Nurses at Salisbury District Hospital have played a key role in developing a patient care pathway in the breast unit.
Sandra Bryan, CNS
Breast Care Nurse
Nurses at Salisbury District Hospital have played a key role in developing a patient care pathway in the breast unit. Last month, we examined integrated care pathways in general (Bryan et al, 2002). This paper takes a closer look at the breast-care pathway at Salisbury and its impact on the nurse’s role. This pathway leads patients from their GP into hospital, returning them diagnosed and treated to their GP. It is not static. The breast-care team is continually seeking ways to refine its pattern of work on the basis of new evidence and feedback from audit and patient groups.
Traditional system - For any condition the assessment starts when the patient sees the GP and is referred to a clinic. Traditionally, GPs dictated a letter, sent it in the post to the hospital, which would receive it centrally and distribute it to the consultant’s office. At some point the consultant would read the letter and prioritise the referral as ‘urgent’ or ‘soon’. The letter would be transferred to a central point in the hospital, where an outpatient appointment would be posted to the patient. This wasted time and resources. A previous audit found that the mean delay from the GP sending a letter to an appointment being sent to a patient was five days.
The diagnosis of breast problems depends on the triple assessment (BASO, 1995):
Patients needing inpatient surgery are seen in a nurse-led pre-assessment clinic soon after diagnosis. The clinic performs the nursing, medical and psychological interventions required for admission on the day of operation. Patients are also given the date and time of the first follow-up visit.
Each patient’s pathology is discussed at a weekly multidisciplinary meeting. Any patients who need oncology appointments have them made at the meeting. A formal notification letter is generated from data added to our computer database during the meeting, and sent to medical and clinical oncologists. The first postoperative visit is the day after the multidisciplinary meeting.
Regular feedback from patients and patient groups is vital. The breast-care team used questionnaires, resulting in changes to the pathway on many occasions. In one case, a male patient indicated that the information leaflet given to all patients before their attendance at the clinic applied only to women. A male patient information leaflet was produced.
Simplifying referral - The principles of this breast-care pathway have been applied to other diseases in the hospital, and elsewhere (Kitchiner et al, 1996). Efficient referral systems can be ensured by following a few basic rules (Box 2).
We have sought to extend the role of nurses within our pathway when this seems appropriate. The aim is always to improve the patient experience. The nurse role has been enhanced in four main areas that were previously performed by medical staff:
Many traditional medical roles within the pathway are better suited to the skills of an appropriately trained nurse. This has improved the patient experience and made better use of nurses’ talents, and should lead to a re-evaluation of their value and the esteem they are given within the trust, in terms of grading and remuneration.
Austoker, J., Mansel, R. (1999) Guidelines for referral of patients with breast problems (2nd edn). Sheffield: NHS Breast Screening Programme on behalf of the Department of Health Advisory Committee on Screening.
British Association of Surgical Oncology. (1995)Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom. European Journal of Surgical Oncology 21: (suppl A), 1-13.
Bryan, S., Holmes, S., Postlethwaite, D. et al.(2002)The role of integrated care pathways in improving the patient experience. Professional Nurse 18: 2, 77-79.
Department of Health. (2000)The NHS Cancer Plan. London: The Stationery Office.
de Salvo, L., Razzetta, F., Aruzzo, A. et al. (1997)Surveillance after colorectal cancer surgery. European Journal of Surgical Oncology 23: 522-525.
Earnshaw, J.J., Stephenson, Y. (1997)First two years of a follow-up breast clinic led by a nurse practitioner. Journal of the Royal Society of Medicine 90: 5, 258-259.
Horgan, K., Benson, E.A., Miller, A., Robertson, A. (2000)Early discharge with drain in situ following axillary lymphadenectomy for breast cancer. The Breast 9: 90-92.
Khandekar, J.D. (1996)Recommendations on follow-up of breast cancer patients following primary therapy. Seminars in Surgical Oncology 12: 346-351.
Kitchiner, D., Davidson, C., Blundred, P. (1996)Integrated care pathways: effective tools for continuous evaluation of clinical practice. Journal of the Evaluation of Clinical Practice 2: 65-69.
Saunders, C., Vijay, V., Stein, J., Baum, M. (1999)Setting up a breast cancer family history clinic. Annals of the Royal College of Surgeons of England 81: 6, 393-398.