PROFESSIONAL ISSUES
Impact of lung cancer clinical nurse specialists on emergency admissions Alison Leary and Jane Baxter
© 2014 MA Healthcare Ltd
I
n 2011, 43 463 people in the UK were diagnosed with lung cancer (Cancer Research UK, 2014). The incidence of lung cancer is strongly related to age, deprivation and smoking. In the UK, from 2007 to 2009, the majority of cases were diagnosed in patients over 65 years of age (Cancer Research UK, 2010). In 2011, there were 35 184 deaths from lung cancer, making it the most common cause of cancer death in both men and women, and accounting for 6% of all deaths in the UK (Cancer Research UK, 2010). The 5-year overall survival rate is 8–11% (Cancer Research UK, 2010). Five-year survival from lung cancer has barely improved in the past 30 years, but there has been a decline in male deaths and an increase in female deaths (Spiro and Silvestri, 2005), largely owing to changes in patterns of tobacco use. One-year survival has improved to some degree. In England and Wales, 1-year survival for men with advanced non-small cell lung cancer rose from 15% in the 1970s to 25% in 2000–2001 (Coleman et al, 2004). Specialist nursing practice in cancer has expanded since the Department of Health (DH) introduced cancer improvement initiatives in 2000 (DH, 2000) and now lung cancer nursing practice is embedded in national guidance (National Lung Cancer Forum for Nurses (NLCFN), 2009; National Institute for Health and Care Excellence (NICE), 2011; Roy Castle Lung Cancer Foundation and NLCFN, 2013) and seen as fundamental to the care of lung cancer patients and carers. However, due to administrative workloads, lung cancer clinical nurse specialists (CNS) have to leave essential clinical work undone (Leary et al, 2014). There were 295 full-time equivalent specialist nurses in lung cancer in England at the time of the 2011 census (National Cancer Action Team (NCAT), 2012), but their distribution varies (Leary et al, 2011). The work of the CNS is complex (Leary et al, 2008; NCAT, 2010) and has many functions, including acting as the ‘keyworker’ (DH, 2007) within the multidisciplinary team. Much of this function is the management of care in partnership with the rest of the multidisciplinary team, patient and family, including being vigilant (Meyer and Lavin, 2005), particularly at times of risk (NCAT, 2013), so that care can be proactively managed (Leary, 2011) rather than reactively managed. There is evidence that offering early proactive intervention and proactive palliation in patients with non-small cell lung cancer increases survival and quality of life, and decreases undesired aggressiveness in end-of-life care where acute care often becomes the default (Temel et al, 2010). In addition, nurse-led follow-up and management have been shown to lessen disease symptom severity and improve emotional
British Journal of Nursing, 2014, Vol 23, No 17
Abstract
Clinical nurse specialists (CNS) in cancer perform a range of complex activities, including the management of care. However, they often report a high administrative burden for services, which makes providing expert nursing care challenging. Administrative work for a service can be seen as a priority for non-nurses, yet a high administrative burden allows less time for complex nursing care. A London trust admitted a mean of four lung cancer patients per month for symptom control in progressive disease or end-of-life care, with a mean stay of 6 days. This was often a default location: the acute hospital was not always the patient’s preferred place of care for end of life. The CNS negotiated away the administrative burden, which occupied 38% of their working time, and adopted standard proactive case management in line with national standards. The CNS were also able to build a collaborative relationship with others, such as local GPs and community palliative care teams. Their proactive and vigilant case management resulted in fewer admissions for non-acute problems: a mean of four emergency admissions per month fell to a mean of fewer than one (0.3). For this service, the mean length of emergency admission was 6 days, so a reduction in the admission rate represented a significant saving in bed days (266 a year) and a higher rate of achieving the preferred place of end-of-life care. In conclusion, CNS who practise proactive case management and refocus services in line with best practice represent a good return on investment (ROI). Key words: Clinical nurse specialists ■ Value ■ Admission avoidance ■ Outcomes functioning (Moore et al, 2002). The English DH Cancer Reform Strategy promotes care in the most appropriate setting, and proactive case management is a patient-centred method of doing this (DH, 2007). The shape and function of these services are well defined and are regularly examined by internal and external peer reviews, as well as the national cancer patient experience survey (DH, 2011; 2012; 2013).The role of the CNS also promotes efficiency and productivity in line with government initiatives, particularly with increasing financial pressures on the NHS. Workload analysis showed that the lung cancer specialist nursing service of two full-time nurses serving an acute hospital Alison Leary, Professor of Healthcare and Workforce Modelling, London Southbank University; Jane Baxter, Clinical Nurse Specialist, Community Palliative Care, Meadow House Hospice, Middlesex Accepted for publication: August 2014
935
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights reserved.
