Download PROCESS OF CARE

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PROCESS OF CARE
Index
1.
1.1
1.2
Information
Role of CNS in providing information
Database
2.
2.1
2.2
2.3
2.4
2.5
2.6
Referral pathway
For GP
For non-oncological consultants/ firms
For referral from unit to centre
Location
Emergency admission
Communication of results
3.
3.1
3.2
3.3
Pre-op assessment
Location of pre-operative assessment
Anaesthetic input
Transfer of information
4.
Staging investigations
5.
5.1
5.2
MDT
MDT Co-ordinator
The role of the CNS within the MDT
6.
Surgery
7.
Follow up
8.
Specialist clinics
9.
Location and timelines of care
North Wales Cancer Guidelines, Process of Care (June, 2008)
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1.
Information
1.1
Role of CNS in providing information
Network agreed local contact details are provided by the CNS as well as site specific details including
likely treatments and complications of treatment. Arrangement of further outpatient appointments and
admissions will be arranged by the CNS.
1.2
Database
CaNISC data items will include:
 Patient name and identifier
 Date of birth
 Date of referral to network
 Name of consultant at referral
 FIGO stage and histology
 Outpatient appointment dates
 Outpatient appointment location
 MDT date
 MDT recommnedation
 Staging imaging
 Tumour markers
 Referral or follow up cervical or other cytology
 Date of definitive surgery/ other treatment/ management
 Definitive surgery/ other treatment/ management location
 Surgery type/ radiotherapy/ chemoradiotherapy type/ chemotherapy treatment regime
 Name of consultant for definitive process
 Date of further surgery/ other treatment/ management location
 Further surgery type/ radiotherapy/ chemoradiotherapy type/ chemotherapy treatment
regime
 Name of consultant for process at recurrence
 Disease free
 Alive/ dead
 Date of death
 Cause of death
These data will be entered by the MDT co-ordinator.
2.
Referral pathway (see 9. Location and timelines of care)
2.1
For GP
If gynaecological cancer is suspected then referral should be to a general gynaecologist, the lead in the
cancer unit or gynaecological oncologist in the cancer centre.
Standards
Rapid access to the specialist should be available with the patient seen within 2
weeks of date of receipt of the referral letter/ fax.
Definitive treatment should be commenced no later than 62 days after receipt of the
referral letter/ fax.
Definitive treatment should be commenced no later than 31 days after diagnosis for
non urgent suspect cancer referrals.
2.2
For non-oncological consultants/ firms
If the diagnosis is suspected or confirmed referral to the local unit lead or gynaecological cancer centre
should be made.
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2.3
For referral from unit to centre
This is appropriate for all endometrial cancer cases FIGO Ic and type 2/ poorly differentiated FIGO Ib;
all cervical cancer cases >FIGO Ia1 and all other gynaecological cancers.
2.4
Location (see 9. Location and timelines of care)
Referrals may be made to Wrexham Maelor, Ysbyty Glan Clwyd or to Ysbyty Gwynedd and patients
will be seen in outpatients locally where possible. Upon diagnosis of gynaecological malignancy
patients will be informed of their diagnosis at their referral hospital and then have staging
investigations and if for surgery their pre-operative assessment at their local hospital. Usually an
outpatient appointment at the referral hospital would be planned to review the staging investigations
and the management recommendation of the network MDT meeting. Occasionally this may need to be
at Ysbyty Gwynedd if surgery is planned at Ysbyty Gwynedd.
Surgery will be performed at the surgical cancer centre (Ysbyty Gwynedd) for all endometrial cancer
cases FIGO Ic and type 2/ poorly differentiated FIGO Ib; all cervical cancer cases >FIGO Ia1 and all
other gynaecological cancers. Radiotherapy will be at Ysbyty Glan Clwyd and chemotherapy is
available at all 3 hospitals.
Subsequent follow up will again be at the local hospital.
2.5
Emergency admission
Cases of suspected gynaecological cancer admitted as emergencies to the non oncological team or
outwith gynaecology should be referred to the cancer lead or gynaecological oncologist at that hospital
at the earliest available opportunity. Appropriate staging investigations and MDT discussion will
follow.
Cases requiring emergency surgery can be managed by the on call gynaecology team and if managed
by the on call surgical team then the on call gynaecologist can be asked to assist. Telephone advice
may be available from the gynaecological oncologist or cancer lead but emergency advice can be
provided by the local on call obstetrician/ gynaecologist. The minimum surgical procedure to manage
the emergency condition is appropriate with definitive surgery reserved as an elective procedure at a
later date.
Emergencies admitted with other problems including sepsis, postmenopausal bleeding or menorrhagia
are also managed by the on call gynaecological team.
2.6
Communication of results
Results of all staging investigations including PACS imaging must be available to Ysbyty Gwynedd at
all times.
Teleconference at the network MDT must be available for all patients and all staging investigations
must be available for all MDT meetings.
The decision of the MDT and of a cancer diagnosis must be sent to the referring practitioner and the
patients GP within 24 hours.
Clinic letters must be posted within a week of the clinic appointment and details of treatment or
management must be sent to the referring practitioner and the patient’s GP upon discharge from
hospital.
3.
