Local MDT Reports on Communication Between Local and Specialist MDTs

CNSs & MDT Co-ordinators

South Mersey SMDT South Mersey SMDT

Graeme Totty, Urology SMDT Co-ordinatorGraeme Totty, Urology SMDT Co-ordinatorJeni Nixon, Local Urology Co-ordinator, WUTHJeni Nixon, Local Urology Co-ordinator, WUTHKaren Beckett, Local Urology Co-ordinator, CoCHKaren Beckett, Local Urology Co-ordinator, CoCHLinda Mallanaphy, Local Urology Co-ordinator, NCHLinda Mallanaphy, Local Urology Co-ordinator, NCH

Referrals to SMDTReferrals to SMDT• > from local co-ordinator via MDT/verbal

• > from Uro-Oncology Nurse by phone

• > Clinic letters from Consultants

• > for NCH & CoCH, patients are referred by local MDT co-ordinators by e-mail

• > proformas not currently used

Liaison between SMDT & local Liaison between SMDT & local MDT co-ordinatorsMDT co-ordinators

• > Wirral MDT co-ordinator works in same office

• > Visit CoCH co-ordinator at least once a week & regular e-mails & phone calls in between

• > Visit NCH co-ordinator each Wednesday & in contact by phone or e-mail

Collection of case notes & slidesCollection of case notes & slides

• Case Notes & slides collected from CoCH MDT co-ordinator each Wednesday

• Slides collected from NCH Pathology Lab each Wednesday (case notes needed at local Hospital for video-conferencing to SMDT)

Pathology reviewPathology review

• All slides from CoCH & NCH (along with WUTH cases) are reviewed prior to SMDT by Consultant Histopathologists

• Histology from CoCH & NCH is displayed & discussed only if there is disagreement with the original report

Role of Co-ordinator @ SMDT Role of Co-ordinator @ SMDT meeting in relation to chairmeeting in relation to chair

• Changed from start of 2010

• Meeting chaired on rotational basis by Consultant Urologists + Oncologists

• Cases discussed in order on agenda

Timeline for referralsTimeline for referrals

• > Most CoCH & NCH referrals are made on Wednesday following discussion at local MDT & discussed @ SMDT on the Friday of the same week

• > Majority of Wirral cases go straight to SMDT without previous discussion.

SMDT OutcomesSMDT Outcomes• > Outcomes are e-mailed to all members

each Monday• > The completed SMDT pro-forma is faxed

to patients G.P. on Monday after the meeting

• > Pro-forma faxed to Consultant @ NCH & CoCH at same time

• > Patients are contacted by Specialist Nurse if applicable

Other responsibilitiesOther responsibilities

• Track patients journey in relation to cancer Waiting Time Targets (now on SCR).

• Co-ordinate cases for discussion @ weekly Penile SnMDT

• Provide data for Audits/Peer Review etc

ChallangesChallanges

• Adapting to Somerset Cancer Registry for use in SMDT

• Obtaining feedback on patients discussed @ SMDT & followed up at local hospital.

• Dealing with increasing number of patients discussed

North Merseyside North Merseyside Urology Specialist MDT Urology Specialist MDT

GroupGroupWill MaitlandWill Maitland

Interaction and co-ordination Interaction and co-ordination with Local MDT groupswith Local MDT groups

North Merseyside Urology SMDT North Merseyside Urology SMDT GroupGroup

Royal Liverpool and Broadgreen NHS TrustRoyal Liverpool and Broadgreen NHS Trust Southport and Ormskirk NHS TrustSouthport and Ormskirk NHS Trust University Hospital Aintree NHS TrustUniversity Hospital Aintree NHS Trust Whiston Hospital NHS TrustWhiston Hospital NHS Trust Nobles Hospital NHS TrustNobles Hospital NHS Trust

Referrals also accepted from South Liverpool NHS TrustsReferrals also accepted from South Liverpool NHS Trusts

SMDT ReferralsSMDT Referrals

Referral deadline = midday Wednesday.Referral deadline = midday Wednesday. Sent via facsimile or secure email links.Sent via facsimile or secure email links. Referrals consist of completed patient proforma Referrals consist of completed patient proforma

accompanied by all relevant radiology and accompanied by all relevant radiology and histopathology reports.histopathology reports.

Majority of patients discussed at SMDT have been Majority of patients discussed at SMDT have been discussed at the Local MDT groups the previous week.discussed at the Local MDT groups the previous week.

SMDT outcomes are sent back to referring Trust by SMDT outcomes are sent back to referring Trust by midday the following Monday and official letters are midday the following Monday and official letters are dictated by SMDT Chair.dictated by SMDT Chair.