3%
10% Faxing results/ requests Chasing up routine results Making routine appointments
8%
10%
MDT admin Other admin
6%
58% 4%
Clinical Research Education
Figure 1. Distribution of CNS work before proactive case management. MDT=multidisciplinary team
was being used primarily to support processes, diagnosis and treatment targets, and non-clinical administration—rather than providing holistic cancer care and management of care. Overall, the two nurses spent 38% of their working time on non-clinical administration, which equated to approximately 26 hours per week. This time was primarily spent on work to support meeting the national cancer 2-week wait target (DH, 2000), as well as administrative and clinical support for the multidisciplinary team meeting, such as taking minutes, booking routine investigations, and providing secretarial support to the cardiothoracic service (Figure 1). Specialist cancer nurses should have input into managing services, but should not have to bear the burden of administration (NCAT, 2008). Yet many specialist nurses spend 20–30% of their time performing administration for a service (Leary et al, 2008; Oliver and Leary, 2010; Royal College of Nursing (RCN), 2010). A concurrent case-mix analysis of the inpatient population showed that patients were being admitted for non-acute problems, such as symptom control in advanced disease, psychosocial issues or end-of-life care where hospital was not their stated preferred place for it. The nature of the nursing service was reactive, attending to crisis or administrative work. The authors’ hypothesis is that bringing the service in line with current best-practice guidance would release administrative time for the purpose of giving clinical care.This, in turn, would result in more proactive case management and fewer admissions for symptom control in progressive disease, as nursing vigilance could be applied at times of higher risk of admission, such as progressive disease, and rescue work (Silber et al, 1992) could be a matter of managing presenting issues.
Methods A retrospective study examining all emergency admissions to the acute centre within a 6-month period for lung cancer took place. This showed 69 emergency admissions via the accident and emergency (A&E) department. The majority of
936
these patients (58) had not had recent contact (>30 days) with the lung cancer team. A distinction was made between admission via the A&E department for acute oncological or non-oncological emergencies that required emergency care—for example, pleural effusions; pulmonary embolism; acute chest infection; spinal-cord compression; new brain metastasis or brain metastasis where acute care is indicated; sepsis; acute noncancer conditions, including respiratory, thoracic procedure readmission; and other chronic diseases—and those admissions where emergency admission is unlikely to be the best option. Such admissions might relate, for example, to symptom control in advanced disease where it is established that symptom control is the agreed ceiling of care, or end-of-life care where the preferred place of care is not the acute centre. Of the 69 emergency admissions, 24 were for symptom control where the ceiling of agreed care with the patient and family was palliation of symptoms or end-of-life care. To assess how the lung CNS’ role was performing against national standards in lung cancer and supportive care, the service was audited against several standards, which were described in the introduction. The activity of the lung cancer nursing service was also analysed with a bespoke data collection tool. This used workload analysis by modelling by means of methods described elsewhere (Leary et al, 2008; RCN, 2010). In addition, a convenience sample of patients on the caseload (n=30) were called to ascertain their needs and deficit in specialist nursing care, and possible interventions in line with current best practice. The basis for selection was no recent contact (>30 days) with any member of the lung cancer multidisciplinary team. The convenience sample had unmet needs (Baxter and Leary, 2011) and some patients had more than one. Three patients had post-thoracic surgery pain that was not being managed; these patients were counselled on lifestyle, rehabilitation and analgesia. Seventeen patients had symptom issues that were subsequently addressed with interventions (for example, with a clinic review or, in one case, referral to a psychologist). Four patients were lost to follow-up from the chest or respiratory service, and two were lost to follow-up from the oncology service (post-radiotherapy). These were then reviewed in scheduled clinic appointments. Overall, 26 of 30 patients had issues concerning pathway management or symptoms related to their disease, including its possible progression. The findings of the needs analysis supported the case for administrative burden to be moved to a more appropriate worker, thereby releasing expert nursing time for care delivery and management. After negotiating this work away to an administrative worker, a more conventional practice in line with bestpractice guidance was instituted. This included increased holistic assessment, presence at diagnosis or impending diagnosis, and nurse-led clinics for patients with progressive disease, both face-to-face and over the telephone. It also allowed for increased case management function and the use of vigilance at times of increased likelihood of symptom issues (NCAT, 2013). Three months of transition to proactive case management followed and, after another 6 months, the rate and reason for emergency admission was reviewed.
© 2014 MA Healthcare Ltd
1%
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights reserved.
PROFESSIONAL ISSUES Patients were contacted regularly at times of increased risk of admission, for example, in progressive disease, and at least once a month. Patients and families could also contact the nurses directly. Colleagues in the community palliative team, hospice at home, hospice daycare and GPs were able to respond to issues as a shared caseload with the specialist nurse as keyworker. If the issue was acute, provision was made to review the patient in the acute centre. For example, if a patient with advanced lung cancer had pain or dyspnea, this could be assessed and managed in the community or admission arranged for an acute cause. Acute oncological emergencies that could not be managed in the community, such as pleural effusions, came back to the acute centre, as did patients needing any other acute intervention. This meant management was in line with best practice guidance in lung cancer and supportive care (NICE, 2005; DH, 2007; NLCFN, 2009, NICE, 2011).
2% 7%
© 2014 MA Healthcare Ltd
Change in rate of admission Before proactive case management, the service averaged (a mean of) 4 avoidable admissions for progressive disease symptom control or end-of-life care per month with an average stay of 6 days. After the introduction of proactive case management, there were 3 such admissions in 9 months, giving a mean of 0.3 per month. If the average rate of admission avoidance is then 3.7 per month, this represents a considerable saving.
