Modernising the NHS into the 21st century is high on the political agenda. The patient experience has become an increasingly important aspect of modernisation, with rapid access to a high-quality service being a particular expectation.
Tracy Kates, BSc (Hons), RGN, DPSN
Lung Cancer Nurse Specialist,George Eliot Hospital, Nuneaton
THE MODERNISATION AGENDA
It is an expectation that was first mooted in a Department of Health paper, A First Class Service (DH, 1998), which stated that all patients were entitled to high-quality care that was fair and easy to access. The paper also emphasised efficiency and cost-effectiveness. This theme was carried through in subsequent papers - notably The NHS Plan (DH, 2000a) and The NHS Cancer Plan (DH, 2000b), the emphasis of these being on modernising, rebuilding and streamlining services to be high quality and patient-centred. NHS staff, in particular nurses, have been identified as being important in shaping services, planning change and reducing waiting times (DH, 2000a; DH, 1998).
At some stage, the lives of one in three people in England will be affected by cancer. Each year, 200,000 patients are diagnosed with cancer and approximately 120,000 people will die from the condition (DH, 2000b).
Lung cancer accounts for 17% of all cancers (Doll and Peto, 1996), with approximately 40,000 new cases being diagnosed each year (Quinn, 1999). Despite advances in diagnosis, staging and treatment, the survival rates for this type of cancer remain extremely poor (Brown and George, 2004). It is the third most common cause of death in the UK (NHSE, 1998).
Patients often present very late in the history of their lung cancer disease, which is a major handicap to its management (Peake, 2004). Timely and prompt access to investigations for those patients, who, it is suspected, may have lung cancer (or any other type of cancer), is particularly important for improving outcomes and survival rates.
Computerised tomography (CT)-guided percutaneous lung biopsy/aspiration is a relatively frequently performed diagnostic procedure for lung cancer. For patients - requiring this procedure it may be the first or second diagnostic procedure that has been undertaken, depending on the position of the presenting lesion; flexible bronchoscopy would be considered first.
Lung biopsy/aspiration involves passing a fine needle through the skin and the chest wall into the lung to where a lesion has been identified. CT scanning allows the radiologist to identify correct positioning of the needle before taking a biopsy or fine-needle aspiration.
At my hospital, the procedure was normally undertaken within two weeks of referral and it was routine for patients to remain in hospital overnight for observation in case of complications, the most common being pneumothorax (Diethelm et al, 1997).
However, anecdotally, it was perceived that an increasing number of procedures were being cancelled on the day for which the procedure had been booked because of lack of bed availability owing to emergency admissions, elective surgical admissions and booked diagnostic procedures.
The NHS Cancer Plan (DH, 2000b) set out the Government’s commitment to improving cancer services, and identified goals and targets to reduce waiting times for diagnosis and treatment. One important target was that by 2005 the maximum time of waiting from urgent GP referral to treatment should be two months. Given the cancellations that were being made in the hospital for CT-guided biopsy procedures, there was concern that the hospital would not be able to meet this target, especially if this was a second diagnostic procedure. There was also concern at the distress the cancellations were causing patients.
Waiting for investigations can be an emotionally difficult time (Leung and Silvey, 2003), because delays in diagnosis and/or treatment make patients anxious about the effect this may have on their overall outcome (National Cancer Alliance, 1996). I was often contacted by distressed patients and relatives concerned about the effect of delays.
Clinical nurse specialists fulfil a multitude of roles (Chuk, 1997), but one that is regarded as vital is that of change agent (Miller, 1995), which means that reviewing and evaluating current practice is a responsibility (Armstrong, 1999).
For services to be effective they need to be SMART - Specific, Measurable, Achievable, Realistic and Timely. It had become evident that the hospital’s lung biopsy/aspiration service could not be considered SMART, especially in terms of its being achievable, realistic and timely. Review was obviously needed and, as part of my role, a service review was initiated.
First, through informal consultation with other members of the multidisciplinary team, the patient’s journey in the lung cancer service was process mapped from referral to diagnosis. The purpose of this exercise was to understand problems and issues from a patient perspective (NHS Modernisation Agency, 2002) and then to identify ways of addressing the issues. Moore et al (2003, p39) identified that the role of the lung cancer nurse, together with members of the multidisciplinary team, is to scrutinise the overall delivery of services to ensure patient pathways are streamlined and delays kept to a minimum.