ISSUEISSUE – Illegible hand-writing makes data entry – Illegible hand-writing makes data entry difficult, leading to data errors on SMDT discussion difficult, leading to data errors on SMDT discussion lists.lists.

SMDT Histopathology ReviewSMDT Histopathology Review

Reviews are undertaken by either Dr Paul Reviews are undertaken by either Dr Paul Mansour, Dr Vijay Aachi or Prof. Chris Foster.Mansour, Dr Vijay Aachi or Prof. Chris Foster.

Pathology review takes place for specified patients Pathology review takes place for specified patients at the SMDT, not every patient at present.at the SMDT, not every patient at present.

Slides are either sent by Local Trust teams ahead Slides are either sent by Local Trust teams ahead of SMDT referral or facsimile requested by the of SMDT referral or facsimile requested by the SMDT co-ordinator after initial discussion.SMDT co-ordinator after initial discussion.

Target turn-around for pathology review is 14 days Target turn-around for pathology review is 14 days after initial discussion.after initial discussion.

Pathology review reports are sent back to original Pathology review reports are sent back to original pathologist at the referring Trust. pathologist at the referring Trust.

SMDT Radiology ReviewSMDT Radiology Review

Reviews undertaken by either Dr Jane Belfield, Dr Reviews undertaken by either Dr Jane Belfield, Dr Peter Rowlands, Dr Gabby Lamb or Dr Kirsty Slaven.Peter Rowlands, Dr Gabby Lamb or Dr Kirsty Slaven.

Radiology reports sent by facsimile with the Radiology reports sent by facsimile with the individual SMDT referral proformas and passed to individual SMDT referral proformas and passed to the core radiologists.the core radiologists.

SMDT co-ordinator completes individual ‘Image SMDT co-ordinator completes individual ‘Image Request’ proformas for each individual patient.Request’ proformas for each individual patient.

‘‘Image Request’ proformas are emailed to the Trust Image Request’ proformas are emailed to the Trust PACS Team who arrange for the notes to be PACS Team who arrange for the notes to be transferred electronically from the referring Trust.transferred electronically from the referring Trust.

ISSUEISSUE – Original radiology reports cannot be sent – Original radiology reports cannot be sent electronically with the images?electronically with the images?

SMDT Patient CasenotesSMDT Patient Casenotes

Notes sent to and from the centre Trust from Notes sent to and from the centre Trust from Aintree and Whiston hospitals only.Aintree and Whiston hospitals only.

Notes are addressed to the recipient and sent by Notes are addressed to the recipient and sent by registered taxi courier.registered taxi courier.

ISSUEISSUE – Reconstituted notes from Whiston Hosp – Reconstituted notes from Whiston Hosp makes locating and presenting patient info makes locating and presenting patient info during SMDT difficult. during SMDT difficult.

Conclusion and Future ChallengesConclusion and Future Challenges

An efficient and robust service however there An efficient and robust service however there are areas which need to be addressed….are areas which need to be addressed….

Hand-written referral proformas.Hand-written referral proformas. Sending of electronic radiology reports with Sending of electronic radiology reports with

requested images.requested images. Reconstituted Whiston notes.Reconstituted Whiston notes.

Pathology review of all patients discussed at Pathology review of all patients discussed at Urology SMDT.Urology SMDT.

Communication/Issues from local MDT’s

Michelle Thomas UHA

North SMDT

Duplication of information sent to SMDT.

Patients are contacted before outcomes are given.

Organisation of patients to be discussed.

Access to MDT co-ordinator.

Renal service appears to be fragmented.

Video link.

Outcomes of patient attending joint clinic.

Reliant on CNS giving outcome.

South SMDT

Video link not reliable.

Patients wait one week for oncology appt.

Patients require separate appointment to discuss surgery.

Patients prefer to be seen at local hospital.

Completely reliant on CNS giving outcome over telephone.

No Issues with outcomes/proformas etc.

Key worker TransferKey worker Transfer

Beverley Rogers/Gill RileyBeverley Rogers/Gill Riley

Urology MacMillan Nurse Urology MacMillan Nurse SpecialistsSpecialists

Mersey South Urology Cancer Mersey South Urology Cancer CentreCentre

POLITICAL AGENDAPOLITICAL AGENDA

• Manual for Cancer Service Standards Manual for Cancer Service Standards 20042004

• NICE Improving Supportive and NICE Improving Supportive and Palliative Care for Adults with Cancer Palliative Care for Adults with Cancer 20042004

• Cancer Reform Strategy 2007Cancer Reform Strategy 2007

• MCCN Key Worker GuidelineMCCN Key Worker Guideline

WHAT IS A KEY WORKER?WHAT IS A KEY WORKER?