British Journal of Nursing, 2014, Vol 23, No 17
4% 4%
2%
4% 12%
Faxing results/ requests Chasing up routine results Making routine appointments MDT admin Clinical admin Clinical Research & audit Education Consultation
62%
Results Change in nursing activity Before the administrative burden was negotiated away, 38% (13 hours per week per whole-time post) of the specialist nurse’s available time was spent on largely routine clerical work (booking routine appointments, faxing results and letters to referring centres, booking transport; Figure 1). This dropped to 24% of the total work and the nature of the administrative burden also changed to essential clinical administration (Figure 2), for example, dictating letters, completing referrals and requesting investigations. Purely clerical work constituted 12% of the workload (4.5 hours per week per whole-time post). There was a small increase in formal and informal teaching activity (from 2% to 7%) and consultation work/service improvement work (from less than 2% to 5%, or approximately 2 hours per week per whole-time equivalent). The primary difference in terms of percentage of time was clinical activity, which rose from 56% to 62% in the clinical category, plus the change in nature of administrative work meant that only 12% of time spent was on purely administrative functions. The increase in clinical activity was in symptom control and psychosocial interventions, such as emotion-focused work and dealing with distress. Thirty-eight per cent of the overall work was done over the telephone, with the post-change service handling an average of nine complex phone calls per day, a similar volume to other expert nursing services (Warren et al, 2012). Symptom-control work included specialist symptom assessment and prescribing or recommending medicines. Of the 62% coded as clinical events, a third were psychological, whereas previously psychological events accounted for less than 10% of the clinical work.
3%
Figure 2. Distribution of CNS work after proactive case management. MDT=multidisciplinary team
Even in this small study, it was calculated that 33 admissions were avoided in 9 months. At an average stay of 6 days, this represents 198 saved bed days over 9 months, or 266 bed days per year as a result of outpatient proactive case management alone. At a minimal cost of £250 per acute bed, based on the 2011 tariff (NHS Institute for Innovation and Improvement, 2011), this represents a total saving of £66 500 per year for the admission avoidance aspect of the service. This would not include income generated from alternative use of those bed days.
Change in service configuration The expert nurses were able to spend more time working with patients and families in areas such as self-management, education and holistic assessment. They were also able to increase the amount of collaborative multidisciplinary working, including referral to a benefits advisory drop-in, face-to-face or telephone clinics. In addition, new activities were undertaken. For example, in collaboration with the psychologist, patients were offered peer support and an intervention/education group once a week for 6 weeks, which was positively evaluated.
Discussion The refocus of the service endorsed the adopting of proactive case management and the implementation of national bestpractice guidance in the nursing management of patients with lung cancer. This resulted in fewer unscheduled admissions for end-of-life care and symptom control in advanced disease. No other service changes took place during this time. These palliative interventions were usually provided in the community setting using shared management approaches, with local services such as the hospice-at-home team for complex needs. This time could also be used at points where higher levels of nursing activity are necessary, such as diagnosis, post-diagnosis and progressive disease (NCAT, 2013).
937
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights reserved.
n Clinical
nurse specialists (CNS) provide complex and holistic care
n The
CNS can have an impact on unscheduled or emergency care through proactive case management
n Using
CNS time to provide complex clinical care, rather than to carry out administrative tasks, can contribute to quality and efficiency of acute services
n Proactive
case management in lung cancer by the expert nurse is likely to represent a good return on investment
Specialist nurses play an important part in making services more cost-effective. Being responsive to patients’ needs and taking a proactive approach to case management, rather than a functional coordinator role, appear to be effective ways of promoting their role. This approach was practised only in the outpatient setting and it would be interesting to see if inpatient proactive case management reduced length of stay. This was a small study examining the impact of moving from administrative work to proactive case management by two whole-time equivalent advanced practice registered nurses who specialised in lung cancer care. The management of care by nurses in this specialism is embedded and valued (Moore et al, 2002; NLCFN, 2012) and there is also evidence to suggest that proactive palliation has benefits (Temel et al, 2010) and that having access to a CNS in lung cancer also increases the chances of active treatment (National Lung Cancer Audit Report, 2012). Other studies have indicated the impact of expert nurse management (Quinn, 2011; Takeda et al, 2012) and this study could be repeated on a larger scale. The cost is attributed to bed days saved and does not factor in any economic benefit of other increased activity for those bed days saved—for example, if the beds were occupied by high-yield activity scheduled patients instead of unscheduled lung cancer patients. The intensive treatment and short survival of people with lung cancer show the need for patient-centred holistic care, and also therefore the importance of the lung cancer CNS role within the multidisciplinary cancer team. The CNS is an important source of patient continuity from referral to postdiagnosis treatment and end-of-life care—even if they do not directly provide that care but support others who do. Despite a growing body of evidence, the value of specialist nurses remains in doubt in the current healthcare economy as their contribution remains unclear. Studies such as this can help clarify just how valuable and important their contribution is.
