Richard Booton Clinical Director for Thoracic Oncology, Wythenshawe Hospital, MFTMatthew Evison Consultant Respiratory Physician, Wythenshawe Hospital, MFTAnna Sharman Lead Thoracic Radiologist, Wythenshawe Hospital, MFTKath Hewitt Lead Specialist Nurse, Thoracic SurgeryPaula Meredith Macmillan Patient Navigator

The RAPID Program 2016-2018Rapid Access to Pulmonary Investigation & Diagnosis

NATIONAL LUNG CANCER NURSES FORUM TELFORD 2018

The National Optimal Lung Cancer Pathway – The Manchester Experience

NOLCP should achieve:

• Fewer emergency admissions as route to diagnosis

• Better use of cancer clinics

• Cancer waiting time targets

• Reduced variation in diagnosis, staging and treatment

• Less MDT discussion

• Improved survival

NLCN Forum Telford 2018

UK’s Most Lethal Common CancerIs this Good Enough for Friend or Family?

Simple

Pathways

Single Visits

Lack of Coordination

Accessible Support

Singlehospital

Complex Pathways

Multiple Visits

Lack of Coordination

Lack of Support

Multi-hospital

Stage I-IIILung Cancer

Stage IVLung Cancer

• Surgery

0

10

20

30

40

50

60

70

T1a T1b T2a T2b T3

• Radiology

• Lung Boost15#20&mm

25#30&mm

35#40&mm

45#50&mm

65#70&mm

• Modelling

• IASLC TNM8

Millimetres Matter

Shorter time decision to treat=40%improved survival

16% increase in HR for death in

stage 1 lung cancer with

surgical delay

26% changed 1 stage

8% changed 2 stages

(TNM 7)

Clear evidence across all specialties that unnecessary delay in diagnostics or commencing treatment is harmful, particularly in early stage, radically treatable disease

Consequences of Delay

Physical Harm

Psychological Harm

Limited Diagnostic Capacity

Stage MigrationTumour Growth Poor Outcomes

PhysiologyImaging Biopsy

Leicester 5th October 2018

1000pts referred to the Wythenshawe Lung Cancer Service (approximately 1/3 response)

• Call centre bookings team

• Radiologists

• Radiographers

• Chest physicians

• Lung CNS

• Disconnect between bookings process, clinicians & patients, lack of control

• Ineffective use of 3x CT scanners 8-9am

• Uncoordinate radiologist-radiographer working practices

• Duplication - Double vetting process

• IRMER compliance an obstacle

• Unnecessary logistical obstacles (near patient testing, hot reporting)

• Silo working prevented CT-Report-Clinic

• Limited CNS workforce – wrong patients/ missed patients, subliminal messaging

Compartmentalised teams Need for integration

Pathway redesign – Referral to CT & OPA

What is the Ideal pathway?Referral to CT & OPA

• Immediate & efficient CT booking process from referral to CT• Dedicated / ‘ring-fenced’ RAPID CT slots 8-9am• LungCNS ‘meet & greet’ with explanation of process & assessment• Real-time radiology vetting & IRMER compliance• Radiology vetting to include regional radiology history review• Point of care eGFR testing• Same day hot reporting of RAPID scans• Same day physician-led triage inc CNS and supported patient consultation• Chest medicine, radiology & nursing integration into the RAPID team • Geographical co-location: RAPID Hub• RAPID Patient navigator – link between call centre, patients and clinicians – band 5

✓Macmillan funding 2 years: Band 5 Patient Navigator

✓Health Foundation Innovation Grant £75,000

RAPID Pathway:Referral to CT & Report

GP referral 2WW suspected lung cancerHigh suspicion – NICE guidelinesNo CXR

GP instigated CXRSuspected lung cancerUpgrade to the 62 day pathway

Patients arrive at CT for 8am – met by a RAPID specialist nurse History taken, point of care eGFR testing via finger prick if required, venflon

Radiologist vetting of referrals – type of imaging confirmed – low dose non-contrast CT / on table review / contrast enhanced CT staging chest and abdomen

CXR report immediately emailed to: RAPID Patient Navigator

RAPID Patient Navigator reviews outlook calendar dailyFollowing morning patients added to CRIS with GP referral attached

RAPID Patient Navigator contacts patient & offer next day CT. Adds patient to RAPID Outlook Calendar & CRIS with CXR report

CTs performed 8-9am RAPID CTs hot reported 9-10am

Call Centre contact patient via phone Patient advised to attend CT department at 8am following dayBookings team add patient to shared RAPID Outlook Calendar

