• 24hr telephone follow
up
• Optimising pre operative
haemoglobin levels
• Managing pre existing co
morbidities e.g. diabetes
Incidence for the London Cancer Alliance region
2005-2009
Head and Neck including thyroid Geographical areas
17.3 SEL: per 100K 252 per yr
16.2 SWL: 259
16.9 NWL: 300
Alliance 16.8: 811
ENGLAND 15.7 9233 ENGLAND
Cancer Survival and Deaths 2005-9
Relative survival estimates Deaths per yr
SEL: 79.6% 74
SWL: 86.2% 64
NWL: 83% 88
Alliance 82.9% 226
Total ENGLAND 2667
3.2% 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!
DOH initiative apply ERP to improve
ONCOLOGICAL OUTCOMES
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)
Page 9
Head and Neck Enhanced Recovery programme
10
FIRST
Consultation
Pre-
Operative/
Diagnostic
Admission
Intra-
Operative
Post-
Operative
NO CANCER
• Primary prevention
MDM
SURVEILLANCE
Radiotherapy/Chemo
RT with curative intent D
I
S
C
H
A
R
G
E
5 YEARS
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
Enhanced Recovery – starting point
Governance / running of the project
• Clinical leads
• Steering group
• Collaborative working
• Project plan
• PDSA cycles
• Clear scope
• Current state pathway map
• Future state pathway map
• Clear project plan
• Clinical engagement
• Management support
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 10.1186/s12913-014-0636-8
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
Page 14
Outcome 2: First consultation patient information
Outcome 3: First consultation pre-assessment
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
Page 15
Panendoscopy
Outcome 5 (SAME DAY ADMISSION)
• Admit on day (90% compliance)
Page 16
Diagnostic work up for patients undergoing pan-
endoscopy and biopsy
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
Page 17
MDM
Diagnosis and treatment plan
SURGICAL PATHWAY PART 2
Page 18
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
Page 19
Outcome 7: Post MDM patient information
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
Nutritional bundle for major Head and Neck Surgery Page 20
Panendoscopy
Outcome 10 (SAME DAY ADMISSION)
• Admit on day (90% compliance)
Page 21
Diagnostic work up for patients undergoing pan-
endoscopy and biopsy
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
Page 22
Wash on day of surgery
Antibiotic prophylactic protocol (95%)
OUTCOME 12 Anti infection bundle Page 23
OUTCOME 13:
MAJOR SURGERY ANAESTHETIC BUNDLE
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
Page 24
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 25:224-
244)
Documentation of pain scores
Documentation of PONV
VTE prophylaxisis (95% compliance)
OUTCOME 14: Post operative early rehabilitation
Page 25
Enhanced Recovery Programme
Head and Neck
Thyroid Surgery Pathway
Ward (circle): BLUNDELL ESTHER
Patient Label:
AFFIX
PATIENT LABEL
HERE
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Patient BMI
Air mattress used (circle)
Patient has had previous chemo radiation therapy
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)?
Diabetic Management Required
If yes, state here
Radioiodine Tx
4 DAYS
AFFIX
PATIENT LABEL
HERE
Haematoma
Initial Record variance
Management of surgical drains
Yes 0-30ml >30ml
No 0-10ml >10ml
Wound management
0 1 2 3
None Mild Moderate Severe
If >=1, REVIEW ANALGESIA
Ward round led by Mr Lyons
(please circle) Jeannon
Simo
Hussain
McGurk
SpR (name)
YES NO
Yes
No
If you trigger a red alert the
nurse in charge and doctor
These patients can be
susceptible to wound infection.
Maintain regular monitoring and
ensure urgent medical review if
infection detected.
Check drains hourly. Seek to
remove according to protocol
Review colour of discharge. Is
discharge…
Review amount of discharge
(over 8 hours)
Has patient had previous
chemoradiation therapy?
Sign off - Named day nurse
Practice nurse support arranged if needed
Pain Score
Patient for facial nerve rehab / physio
Activities of Daily Living Assessment
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.
Sign off - Named night nurse
Patient on track for discharge?