Conclusion National guidance recommends that specialist nursing time not be used to bear the administrative burden of a service. By removing this burden and using expert nursing time better, much can be achieved in terms of service provision for patients BJN and efficiency for the service, including cost savings. Conflict of interest: none
938
Baxter J, Leary A (2011) Productivity gains by specialist nurses. Nurs Times 107(30–31): 15–7 Cancer Research UK (2010) Lung cancer incidence statistics. tinyurl.com/ cancer-lung-incidence (accessed 8 September 2014) Cancer Research UK (2014) Cancer incidence and mortality in the UK. http://tinyurl.com/ngtsd94 (accessed 8 September 2014) Coleman MP, Rachet B, Woods LM et al (2004) Trends and socioeconomic inequalities in cancer survival in England and Wales to 2001. Br J Cancer 90(7): 1367–73 Department of Health (2000) The NHS Cancer Plan. DH, London Department of Health (2007) Cancer Reform Strategy. DH, London Department of Health (2011) National Cancer Patient Experience Survey 2011: National Report. DH, London Department of Health (2012) National Cancer Patient Experience Survey 2012: National Report. DH, London Department of Health (2013) National Cancer Patient Experience Survey 2013: National Report. DH, London Leary A (2011) Lung cancer in England. In: Leary A, ed. Lung Cancer: A Multidisciplinary Approach. Wiley-Blackwell, Oxford Leary A, Crouch H, Lezard A, Rawcliffe C, Boden L, Richardson A (2008) Dimensions of clinical nurse specialist work in the UK. Nurs Stand 23(15–17): 40–4 Leary A, Mak V, Trevatt P (2011) The variance in distribution of cancer nurse specialists in England. Br J Nurs 20(4): 228–230 Leary A, White J,Yarnell L (2014) The work left undone. Understanding the challenge of providing holistic lung cancer nursing care in the UK. Eur J Oncol Nurs 18(1): 23–8. doi: 10.1016/j.ejon.2013.10.002 Meyer G, Lavin MA (2005) Vigilance: The Essence of Nursing. Online Journal of Issues in Nursing (OJIN). http://tinyurl.com/oech92u (accessed 8 September 2014) Moore S, Corner J, Haviland J, et al (2002) Nurse led follow up and conventional medical follow up in management of patients with lung cancer: randomised trial. BMJ 325(7373): 1145 National Cancer Action Team (2008) National Cancer Peer Review Programme: Manual for Cancer Services Lung Cancer Measures. NCAT, London National Cancer Action Team (2010) Excellence in Cancer Care: the Contribution of the Clinical Nurse Specialist. NCAT, London National Cancer Action Team (2012) Quality in Nursing: Clinical Nurse Specialists in Cancer Care; Provision, Proportion and Performance. NCAT, 2012 National Cancer Action Team (2013) The Alexa Toolkit-calculating optimum caseload guidance for lung cancer nurse specialists National Cancer Action Team Department of Health, England. https://www.cancertoolkit.co.uk/ (accessed 8 September 2014) National Institute for Health and Care Excellence (2005) Lung cancer: diagnosis and treatment [CG24]. http://www.nice.org.uk/guidance/cg24 (accessed 8 September 2014) National Institute for Health and Care Excellence (2011) Lung cancer: diagnosis and treatment [CG121]. http://guidance.nice.org.uk/cg121 (accessed 8 September 2014) NHS Institute for Innovation and Improvement (2011) Return on Investment (ROI) calculator. tinyurl.com/return-investment-calculator (accessed 8 September 2014) National Lung Cancer Audit Report (2012) Report for the audit period 2011. http://tinyurl.com/p4tcg2w (accessed 8 September 2014) National Lung Cancer Forum for Nurses (2009) Lung Cancer Good Practice Guide. http://www.nlcfn.org.uk/content/good-practice-guide (accessed 8 September 2014) National Lung Cancer Forum for Nurses (2012) Guidance for the Supportive and Palliative Care of Lung Cancer and Mesothelioma Patients and their Carers. http://www.nlcfn.net/NLCFN-guidelines.htm (accessed 8 September 2014) Oliver S, Leary A (2010) The value of the nurse specialists’ role: Pandora initial findings. Musculoskeletal Care 8(3): 175–7 Quinn D (2011) A collaborative care pathway to reduce admission to secondary care for multiple sclerosis. British Journal of Neuroscience Nursing 7(2): 497–9 Royal College of Nursing (2010) Clinical nurse specialists: adding value to care. An executive summary. RCN, London Roy Castle Lung Cancer Foundation, National Lung Cancer Forum for Nurses (2013) Understanding the value of lung cancer specialists. Roy Castle Lung Cancer Foundation & NLCFN, Liverpool Silber J, Williams V, Krakaur H, Schwartz JS (1992) Hospital and patient characteristics associated with death after surgery. A study of adverse occurrences and failure to rescue. Med Care 30(7): 615–29 Spiro SG, Silvestri GA (2005) One hundred years of lung cancer. Am J Respir Crit Care Med 172(5): 523–9 Takeda A, Taylor SJ, Taylor RS, Khan F, Krum H, Underwood M (2012) Clinical service organisation for heart failure. Cochrane Database Syst Rev 9:CD002752. doi: 10.1002/14651858.CD002752.pub3. Temel JS, Greer JA, Muzikansky A, et al (2010) Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med 363: 733–42. doi: 10.1056/NEJMoa1000678. Warren M, Mackie D Leary A (2012) The complexity of non face-to-face work with patients affected by metastatic breast cancer and their carers. The ‘hidden consultations’ of the clinical nurse specialist. Eur J Oncol Nurs 16(5): 460–4. doi: 10.1016/j.ejon.2011.10.009
© 2014 MA Healthcare Ltd
KEY POINTS
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights reserved.