Pre-op assessment
3.1
Location of pre-operative assessment
Pre-op assessment for surgical patients will be undertaken at the referral (source) hospital with a nurse
assessment. Consent will be obtained by the operating surgeon when the patient is admitted for surgery
at the cancer unit or at Ysbyty Gwynedd. Saved serum will be taken at the time of the pre-operative
assessment but cross matching will be taken at the time of admission to hospital. Due to long distances
to travel to hospital in many cases, anaesthetic assessment with an anaesthetist should be at the local
hospital but details forwarded to the anaesthetist providing the anaesthetic who may be at Ysbyty
Gwynedd. Same day admission may be possible in only a minority of cases.
Where possible pre-op assessment will immediately follow a scheduled outpatient appointment.
3.2
Anaesthetic input
High risk cases will also involve a local anaesthetist at the pre-op assessment. Pre-operative details will
be forwarded immediately by fax or telephone to the surgical/ anaesthetic team at the treating hospital.
This will include the results of all investigations including imaging.
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3.3
Transfer of information
A timely, secure and reliable system of transferring patient details between trusts is required by email,
fax or post and the mode of data transfer will be dictated by clinical urgency. There must be sufficient
secretarial/ clerical time to ensure efficient transfer of data.
4.
Staging investigations
Blood samples (apart from cross-matching) will be taken at the referral (source) hospital. All radiology
investigations (USS, CXR, CT/MR) will be performed at the source hospital. All images stored on
PACS will be readily available for review at the source hospital and Ysbyty Gwynedd.
5.
MDT
A weekly MDT meeting will discuss all patients at diagnosis, when having completed staging
investigations, after definitive treatment and at recurrence. The meeting will be based at Ysbyty
Gwynedd but linked by videoconference to Ysbyty Maelor and Ysbyty Glan Clwyd (see North Wales
Gynaecological Surgical Cancer Centre MDT Meeting SOPP; 5 Policy: Frequency of meetings).
5.1
MDT Co-ordinator
Will be responsible for listing patients, ensuring all notes, reports and results are available at the
MDT meeting for discussion, minuting and distributing the decisions of the MDT. For cases
presented from YGC and NEWT notes should remain at their host units for the meeting and
documentation. The MDT co-ordinator must ensure that the rooms are available for MDT meetings
and that the VC is fully functional for all 3 sites.
The list of patients for each meeting must be provided by the MDT co-ordinator but approved by the
core membership. The MDT co-ordinator must inform relevant MDT members of any cases removed
from the MDT.
The MDT co-ordinator is responsible for updating entries onto CaNISC.
5.2
The role of the CNS within the MDT
Out-patient appointments and theatre dates must be co-ordinated with the MDT clinicians. The
CNS’s will inform the relevant referring practitioner/ GP and, if needed, the patient of the decision of
the MDT within 1 working day.
6.
Surgery
Surgery for FIGO stage Ia/ Ib well or moderately differentiated endometrial carcinoma and FIGO stage
Ia1 cervical carcinoma can be performed at any of the 3 acute north Wales hospitals. Surgical treatment
for all the remaining tumours will be at the surgical centre at Ysbyty Gwynedd and managed by the
gynaecological oncologists.
Staging procedures (such as EUA/ biopsy) need not be at Ysbyty Gwynedd but should be performed by
a gynaecological oncologist.
Whilst some endometrial tumours surgically treated at unit level may not be low risk endometrial
carcinoma despite appropriate pre-operative staging their subsequent management will be determined
by the north Wales MDT.
All pathology will be reported at the site of surgery. The majority of all reporting will be at Ysbyty
Gwynedd.
7.
Follow up
Outpatient follow up should be at the referral or source hospital. Appointments should be 3 monthly for
2 years, 6 monthly for 1 year and then annually. Hospital follow up should be for 5 years.
Additionally ovarian carcinoma follow up should have a CA125 estimation 2 weeks prior to each visit.
For cervical carcinoma, cervical or vaginal vault cytology should be at the discretion of the reviewing
gynaecological oncologist or lead gynaecological cancer surgeon. Cervical or vault cytology is not
recommended after pelvic radiotherapy.
Follow up should alternate with the medical or clinical oncologist if radiotherapy/ chemoradiotherapy
or chemotherapy was part of treatment.
All patients must be encouraged to report any symptoms suggestive of recurrent disease immediately
by contacting their CNS rather than wait until their next outpatient appointment.
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8.
Specialist clinics
All specialist clinics can be any of the 3 hospital sites (eg. colposcopy/ postmenopausal bleeding or
hysteroscopy/ cancer genetics).
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9.
Location and timelines of care
Patient referred to
YM/YGC/YG as non USC
Patient referred to
YM/YGC/YG as USC
10d from receipt of referral to 1st
appointment for USC referrals
31d from diagnosis to treatment
for non USC referrals
Palliative care at
YG/YGC/YM/community
Cancer confirmed
Network MDT
62d from receipt of referral to
treatment for USC referrals
Staging investigations
Pre-op assessment at
referral hospital
Network MDT
Surgery at unit
Pre-op assessment at
referral hospital
Surgery at YG
(Ia/b well/ mod diff
endometrial carcinoma
Ia1 cervix)
Palliative care at
YG/YGC/YM/community
Chemotherapy
at YG/YM/YGC
Radiotherapy or
chemoradiotherapy at
YGC+/-Christie
Date of starting definitive mangement
Follow up at
referral hospital
Date of starting definitive mangement
Box colours
Management at source hospital
Management at specified hospital
Timelines
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