Download Storyboard Entry Form 2014 Main author: Hilary Williams Email

Storyboard Entry Form 2014
Main author: Hilary Williams
Email: [email protected]
Telephone: 02920316202
Follow the detailed instructions in this template for writing your
storyboard. Add your information in each section below and save this
completed storyboard document. Please not amend this template.
Follow the instructions in the Information Guide for Authors to submit
your storyboard.
The word limit is 1100 words including references. Your storyboard will
not be accepted if you exceed the word limit.
1. Storyboard title: a clear concise title which describes the work
Working together across health boards to streamline services for emergency
cancer care in SE Wales.
2. Brief outline of context: where this improvement work was done;
what sort of unit/department; what staff/client groups were involved
Our entry is a collaboration between Velindre Cancer Centre (VCC), Aneurin
Bevan University Health Board (ABUHB) and the SE Wales Cancer Network
(SEWN).
Patients in SE Wales benefit from the internationally recognised cancer
expertise of VCC. However there is increasing recognition that unscheduled
care is frequently provided by acute teams in local LHB’s. Clinicians (ABUHB
and VCC) were worried by patient’s experiences of variable care and in
particular the lack of robust & timely links between the cancer centre and
teams in ABUHB
3. Brief outline of problem: statement of problem; how you set out to
tackle it; how it affected patient/client care
Acute oncology (AOS) is a key priority for improvement in UK cancer care
(ref 1). 3 groups of patients particularly benefit from early specialist
cancer input following acute admission; patients with new a diagnosis of
cancer (usually metastatic disease), those with complications of treatment
(e.g. neutropenic sepsis), and those with complications of cancer (e.g.
spinal cord compression).
4. Assessment of problem and analysis of its causes: quantified
problem; staff involvement; assessment of the cause of problem;
solutions/changes needed to make improvements
The problem - baseline data
The first collaborative step was demonstrating the local need for an AOS
service in SEWN.
Our ‘headline ’figures demonstrated a clear need, 10% of acute admissions in
ABuHB have active cancer (e.g.6000 patients a year), lengths of stay were
long; a mean of 12 days. Audits of key emergencies raised significant concern
about patient safety (Life threatening Neutropenic Sepsis and Cord
Compression).
ABUHB Acute Admissions for Cancer
Site of Colorectal Cancer Emergency Admissions
This demonstrates complex pathways in unscheduled cancer care
General surgery
Gastroenterology
Geriatric medicine
Endocrinology
General medicine
Thoracic medicine
Gynaecology
Cardiology
Infectious diseases
Urology
Accident and emergency
Clinical haemotology
Baseline audit against key AOS metrics
Results of staff survey to demonstrate pre- AOS understanding of acute
cancer related issues. Teams reported they regular cared for cancer
patients but training in cancer emergencies was lacking.
.
The solution - hub and spoke model of acute cancer care. VCC
developed a daily acute oncology meeting (the hub), supported by the VCC
on call team, with teleconferencing to facilitate interaction with local hospitals.
In parallel, we proposed a nurse led ‘in reach team’ who would ‘bridge the
gap’ between ABUHB unscheduled care and VCC, and so fulfil requirements
for AOS in Welsh Government Cancer strategy.
Direct Clinical Role
Support
management
complications of
treatment
Patient focused care
Appropriate rapid
decision
making
Rapid focused
pathway cancer
unknown primary
Benefit- Patient
Predict
5 patients admitted every
24 hours to
ABH with known or
likely cancer
Benefit- Cost
Reduced length stay
Reduced investigations
Reduced admissions
Rapid liaison VCC &
rapid access clinics
7day Service at RGH
& NHH
Costs
Engage
Palliative care
Radiology
Current pathways
Education
Admitting & A & E
teams
Link with
Visiting Consultants
3 Specialist nurse
Admin
Office & Clinic space
IT
Protocols e. g.
Unknown primary
Spinal Cord
Compression
Education junior
doctor teams
Developmental Role
- -
5. Strategy for change: how the proposed change was implemented;
clear client or staff group described; explain how you disseminated the
results of the analysis and plans for change to the groups involved
with/affected by the planned change; include a timetable for change
Proving the need. (Sep 2011- 12 months). The first challenge, was to prove a
clear ‘invest to spend’ case. Local data was pivotal. We confirmed areas of concern;
lengths of stays were long and patients underwent excessive diagnostic tests (ref 2).