Impact of lung cancer clinical nurse specialists on emergency admissions Alison Leary and Jane Baxter
© 2014 MA Healthcare Ltd
I
n 2011, 43 463 people in the UK were diagnosed with lung cancer (Cancer Research UK, 2014). The incidence of lung cancer is strongly related to age, deprivation and smoking. In the UK, from 2007 to 2009, the majority of cases were diagnosed in patients over 65 years of age (Cancer Research UK, 2010). In 2011, there were 35 184 deaths from lung cancer, making it the most common cause of cancer death in both men and women, and accounting for 6% of all deaths in the UK (Cancer Research UK, 2010). The 5-year overall survival rate is 8–11% (Cancer Research UK, 2010). Five-year survival from lung cancer has barely improved in the past 30 years, but there has been a decline in male deaths and an increase in female deaths (Spiro and Silvestri, 2005), largely owing to changes in patterns of tobacco use. One-year survival has improved to some degree. In England and Wales, 1-year survival for men with advanced non-small cell lung cancer rose from 15% in the 1970s to 25% in 2000–2001 (Coleman et al, 2004). Specialist nursing practice in cancer has expanded since the Department of Health (DH) introduced cancer improvement initiatives in 2000 (DH, 2000) and now lung cancer nursing practice is embedded in national guidance (National Lung Cancer Forum for Nurses (NLCFN), 2009; National Institute for Health and Care Excellence (NICE), 2011; Roy Castle Lung Cancer Foundation and NLCFN, 2013) and seen as fundamental to the care of lung cancer patients and carers. However, due to administrative workloads, lung cancer clinical nurse specialists (CNS) have to leave essential clinical work undone (Leary et al, 2014). There were 295 full-time equivalent specialist nurses in lung cancer in England at the time of the 2011 census (National Cancer Action Team (NCAT), 2012), but their distribution varies (Leary et al, 2011). The work of the CNS is complex (Leary et al, 2008; NCAT, 2010) and has many functions, including acting as the ‘keyworker’ (DH, 2007) within the multidisciplinary team. Much of this function is the management of care in partnership with the rest of the multidisciplinary team, patient and family, including being vigilant (Meyer and Lavin, 2005), particularly at times of risk (NCAT, 2013), so that care can be proactively managed (Leary, 2011) rather than reactively managed. There is evidence that offering early proactive intervention and proactive palliation in patients with non-small cell lung cancer increases survival and quality of life, and decreases undesired aggressiveness in end-of-life care where acute care often becomes the default (Temel et al, 2010). In addition, nurse-led follow-up and management have been shown to lessen disease symptom severity and improve emotional
British Journal of Nursing, 2014, Vol 23, No 17
Abstract
Clinical nurse specialists (CNS) in cancer perform a range of complex activities, including the management of care. However, they often report a high administrative burden for services, which makes providing expert nursing care challenging. Administrative work for a service can be seen as a priority for non-nurses, yet a high administrative burden allows less time for complex nursing care. A London trust admitted a mean of four lung cancer patients per month for symptom control in progressive disease or end-of-life care, with a mean stay of 6 days. This was often a default location: the acute hospital was not always the patient’s preferred place of care for end of life. The CNS negotiated away the administrative burden, which occupied 38% of their working time, and adopted standard proactive case management in line with national standards. The CNS were also able to build a collaborative relationship with others, such as local GPs and community palliative care teams. Their proactive and vigilant case management resulted in fewer admissions for non-acute problems: a mean of four emergency admissions per month fell to a mean of fewer than one (0.3). For this service, the mean length of emergency admission was 6 days, so a reduction in the admission rate represented a significant saving in bed days (266 a year) and a higher rate of achieving the preferred place of end-of-life care. In conclusion, CNS who practise proactive case management and refocus services in line with best practice represent a good return on investment (ROI). Key words: Clinical nurse specialists ■ Value ■ Admission avoidance ■ Outcomes functioning (Moore et al, 2002). The English DH Cancer Reform Strategy promotes care in the most appropriate setting, and proactive case management is a patient-centred method of doing this (DH, 2007). The shape and function of these services are well defined and are regularly examined by internal and external peer reviews, as well as the national cancer patient experience survey (DH, 2011; 2012; 2013).The role of the CNS also promotes efficiency and productivity in line with government initiatives, particularly with increasing financial pressures on the NHS. Workload analysis showed that the lung cancer specialist nursing service of two full-time nurses serving an acute hospital Alison Leary, Professor of Healthcare and Workforce Modelling, London Southbank University; Jane Baxter, Clinical Nurse Specialist, Community Palliative Care, Meadow House Hospice, Middlesex Accepted for publication: August 2014
935
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights reserved.