RAPID Pathway:Referral to CT – Triage - OPA

CTs performed 8-9am RAPID CTs hot reported 9-10am

Patient attends the RAPID hub clinicSpecialist nurse clerking 9-10am

Daily triage:GP referral, nursing history, CT images & report

Chest physicianRadiologist

RAPID nursing teamPatient Navigator

No cancer No ongoing issues for secondary care

Nurse-led discharge back to GP

No cancer Non-malignant respiratory issues

Specialist clinician reviewRefer to general respiratory clinic

Suspected Lung CancerSpecialist clinician consultation & Lung CNS review

Diagnostic algorithms 1-5

Daily RAPID Radiology Timetable

8-9am Specialist Nurse ReviewRAPID CT scans completed

9-10am RAPID CT hot reporting

10am-12pm Image-guided biopsy list

10am-2pm CTGB recovery – LUCIS Centre

Daily RAPID Physician Timetable

8-10am RAPID Board RoundSpecialist Nurse Input

10am-12pm RAPID CT & Referral TriageNurse Led DischargeMacmillan CNS Review

1-5pm Bronchoscopy & EBUS list

Referral to specialist consultation

1 working day • CT scan

• CT report

• Diagnostic MDT

• Specialist consultation

• CNS support

• Protocolised diagnostic and staging pathway commenced

• Diagnosis of no cancer

Data analysis: 2016-2017 = 526 2WW GP referrals

NLCNF TELFORD 2018

Increased Team Work

Agreed Standards

Packages of Care

Clearer Communication

SUSPECTED CANCER – CT Category

Data analysis: 2016-2017 = 526 2WW GP referrals

Data analysis: 2016-2017 = 526 2WW GP referrals

Introduction of RAPID programme

Special Cause Variation (Run length = 8)

Leicester 5th October 2018

Data analysis: 2016-2017 = 526 2WW GP referrals

‘A first class service all round’;

‘All the staff at Wythenshawe Hospital so caring, all went the

extra mile’;

‘Consultants and everybody were excellent. Through a

worrying time for me having lots of scans and surgery, I

couldn’t have had better care’;

‘Fantastic from start to finish. I was so scared but the team

were there for me. Lead nurse and the doctor who gave me

the results’;

‘High praise for the whole unit, complete efficiency’;

‘My cancer was detected on May 4th, operated on 13 days

later. Fantastic service by the most dedicated people I have

ever met’;

‘I was extremely fortunate to have benefited from the RAPID

programme which had only recently started at the time I was

being diagnosed. Without exception, the staff were efficient,

caring and sensitive. Even now I am stunned at how

efficient the NHS was’;

‘Efficient. I’ve never enjoyed the NHS before, very very

impressed’.

Consistent themes appeared aroundcommunication, lack of awareness of reason forreferral or appointments, and difficulty carparking.

‘Car parking at hospital is a nightmare’

‘It was a whirlwind of appointments thatoverwhelmed me as I was trying to take it allin’

‘Need to be more clear on the phone whencontacting people to invite to CT’.

Conclusions• Integration between chest medicine, radiology & thoracic surgery

• Fined tuned the very front end of the pathway

• Significant improvements in the pathway

• Exceptional patient experience

• Exceptional professional satisfaction

2014 2015 2016 National 2016

Number of cases 212 274 338 -

Surgical resection

22.9% 25.2% 32.9% 17.5%

Systemic therapy

62.2% 67.6% 70.6% 62.6%

1yr Survival - 47.8% 50% 37%

Challenges….and how to overcome?!• Understanding the problem – process mapping

• Resistance to change – clinical champions in all areas, evidence, acceptability, planning for future (screening)

• Resource implications – eliminate inefficiency, coding, business plans and begging

• Cross Boundary working – integration, facilitation – keep patient at the centre, pathway without walls

• Trust priorities – management & executive buy in, A&E, 4 hr wait, bedstock

• Direct access to CT – senior physician (GP) who is concerned about lung cancer. No increased work or abuse of system, radiologist and team support

• IRMER regulations – radiologist vetting ensuring the right CT for the right patient. ‘Physician radiologist’

• Lack of investment – know your business, service lines, reinvestment

• Change in Role & Territory – leadership, facilitation, patient first, ‘the big picture’

‘A Nursing Perspective’

• Patient Experience• Less Uncertainty• Shorter Pathways, Less Waiting• Patients Have More Realistic

Expectations• Protocols give Clarity to Patients &

Team• All Give Same Message• Better Access Back into Service

• Team Integration Gives More Flexibility

• Structured Nursing Support & Better Admin Support Releases Nursing Time

• Admin Support Enabled Delivery of Recovery Package

• Improved Data Collection/ Somerset Record

• Improved Data Collection, Increased Income = Team Expansion

Macmillan Cancer Improvement Partnership

Acknowledgements - RAPIDMatt Evison

Phil Crosbie

Judith Lyons

Julie Martin

Our Clinical Fellows

Anna Sharman

Rebecca Duerden

Radiology Workforce

Rajesh Shah & Consultant Team

Kath Hewitt

Caroline Gee

Paula Meredith

Thoracic Surgical Nursing Team

Karen Peplow

Julie Watts

Lung Cancer CNS Team

Ailsa Rowlands

Angela Watts

Mabs Rahman

Florence Rodriguez & Bronchoscopy Unit Staff

26

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