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A breast unit care pathway: enhancing the role of the nurse

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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.



Recently, two standards of care have been introduced for people seen by a GP thought to have a risk of cancer (Department of Health, 2000). First, the referral should be received in the cancer unit within 24 hours of the GP seeing the patient. Second, the unit should assess these patients in a specialist clinic within two weeks. The usual referral practices were obviously not compatible with this.



First attempt at a solution - The first modification was to introduce a simple referral template, completed by the GP and faxed into the breast service co-ordinator’s office. The template set out guidelines for referral and indicated if a particular set of features would result in an urgent or non-urgent appointment. The referrals would be assessed by a clinic co-ordinator, who would fax back an appointment to the GP surgery. The breast service aimed to fax back within 10 minutes, to allow patient feedback.



The patient would be sent a clinic appointment and information leaflet. This system accorded theoretically with a booked admission but still had shortcomings. Fax-back only worked in a few cases. Often the patient had left the surgery when the return fax arrived. We created expectations we could not meet. In its simple template, the breast-care team underestimated the number of patients who would be categorised urgent - 80% of referrals, compared to an incidence of 5-10% of cancer in the breast clinic. We saw too many patients urgently, so urgent referrals were not seen as soon as they should be - with potential delays in non-urgent referrals, a few of whom might have cancer.



The modified template - The referral template was modified and refined to incorporate a new set of guidelines adapted from national guidelines (Austoker and Mansel, 1999) in a bid to reduce inappropriate urgent referrals (Table 1). A scoring system is used to predict more accurately those patients likely to have cancer. Since then, the number of urgent referrals has fallen from 80% to just 34%. The unit can now see urgent patients at a mean delay of five days from their GP visit and all (‘urgent’ and ‘soon’) are seen within two weeks.



The clinic
The diagnosis of breast problems depends on the triple assessment (BASO, 1995):



- Examination



- Breast imaging



- Cytology.



These three activities need to be co-ordinated to diagnose the large number of patients typically seen in a clinic. Once patients have been fully assessed, they are given a personal plan, which indicates their diagnosis and any follow-up plans.



It is stressed that if they have any lingering anxiety, because of progression of or new symptoms, they should telephone us to be seen again.



Those with cancer are given counselling by the breast-care nurse and access to further information on paper and via a hospital website (Box 1). This website is available off-line on laptop computers, which can be loaned to patients newly diagnosed with cancer.



Patients are given a date for the pre-assessment clinic later that week. They are reassured that they can delay their surgery if they feel unable to make an informed treatment choice by this time, despite the information they have received.



Shortly after the one-stop clinic, the results are discussed in a multidisciplinary meeting, and the management plan confirmed. One problem we had encountered was a delay in planning appointments for patients who needed radiotherapy after an operation. This has been reduced by notifying the radiotherapy department before surgery of any patients likely to need the procedure afterwards.



Admission for operation
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.



These and other patient data are recorded in a patient-held record, issued at pre-assessment, and used throughout the follow-up period. Most patients can now be admitted on the day of their operation and are discharged two days afterwards. In our unit, the mean hospital stay has fallen from eight to three days since the pathway was introduced. This has not been accompanied by increased complications, and a Community Health Council survey of our patients indicated that they want this pattern of care.



At discharge, a summary is faxed to the GP and to an identified nurse at each practice. The practice nurse arranges a visit to the patient’s home within 48 hours to assess the wound and enquire about any problems. If any problems arise the patient or nurse can contact the surgical ward for advice.



The first postoperative 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.



Removing the wound drain - When the pathway was introduced, it was envisaged that community nurses would remove the wound drain and sutures and an education process was set up. But this did not work; the community nurses felt the increased workload could become a problem and there were some drain complications. Now the drain is removed in clinic. Absorbable wound sutures are now used. An oncology nurse attends the clinic to counsel patients referred for chemotherapy.



Patient feedback
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.



We also get valuable feedback and test new ideas by talking to patient support groups. For example, one such discussion contributed to the format of the patient-held diary and website. There are plans to video patient focus groups to identify gaps in care. This has been successful elsewhere, according to a personal communication from the Cancer Services Collaborative.



Lessons for others
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).



In general, the clinic must enable patients to be investigated fast. Predicting need can mean the investigation starting as soon as the referral arrives rather than when the patient is seen in clinic.



Ways to achieve this include, for example, pre-clinic mammograms. In colorectal disease it may involve organising barium enemas or flexible sigmoidoscopy before the patient attends the clinic.