3%
10% Faxing results/ requests Chasing up routine results Making routine appointments
8%
10%
MDT admin Other admin
6%
58% 4%
Clinical Research Education
Figure 1. Distribution of CNS work before proactive case management. MDT=multidisciplinary team
was being used primarily to support processes, diagnosis and treatment targets, and non-clinical administration—rather than providing holistic cancer care and management of care. Overall, the two nurses spent 38% of their working time on non-clinical administration, which equated to approximately 26 hours per week. This time was primarily spent on work to support meeting the national cancer 2-week wait target (DH, 2000), as well as administrative and clinical support for the multidisciplinary team meeting, such as taking minutes, booking routine investigations, and providing secretarial support to the cardiothoracic service (Figure 1). Specialist cancer nurses should have input into managing services, but should not have to bear the burden of administration (NCAT, 2008). Yet many specialist nurses spend 20–30% of their time performing administration for a service (Leary et al, 2008; Oliver and Leary, 2010; Royal College of Nursing (RCN), 2010). A concurrent case-mix analysis of the inpatient population showed that patients were being admitted for non-acute problems, such as symptom control in advanced disease, psychosocial issues or end-of-life care where hospital was not their stated preferred place for it. The nature of the nursing service was reactive, attending to crisis or administrative work. The authors’ hypothesis is that bringing the service in line with current best-practice guidance would release administrative time for the purpose of giving clinical care.This, in turn, would result in more proactive case management and fewer admissions for symptom control in progressive disease, as nursing vigilance could be applied at times of higher risk of admission, such as progressive disease, and rescue work (Silber et al, 1992) could be a matter of managing presenting issues.
Methods A retrospective study examining all emergency admissions to the acute centre within a 6-month period for lung cancer took place. This showed 69 emergency admissions via the accident and emergency (A&E) department. The majority of
936
these patients (58) had not had recent contact (>30 days) with the lung cancer team. A distinction was made between admission via the A&E department for acute oncological or non-oncological emergencies that required emergency care—for example, pleural effusions; pulmonary embolism; acute chest infection; spinal-cord compression; new brain metastasis or brain metastasis where acute care is indicated; sepsis; acute noncancer conditions, including respiratory, thoracic procedure readmission; and other chronic diseases—and those admissions where emergency admission is unlikely to be the best option. Such admissions might relate, for example, to symptom control in advanced disease where it is established that symptom control is the agreed ceiling of care, or end-of-life care where the preferred place of care is not the acute centre. Of the 69 emergency admissions, 24 were for symptom control where the ceiling of agreed care with the patient and family was palliation of symptoms or end-of-life care. To assess how the lung CNS’ role was performing against national standards in lung cancer and supportive care, the service was audited against several standards, which were described in the introduction. The activity of the lung cancer nursing service was also analysed with a bespoke data collection tool. This used workload analysis by modelling by means of methods described elsewhere (Leary et al, 2008; RCN, 2010). In addition, a convenience sample of patients on the caseload (n=30) were called to ascertain their needs and deficit in specialist nursing care, and possible interventions in line with current best practice. The basis for selection was no recent contact (>30 days) with any member of the lung cancer multidisciplinary team. The convenience sample had unmet needs (Baxter and Leary, 2011) and some patients had more than one. Three patients had post-thoracic surgery pain that was not being managed; these patients were counselled on lifestyle, rehabilitation and analgesia. Seventeen patients had symptom issues that were subsequently addressed with interventions (for example, with a clinic review or, in one case, referral to a psychologist). Four patients were lost to follow-up from the chest or respiratory service, and two were lost to follow-up from the oncology service (post-radiotherapy). These were then reviewed in scheduled clinic appointments. Overall, 26 of 30 patients had issues concerning pathway management or symptoms related to their disease, including its possible progression. The findings of the needs analysis supported the case for administrative burden to be moved to a more appropriate worker, thereby releasing expert nursing time for care delivery and management. After negotiating this work away to an administrative worker, a more conventional practice in line with bestpractice guidance was instituted. This included increased holistic assessment, presence at diagnosis or impending diagnosis, and nurse-led clinics for patients with progressive disease, both face-to-face and over the telephone. It also allowed for increased case management function and the use of vigilance at times of increased likelihood of symptom issues (NCAT, 2013). Three months of transition to proactive case management followed and, after another 6 months, the rate and reason for emergency admission was reviewed.
© 2014 MA Healthcare Ltd
1%
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights reserved.
PROFESSIONAL ISSUES Patients were contacted regularly at times of increased risk of admission, for example, in progressive disease, and at least once a month. Patients and families could also contact the nurses directly. Colleagues in the community palliative team, hospice at home, hospice daycare and GPs were able to respond to issues as a shared caseload with the specialist nurse as keyworker. If the issue was acute, provision was made to review the patient in the acute centre. For example, if a patient with advanced lung cancer had pain or dyspnea, this could be assessed and managed in the community or admission arranged for an acute cause. Acute oncological emergencies that could not be managed in the community, such as pleural effusions, came back to the acute centre, as did patients needing any other acute intervention. This meant management was in line with best practice guidance in lung cancer and supportive care (NICE, 2005; DH, 2007; NLCFN, 2009, NICE, 2011).
2% 7%
© 2014 MA Healthcare Ltd
Change in rate of admission Before proactive case management, the service averaged (a mean of) 4 avoidable admissions for progressive disease symptom control or end-of-life care per month with an average stay of 6 days. After the introduction of proactive case management, there were 3 such admissions in 9 months, giving a mean of 0.3 per month. If the average rate of admission avoidance is then 3.7 per month, this represents a considerable saving.