Pilot agreed. (March 2013, team started August 2013). A 1 year pilot, funding 3
senior cancer nurses was agreed. The key roles for the nursing team is to ensure
rapid decision making (linking to VCC where necessary), compliance with AOS
pathways and support for patients and families.
Challenge – identifying patients admitted via multiple routes (March 2013 –
ongoing) . One of key challenges of the pilot was to reduce length of stay and so
improve patient experience and reduce cost. We developed 2 novel mechanisms to
ensure rapid recognition of patients (first in Wales). All cancer patients in ABUHB are
now flagged on the PAS system. This is cross linked daily with patient admissions to
identify patients requiring review. Secondly we worked with radiology, to link patients
with a new diagnosis of metastatic cancer directly to the nursing team, via alerts on
radiology reports.
Challenge – Education & 24/7 advise for acute teams (Jan – March 2013 ongoing). VCC set up an acute oncology intranet page, based on UK standards,
with a linked page on ABUHB PAS. Our principal is advice must be ‘user friendly’
(e.g. available in ‘1 click’ and maximum of 2 pages). AOS teams have secured
regular training programmes in ABUHB & VCC
AOS Webpage
This links to protocol flowcharts
for common cancer-related emergencies
Challenge – working more closely with the community. We have linked with
the local community teams (GP and palliative care) to enable rapid
assessment of patients. For example a patient with back pain was referred
directly to AOS, had appropriate imaging of spine to exclude cord
compression and was discharged within 24 hours. Developing this further is a
key goal for 2014.
6. Measurement of improvement: details of how the effects of the
planned changes were measured
We have analysed results in terms of patient safety, resource use, and patient
experience.
Patient safety outcomes have been agreed using key metrics of AOS in and in
line with English Peer Review measures.
ABUHB measured their compliance with these standards before and after the
implementation of the AOS service and showed marked improvements
Neutropenic sepsis
Metastatic Spinal Cord Compression
Use of resource. We demonstrated both reduced length of stay and reduce number of
investigations.
Patient experience Feedback on the service:- Wife of patient (Ex Nursing Sister) called
on Monday bank holiday stating that everything had been excellent on arrival to A&E
on the previous Wednesday– Her husband had been seen swiftly in A&E – AOS nurse
had met them on arrival as promised by the VCC chemo pager. Treatment was started
immediately – “they already knew everything about my husband’s case, I didn’t have
to explain anything – they were brilliant”
7. Effects of changes: statement of the effects of the change; how far
these changes resolve the problem that triggered the work; how this
improved patient/client care; the problems encountered with the process
of changes or with the changes
Analysis of the first 3 months of the service has shown marked improvement
in key safety measures and objective improvements in LOS for all acute
cancer patients.
Interestingly, the service has become a central forum for development of care
of acute cancer patients in ABUHB; increasingly teams, beyond those directly
involved with the pilot, are working on finding solutions which are right for the
patient rather than feeling frustrated with outdated pathways.
8. Lessons learnt: statement of lessons learnt from the work; what
would be done differently next time
One of the most positive outcomes has been flexible cross organisation and
cross department working. For example, creative use of IT at both sites has
led to new sustainable ways of working at minimal cost (Patient flag and
radiology flag).
Improving door to antibiotic time in neutropenic sepsis is challenging; having
now used 1000 lives methodology in other areas of AOS, it would have been
useful to use quality improvement methodologies earlier.
9. Message for others: statement of the main message you would like
to convey to others, based on the experience described
The Hub and Spoke pilot of the AOS service is a proven, cost effective model
leading to real improvements in patient safety and experience by ensuring
rapid access to treatment and care. This is a model that could transferred to
other health boards, which would link in to VCC as the central hub. Key to the
success has been honest analysis of the ‘baseline’ service, and real focus on
developing service around the patient across organisational boundaries. We
are now working with cancer teams throughout SEWN to support this critical
development in all LHB’s.
1.
2.
NCAG Chemotherapy services in England ensuring quality and safety
Audit of Liver Biopsy of Patients with Malignancy of Undefined Primary Origin (ABUHB).
Poster RCR 2013.
The NHS Wales Awards are organised by the 1000
Lives Improvement Service in Public Health Wales.
www.1000livesi.wales.nhs.uk