If no, state reason
Observations
Observe for haematoma
Regular paracetamol 1g QDS and PRN analgesia
prescribed
Ted stockings
Review Drug Chart
Ensure Prescription Complete
Write TTOs
Nutrition
Follow a normal diet.
Named night nurse (+PIN)
Staple remover kept beside bed
Post op MRSA swabs
Post op cardiovascular observations
Patients with haematoma may
have swelling, oozing, pain,
bleeding or inflammation
NURSING
Mobilisation
Patient out of bed
Thyroxine replacement prescribed
Ward round summary completed in blue notes
pages
Has the drain been vacced?
Red
Clear
Creamy
Encourage fluid intake if IVAD removed
Calcium level (state)
Monitor fluid balance
Hourly check of drains
Hourly check of wound
Day 1 (dd/mm)
Named day nurse (+PIN)
Hypocalceamia
Discharge Planning
MDT
Send section 2 if required
FY1
Indwelling devices
Diagnostics
Medication
Remove IVAD if eating and drinking normally.
Assess if IVAD and drains are safe to remove.
Ward round
3 DAYS
3 DAYS
OUTCOME 15: BESPOKE CARE PATHWAYS (95%)
• Ward based care pathways specific to operation
• Laryngectomy +/- free flap
• Free flap +/- neck disection
• Neck dissection alone
• parotidectony
• Thyroidectomy
Page 27
OUTCOME 16:Mortality morbidity data collection
• 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
Page 28
‘Enhance your recovery: Wallet sized Five year follow up plan
OUTCOME 16: SURVEILLANCE
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
Page 30
Head and Neck Enhanced Recovery programme
31
FIRST
Consultation
Pre-
Operative/
Diagnostic
Admission
Intra-
Operative
Post-
Operative
NO CANCER
• Primary prevention
MDM
SURVEILLANCE
Radiotherapy/Chemo
RT with curative intent D
I
S
C
H
A
R
G
E
5 YEARS
AGGREGATION OF MARGINAL GAINS
OLD NEWS “Everybody's doing it”!!!!
Overview of Cancer Data Sources – Head and Neck Cancers
Stephen Scott, LCA senior analyst
Please contact [email protected] for information
Lymphoedema in Head and Neck Cancer
Martine Huit
Lymphoedema CNS, Guy’s and St Thomas’ NHS Foundation Trust
LCA Lymphoedema Community of Practice member
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
The London Cancer Alliance
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 (13th 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.
The London Cancer Alliance
GSTT Lymphoedema Service
0%
5%
10%
15%
20%
25%
30%
35%
2011
2012
2013
2014
% Head and Neck Referrals at GSTT from 2011 – 2014
In 2014 total number of patients with head and neck lymphoedema = 247 which is equivalent to 35% of the caseload
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?
The London Cancer Alliance
Impact of changes to lymphoedema practice
• Number of MLD appointments reduced from 108 in 2010 to 16 in 2012-13
• 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
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?
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
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., Møller, 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.
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?
METHODS
Online survey of H+N/MaxFax consultants
Email distribution via the LCA
Questionnaires for qualitative component (for MEd. project)
https://www.surveymonkey.com/s/surgeonss
mokingadvice
RESULTS
n=11
H+N = 9
MaxFax = 2
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
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
RESULTS
In the last 6months,
estimate the
proportion of
patients that you
have…
0 2 4 6 8
Did not answer
<20%
20-50%
50-80%
>80%
All smokers
Did not answer
<20%
20-50%
50-80%
>80%
All smokers
Did not answer
<20%
20-50%
50-80%
>80%
All smokersc
) Fo
rma
lly
refe
rre
d t
o
smo
kin
g
ce
ssa
tio
n
serv
ice
s
b)
Ve
rba
lly
ad
vis
ed
to
sto
p
smo
kin
g
a)
Ve
rba
lly
dis
cu
sse
d t
he
ir
smo
kin
g h
ab
its
RESULTS
Do you know how to refer a patient to
smoking cessation services at your
trust?
Yes
55%
No
45%
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
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