British Journal of Nursing, 2014, Vol 23, No 17
4% 4%
2%
4% 12%
Faxing results/ requests Chasing up routine results Making routine appointments MDT admin Clinical admin Clinical Research & audit Education Consultation
62%
Results Change in nursing activity Before the administrative burden was negotiated away, 38% (13 hours per week per whole-time post) of the specialist nurse’s available time was spent on largely routine clerical work (booking routine appointments, faxing results and letters to referring centres, booking transport; Figure 1). This dropped to 24% of the total work and the nature of the administrative burden also changed to essential clinical administration (Figure 2), for example, dictating letters, completing referrals and requesting investigations. Purely clerical work constituted 12% of the workload (4.5 hours per week per whole-time post). There was a small increase in formal and informal teaching activity (from 2% to 7%) and consultation work/service improvement work (from less than 2% to 5%, or approximately 2 hours per week per whole-time equivalent). The primary difference in terms of percentage of time was clinical activity, which rose from 56% to 62% in the clinical category, plus the change in nature of administrative work meant that only 12% of time spent was on purely administrative functions. The increase in clinical activity was in symptom control and psychosocial interventions, such as emotion-focused work and dealing with distress. Thirty-eight per cent of the overall work was done over the telephone, with the post-change service handling an average of nine complex phone calls per day, a similar volume to other expert nursing services (Warren et al, 2012). Symptom-control work included specialist symptom assessment and prescribing or recommending medicines. Of the 62% coded as clinical events, a third were psychological, whereas previously psychological events accounted for less than 10% of the clinical work.
3%
Figure 2. Distribution of CNS work after proactive case management. MDT=multidisciplinary team
Even in this small study, it was calculated that 33 admissions were avoided in 9 months. At an average stay of 6 days, this represents 198 saved bed days over 9 months, or 266 bed days per year as a result of outpatient proactive case management alone. At a minimal cost of £250 per acute bed, based on the 2011 tariff (NHS Institute for Innovation and Improvement, 2011), this represents a total saving of £66 500 per year for the admission avoidance aspect of the service. This would not include income generated from alternative use of those bed days.
Change in service configuration The expert nurses were able to spend more time working with patients and families in areas such as self-management, education and holistic assessment. They were also able to increase the amount of collaborative multidisciplinary working, including referral to a benefits advisory drop-in, face-to-face or telephone clinics. In addition, new activities were undertaken. For example, in collaboration with the psychologist, patients were offered peer support and an intervention/education group once a week for 6 weeks, which was positively evaluated.
Discussion The refocus of the service endorsed the adopting of proactive case management and the implementation of national bestpractice guidance in the nursing management of patients with lung cancer. This resulted in fewer unscheduled admissions for end-of-life care and symptom control in advanced disease. No other service changes took place during this time. These palliative interventions were usually provided in the community setting using shared management approaches, with local services such as the hospice-at-home team for complex needs. This time could also be used at points where higher levels of nursing activity are necessary, such as diagnosis, post-diagnosis and progressive disease (NCAT, 2013).
937
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights reserved.
n Clinical
nurse specialists (CNS) provide complex and holistic care
n The
CNS can have an impact on unscheduled or emergency care through proactive case management
n Using
CNS time to provide complex clinical care, rather than to carry out administrative tasks, can contribute to quality and efficiency of acute services
n Proactive
case management in lung cancer by the expert nurse is likely to represent a good return on investment
Specialist nurses play an important part in making services more cost-effective. Being responsive to patients’ needs and taking a proactive approach to case management, rather than a functional coordinator role, appear to be effective ways of promoting their role. This approach was practised only in the outpatient setting and it would be interesting to see if inpatient proactive case management reduced length of stay. This was a small study examining the impact of moving from administrative work to proactive case management by two whole-time equivalent advanced practice registered nurses who specialised in lung cancer care. The management of care by nurses in this specialism is embedded and valued (Moore et al, 2002; NLCFN, 2012) and there is also evidence to suggest that proactive palliation has benefits (Temel et al, 2010) and that having access to a CNS in lung cancer also increases the chances of active treatment (National Lung Cancer Audit Report, 2012). Other studies have indicated the impact of expert nurse management (Quinn, 2011; Takeda et al, 2012) and this study could be repeated on a larger scale. The cost is attributed to bed days saved and does not factor in any economic benefit of other increased activity for those bed days saved—for example, if the beds were occupied by high-yield activity scheduled patients instead of unscheduled lung cancer patients. The intensive treatment and short survival of people with lung cancer show the need for patient-centred holistic care, and also therefore the importance of the lung cancer CNS role within the multidisciplinary cancer team. The CNS is an important source of patient continuity from referral to postdiagnosis treatment and end-of-life care—even if they do not directly provide that care but support others who do. Despite a growing body of evidence, the value of specialist nurses remains in doubt in the current healthcare economy as their contribution remains unclear. Studies such as this can help clarify just how valuable and important their contribution is.