The process mapping exercise confirmed that, from a patient perspective, waiting times for CT scans and frequent cancellation of CT-guided biopsies were the main areas where improvement was required. My brief was to focus on the issue of cancellations. First, I discussed with the lead radiologist for lung cancer the reasons for the cancellations and then raised the issue of having patients stay overnight: what was the evidence for this practice being necessary? What was the optimum time for post-procedure complications to become apparent and which patients were likely to be at increased risk of complications?
A review of the literature suggested that common complications such as pneumothorax are often diagnosed at the time of the biopsy/aspiration or within the first hour, and that a routine recovery period was one to four hours (Diethelm et al, 1997). In the light of these findings, further discussion took place with the lead radiologist for lung cancer and the lead lung cancer clinician, following which it was agreed that I would take the lead on writing a protocol on offering a CT-guided biopsy/aspiration service on a day-case basis. The guidance would include day-case criteria, patient information, post-biopsy/aspiration care, and discharge information.
When planning change it is important to ensure that all stakeholders are included in the process, and for successful implementation good communication and gaining staff commitment and involvement are key activities (Plant, 1987). Accordingly, the following groups of staff were approached:
- Radiographers working in CT scanning
- The lead lung cancer clinician
- Respiratory physicians
- The day procedures manager and staff.
A protocol was developed that considered carefully issues relating to day-case criteria and emphasised the importance of identifying post-procedure complications and patient safety while the patient was in hospital and on discharge.
Several drafts of the protocol were made before there was agreement from all stakeholders. The discussion had focused particularly on the timing of the post-procedure chest X-ray. The agreed protocol changed the service into a day-case procedure for patients meeting specified criteria. Day-case patients would recover in the day procedures unit.
As part of a wider lung biopsy/fine needle aspiration audit that had been planned by the lead radiologist for lung cancer, an audit of the day-case service was undertaken. It was designed to evaluate whether the change in practice had been detrimental to patient care by identifying complication and admission rates for the planned day cases. The audit showed that no day-case patients had had their procedure cancelled because of a lack of recovery beds in the day procedures unit.
Although it was considered important that procedures went ahead as scheduled, post-procedure complications and readmission post-discharge were also considered important issues. Manhire et al. (2003) identified that pneumothorax after a lung biopsy can occur in 0-61% of patients. The audit recorded an overall pneumothorax rate of 30% (23% for day cases). However, a majority of these did not require medical intervention as the pneumo-thorax was considered to be small and patients were asymptomatic. These rates were slightly higher than had been expected, but the protocol was developed so that staff looked for complications rather then relying on patients reporting symptoms.
The audit identified that only two patients required admission from the day procedure unit as a result of a post-biopsy pneumothorax.
The cost-effectiveness of a service is also a consideration. The audit findings concluded that 23 patients were discharged the same day. The standard cost saving to the hospital for medical patients per patient day is £200. By performing CT-guided biopsies/aspirations as day cases, a cost saving of £4600 was made.
Overall, the audit findings supported continuing with planned day cases for those patients fitting the criteria.
The change agent component of the clinical nurse specialist role facilitated a review of the lung biopsy/aspiration service. Subsequent evaluation showed that, through multidisciplinary and multi-departmental working, the service was able to be modernised and streamlined.
The service provided can now be considered SMART in its delivery, particularly in respect to timeliness. As a consequence, patient experience and perception of this diagnostic procedure has improved.
Author’s contact details
Tracy Kates, Lung Cancer Specialist, George Eliot Hospital, Nuneaton Email: firstname.lastname@example.org
Guidelines for radiologically guided lung biopsy for outpatient and day cases have been published by the British Thoracic Society (Manhire et al, 2003). These suggest that:
- High-risk patients (those with poor lung function and significant co-morbidity) should not be considered for day-case procedures
- Patients should be warned of delayed complications and given verbal written instructions to return if symptomatic
- Patients should live within 30 minutes of a hospital, have adequate home support, and access to a telephone.
- An important element of the clinical nurse specialist role is to act as an agent for change
- Lung cancer is known to have poor prognostic outcomes
- Improving quality of service to achieve timely diagnosis is important
- Patient experience and satisfaction should be an identified goal in service
- Governement targets as identified in the NHS Cancer Plan must be achieved
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