Non-medical pre-assessment of our patients has improved the process of their admission by avoiding duplication. Patients can be seen a few days before planned admission by a nurse. They perform routine nursing assessments and also the basic medical assessment of pulse and blood pressure. They organise blood tests, chest X-rays and ECGs according to protocols. If abnormalities are found in these tests, patients can be referred as appropriate. Patients then only need to be seen by the anaesthetist immediately before the operation.



Preparing for follow-up - Planning for discharge should also be set in motion. This may involve social adjustments or education, such as in wound and drain care, or the management of a stoma. Organisations should re-evaluate the follow-up process. What should its role be? When is the aim to detect recurrence? When is it to apply an intensified screening process, and when is it just to give psychological support? In colorectal disease, for example, the risk of recurrence is highest in the first three years after treatment; from then on regular colonoscopies may continue to detect a new cancer (de Salvo, 1997).



Support needs to be offered throughout, especially for patients with stomas. After appreciating the reasons for follow-up, a protocol can be devised, often with a significant role for a suitably trained nurse. It is possible to predict when patients will need certain interventions well in advance.



The follow-up protocols are an example, but there is scope even sooner in the patient journey. The date of a pre-assessment visit and operation can be set when diagnostic and staging investigations are completed. The date of the post-operative visit can be arranged if the patient’s length of stay is known in advance. Information for patients should be reviewed regularly, and stratified to give them access to as much as they need at each stage in their treatment.



The role of breast-care nurses
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:



- Nurse-led pre-assessment clinic



- Follow-up clinic



- Family history clinic



- Seroma aspiration.



Pre-assessment clinic - A staff nurse with specialist training now runs the entire pre-assessment process in the hospital. The assessment nurse carries out functions previously performed by ward nurses on admission, and junior medical staff in assessing fitness for anaesthetic. The nurse offers the patient counselling from the breast-care nurses when this is needed. A typical consultation could be made up of 30 minutes’ pre-assessment with the staff nurse and 30 minutes’ counselling with the breast-care nurse. The form of assessment was agreed with the anaesthetists, who still need to see each patient immediately before the operation.



Preparing for discharge - Studies have shown that early discharge is safe (Horgan et al, 2000), but in this unit it was rare if discussion was left until after the operation. We familiarise patients in advance with the use of the wound drain, which will be inserted at the operation. We check on their social environment. If appropriate, patients can plan to be discharged one or two days after surgery.



The nurse-led clinic offers continuity; the patient is not given conflicting information, which can occur with changing junior medical staff. Duplication of information is avoided. Since adequate nursing assessment takes place before admission and all the paperwork is done, ward nurses can prepare patients more sympathetically for their operation.



Follow-up clinic - The usual model for follow-up after the treatment of common tumours is that patients are seen regularly in hospital by a variety of hospital doctors (Khandekar, 1996). Follow-up has not produced significant physical benefit for most patients (Earnshaw and Stephenson, 1997). Its major role is to support the patient psychologically, and its secondary role is to detect recurrent disease (Box 3) (Earnshaw and Stephenson, 1997).



Family history clinic - More women are referred to such clinics because their family history is seen to place them at an increased risk (Saunders et al, 1999) (Table 2). A family history clinic quantifies this risk, educates patients in breast awareness and institutes appropriate follow-up. A short course was organised for the clinic’s nurses by the hospital’s clinical geneticist. The nurses also attended the regular genetics clinic on several occasions. This was followed by an apprenticeship scheme, where nurses accompanied the consultant and reported their findings. The clinic now runs parallel to, but separate from, the consultant clinic, organised by the breast-care department. The nurses enter their findings and follow-up strategy onto a form. A laminated follow-up plan is given to the patient to confirm the screening plan. A referral is made to the genetics clinic for women at high risk.



Seroma aspiration - After operations involving axillary dissection there is a significant incidence of seroma formation (about 30-50%) following removal of the wound drain. Usual practice has been for this to be aspirated by a doctor. However, after a period of mentored training, nurse-led aspiration has been introduced. Audit has shown no increase in wound complications.



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.



Senior trust members’ support is vital to underwrite the nurses’ increased responsibilities. The extra duties, particularly of the breast-care nurses, means that the number of nurses within the department needs to be looked at again. The case for change will be strengthened if the success of these clinics is supported by objective data as well as subjective feedback from staff and patients. Objective measures that will help determine this include the number of patients seen per clinic, the percentage of visits when patients or nurses request them, and a review by senior medical staff.



Involvement in a pathway can be a rewarding experience. Patients receive better treatment, and because there is less duplication and tasks are better suited to team members’ training and interests, staff work more efficiently. Working in a team where a ‘can-do’ attitude prevails and which is responsive to suggestions for innovation has proved a source of inspiration for those involved.




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.


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