Conclusion National guidance recommends that specialist nursing time not be used to bear the administrative burden of a service. By removing this burden and using expert nursing time better, much can be achieved in terms of service provision for patients BJN and efficiency for the service, including cost savings. Conflict of interest: none
938
Baxter J, Leary A (2011) Productivity gains by specialist nurses. Nurs Times 107(30–31): 15–7 Cancer Research UK (2010) Lung cancer incidence statistics. tinyurl.com/ cancer-lung-incidence (accessed 8 September 2014) Cancer Research UK (2014) Cancer incidence and mortality in the UK. http://tinyurl.com/ngtsd94 (accessed 8 September 2014) Coleman MP, Rachet B, Woods LM et al (2004) Trends and socioeconomic inequalities in cancer survival in England and Wales to 2001. Br J Cancer 90(7): 1367–73 Department of Health (2000) The NHS Cancer Plan. DH, London Department of Health (2007) Cancer Reform Strategy. DH, London Department of Health (2011) National Cancer Patient Experience Survey 2011: National Report. DH, London Department of Health (2012) National Cancer Patient Experience Survey 2012: National Report. DH, London Department of Health (2013) National Cancer Patient Experience Survey 2013: National Report. DH, London Leary A (2011) Lung cancer in England. In: Leary A, ed. Lung Cancer: A Multidisciplinary Approach. Wiley-Blackwell, Oxford Leary A, Crouch H, Lezard A, Rawcliffe C, Boden L, Richardson A (2008) Dimensions of clinical nurse specialist work in the UK. Nurs Stand 23(15–17): 40–4 Leary A, Mak V, Trevatt P (2011) The variance in distribution of cancer nurse specialists in England. Br J Nurs 20(4): 228–230 Leary A, White J,Yarnell L (2014) The work left undone. Understanding the challenge of providing holistic lung cancer nursing care in the UK. Eur J Oncol Nurs 18(1): 23–8. doi: 10.1016/j.ejon.2013.10.002 Meyer G, Lavin MA (2005) Vigilance: The Essence of Nursing. Online Journal of Issues in Nursing (OJIN). http://tinyurl.com/oech92u (accessed 8 September 2014) Moore S, Corner J, Haviland J, et al (2002) Nurse led follow up and conventional medical follow up in management of patients with lung cancer: randomised trial. BMJ 325(7373): 1145 National Cancer Action Team (2008) National Cancer Peer Review Programme: Manual for Cancer Services Lung Cancer Measures. NCAT, London National Cancer Action Team (2010) Excellence in Cancer Care: the Contribution of the Clinical Nurse Specialist. NCAT, London National Cancer Action Team (2012) Quality in Nursing: Clinical Nurse Specialists in Cancer Care; Provision, Proportion and Performance. NCAT, 2012 National Cancer Action Team (2013) The Alexa Toolkit-calculating optimum caseload guidance for lung cancer nurse specialists National Cancer Action Team Department of Health, England. https://www.cancertoolkit.co.uk/ (accessed 8 September 2014) National Institute for Health and Care Excellence (2005) Lung cancer: diagnosis and treatment [CG24]. http://www.nice.org.uk/guidance/cg24 (accessed 8 September 2014) National Institute for Health and Care Excellence (2011) Lung cancer: diagnosis and treatment [CG121]. http://guidance.nice.org.uk/cg121 (accessed 8 September 2014) NHS Institute for Innovation and Improvement (2011) Return on Investment (ROI) calculator. tinyurl.com/return-investment-calculator (accessed 8 September 2014) National Lung Cancer Audit Report (2012) Report for the audit period 2011. http://tinyurl.com/p4tcg2w (accessed 8 September 2014) National Lung Cancer Forum for Nurses (2009) Lung Cancer Good Practice Guide. http://www.nlcfn.org.uk/content/good-practice-guide (accessed 8 September 2014) National Lung Cancer Forum for Nurses (2012) Guidance for the Supportive and Palliative Care of Lung Cancer and Mesothelioma Patients and their Carers. http://www.nlcfn.net/NLCFN-guidelines.htm (accessed 8 September 2014) Oliver S, Leary A (2010) The value of the nurse specialists’ role: Pandora initial findings. Musculoskeletal Care 8(3): 175–7 Quinn D (2011) A collaborative care pathway to reduce admission to secondary care for multiple sclerosis. British Journal of Neuroscience Nursing 7(2): 497–9 Royal College of Nursing (2010) Clinical nurse specialists: adding value to care. An executive summary. RCN, London Roy Castle Lung Cancer Foundation, National Lung Cancer Forum for Nurses (2013) Understanding the value of lung cancer specialists. Roy Castle Lung Cancer Foundation & NLCFN, Liverpool Silber J, Williams V, Krakaur H, Schwartz JS (1992) Hospital and patient characteristics associated with death after surgery. A study of adverse occurrences and failure to rescue. Med Care 30(7): 615–29 Spiro SG, Silvestri GA (2005) One hundred years of lung cancer. Am J Respir Crit Care Med 172(5): 523–9 Takeda A, Taylor SJ, Taylor RS, Khan F, Krum H, Underwood M (2012) Clinical service organisation for heart failure. Cochrane Database Syst Rev 9:CD002752. doi: 10.1002/14651858.CD002752.pub3. Temel JS, Greer JA, Muzikansky A, et al (2010) Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med 363: 733–42. doi: 10.1056/NEJMoa1000678. Warren M, Mackie D Leary A (2012) The complexity of non face-to-face work with patients affected by metastatic breast cancer and their carers. The ‘hidden consultations’ of the clinical nurse specialist. Eur J Oncol Nurs 16(5): 460–4. doi: 10.1016/j.ejon.2011.10.009
© 2014 MA Healthcare Ltd
KEY POINTS
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights reserved.