The key worker is defined in the NICE The key worker is defined in the NICE guidance (2004) as:guidance (2004) as:

““A person who with the patient’s consent A person who with the patient’s consent and agreement takes a key role in co-and agreement takes a key role in co-ordinating the patient’s care and ordinating the patient’s care and promoting continuity, ensuring the promoting continuity, ensuring the patient knows who to access for patient knows who to access for information and advice.”information and advice.”

WHY DO PATIENTS NEED A KEY WHY DO PATIENTS NEED A KEY WORKER?WORKER?

There is a need to ensure integration There is a need to ensure integration and co-ordination of care, throughout and co-ordination of care, throughout the patients cancer journeythe patients cancer journey

The aim should be to provide continuity The aim should be to provide continuity ofof care throughout the patient pathway.care throughout the patient pathway.

DESIGNATING THE KEY DESIGNATING THE KEY WORKERWORKER

Each patient should have a named key Each patient should have a named key worker who will be identified at the worker who will be identified at the MDT where the initial cancer diagnosis MDT where the initial cancer diagnosis is made and treatment planning is made and treatment planning decisions discussed. decisions discussed.

The key worker will ideally be a The key worker will ideally be a

Clinical Nurse Specialist. Clinical Nurse Specialist.

The named key workers should be The named key workers should be reviewed at key points in the patient’s reviewed at key points in the patient’s cancer journey:cancer journey:

• Around the time of diagnosisAround the time of diagnosis

• Commencement of treatmentCommencement of treatment

• Completion of the primary treatment Completion of the primary treatment planplan

• Disease recurrenceDisease recurrence

• The point of recognition of incurabilityThe point of recognition of incurability

• The point at which dying is diagnosedThe point at which dying is diagnosed

RECORD KEEPINGRECORD KEEPING

The name, designation and contact details of the The name, designation and contact details of the key worker should be recorded within the patient key worker should be recorded within the patient notes. notes.

Multi-disciplinary teams must agree a method ofMulti-disciplinary teams must agree a method of documentation, for example, the MDT proforma, documentation, for example, the MDT proforma,

which is signed and dated.which is signed and dated.

The patient should be provided with written The patient should be provided with written information detailing the name of the key worker, information detailing the name of the key worker, designation and contact details. designation and contact details.

The key worker’s details should be included in all The key worker’s details should be included in all correspondence.correspondence.

What happens South of the What happens South of the Mersey….Mersey….• Uro oncology nurses both attend SMDTUro oncology nurses both attend SMDT

• Pick up patients who will need Pick up patients who will need appointments/investigations at cancer appointments/investigations at cancer centrecentre

• Ensure appropriate appointments madeEnsure appropriate appointments made

• Ensure available at clinic appointment Ensure available at clinic appointment (transfer of key worker)(transfer of key worker)

Tools UsedTools Used

• ““business card” and information leaflet with business card” and information leaflet with specialist nurse contact names and direct dial specialist nurse contact names and direct dial numbernumber

• Patient access to permanent record of Patient access to permanent record of consultationconsultation

• Letter link Letter link

• Diaries!!Diaries!!

Liaison with Key Worker at Liaison with Key Worker at Referring HospitalReferring Hospital

• Not on a routine basisNot on a routine basis

• No formal handoverNo formal handover

• Contact on an individual basis Contact on an individual basis following patient assessment of following patient assessment of understandingunderstanding

Does it work ?Does it work ?

• Three patient experience surveys Three patient experience surveys undertaken;undertaken;

• > penile cancer> penile cancer

• > cystectomy> cystectomy

• > nephrectomy> nephrectomy

PENILE CANCERPENILE CANCER

• 63% RETURN63% RETURN

• 95% knew who specialist nurse/key 95% knew who specialist nurse/key worker wasworker was

• 84% Knew how to contact specialist 84% Knew how to contact specialist nurse/ key workernurse/ key worker

CystectomyCystectomy

• 61% return rate61% return rate

• 100% patients knew who their 100% patients knew who their specialist nurse/key worker wasspecialist nurse/key worker was

• 100% of patients knew how to contact 100% of patients knew how to contact their specialist nurse/key workertheir specialist nurse/key worker

NephrectomyNephrectomy

• 85% return rate85% return rate

• 100% of patients knew who their 100% of patients knew who their specialist nurse/key worker wasspecialist nurse/key worker was

• 100% of patients knew how to contact 100% of patients knew how to contact their specialist nurse/key workertheir specialist nurse/key worker

IssuesIssues

• Lack of uro oncology cns at CCOLack of uro oncology cns at CCO

• Major impact on workload WUTH Major impact on workload WUTH (from a local perspective)(from a local perspective)

• Can not transfer key workerCan not transfer key worker

CONCLUSIONSCONCLUSIONS

• Appears to work wellAppears to work well

• Patient satisfactionPatient satisfaction

• No need for another form of paperworkNo need for another form of paperwork

• ??????

The Role Of Radiotherapy The Role Of Radiotherapy Liaison & Support Liaison & Support

Practitioner.Practitioner.

Martin WoodsMartin WoodsRadiotherapy Liaison & Support Radiotherapy Liaison & Support

PractitionerPractitionerClatterbridge Centre for OncologyClatterbridge Centre for Oncology

0151-334-1155 Ext 4727 Bleep 41950151-334-1155 Ext 4727 Bleep 4195martin.woods@ccotrust.nhs.ukmartin.woods@ccotrust.nhs.uk

Key SkillsKey Skills

Communication

Liaison & Teamwork

Signposting

Enthusiasm & Motivation

Documentation & Accuracy

Patient centred approach

• Bladder CancerBladder Cancer

• Prostate CancerProstate Cancer

• Upper G.I. Cancers (oesophagus, Upper G.I. Cancers (oesophagus, stomach, gall bladder, liver).stomach, gall bladder, liver).

• Brain TumoursBrain Tumours

• LymphomasLymphomas

• Melanomas/SarcomasMelanomas/Sarcomas

• Testicular CancersTesticular Cancers

I provide holistic assessment & care to I provide holistic assessment & care to patients’ receiving radiotherapy& chemo-patients’ receiving radiotherapy& chemo-radiotherapy who are not linked with a radiotherapy who are not linked with a site specific CNS. This includes:-site specific CNS. This includes:-

CommunicationCommunicationNICE Guidance states: Interpersonal communication is the process through which patients & carers can explore issues & arrive at decisions in discussions with health & social care professionals. It is most effective when there is mutual understanding, respect & awareness of individuals’ roles & functions.

• Important to establish an excellent rapport Important to establish an excellent rapport with patients’ & carers – vital to enable me with patients’ & carers – vital to enable me to assess their immediate & future needs.to assess their immediate & future needs.

•Establishing that initial rapport can pay dividends Establishing that initial rapport can pay dividends for the future relationship with the patient – for the future relationship with the patient – common groundcommon ground

CommunicationCommunication

•Discussions with patients and carers at key stagesDiscussions with patients and carers at key stagesaids holistic assessment and identifies existing and aids holistic assessment and identifies existing and potential needs.potential needs.

•I monitor patients’ progress throughout the I monitor patients’ progress throughout the course of treatment & make further referrals if course of treatment & make further referrals if necessary.necessary.

•I have a patient centred approach & provide an I have a patient centred approach & provide an empathetic & sympathetic ear to patients’ & their empathetic & sympathetic ear to patients’ & their carers’.carers’.

Liaison & TeamworkLiaison & Teamwork

I have an excellent working relationship I have an excellent working relationship Radiotherapy colleagues, with members of Radiotherapy colleagues, with members of the CReST team & Doctors.the CReST team & Doctors.

Developed good working relationship with Developed good working relationship with Specialist Nurses.Specialist Nurses.

SignpostingSignposting

The Radiotherapy Support Practitioner is a The Radiotherapy Support Practitioner is a link to the other professionals & link to the other professionals & services the patient/carer may needservices the patient/carer may need

• CReST TeamCReST Team• Cancer Nurse Specialist (CNS)Cancer Nurse Specialist (CNS)• District nurseDistrict nurse• Macmillan NurseMacmillan Nurse• Occupational therapistOccupational therapist• Social workersSocial workers• PsychologistPsychologist• ChaplainChaplain

SignpostingSignposting

I am aware of my limitations & can recognise when the solution to the patient’s needs are outside of my competencies – referring to the appropriate professional.

What makes this post What makes this post special?special?

The difference between involvement and The difference between involvement and commitment is like egg and bacon. commitment is like egg and bacon.

The chicken is involved; the pig is The chicken is involved; the pig is committed!committed!

I am committed to giving the best I am committed to giving the best care & support to patients’ & their care & support to patients’ & their carerscarers

Local MDT’s – common problems◦ Reliance on CNSs to give feedback on outcomes◦ Difficulties with video link

SMDT co-ordinators –◦ Issues variable

Lack of a forum between the CNSs and the MDT co-ordinators within the Network to discuss issues and share good practice

Need to identify how there can be a seamless transition in the role of key worker from centre to centre ◦ CNSs from local centres attend joint clinics – i.e.

the key worker stays with the patient where possible

◦ Improved transfer of information between key workers if different at each centre – how??

◦ Leaflets to be given to patients at diagnosis / transfer of care explaining how the key worker changes