My Improvement Project: Rapid-Access Jaundice Pathway

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NHS Quest members were invited to attend the annual WWL Quality Champions Celebratory event in October 2018.  This programme first launched 7 years ago and aims to build quality improvement capacity and capability across Wrightington, Wigan and Leigh NHS Foundation Trust.

Vicki Stevenson-Hornby achieved Quality Champion Gold status after completing the training programme, successfully achieving her project aim, and having her project adopted by other organisations.

After hearing her compelling story we invited Vicki to tell us more about her achievements and what motivated her to take on this ambitious challenge.

Vicki is the lead Macmillan Hepato-Pancreatico-Billiary Clinical Nurse Specialist who works in the gastroenterology department at Wrightington, Wigan and Leigh (WWL) NHS Foundation Trust. Having recently received the Nursing Times Cancer Nursing Award 2018, we sat down with Vicki to find out about her achievements which saw her commitment to improving care for people with pancreatic cancer evolve into an improvement project and positive outcome patients in her care.

Vicki explained that surgery remains the only curative treatment option for pancreatic cancer, but by the time of diagnosis many patients are no longer eligible for surgery. An earlier diagnosis would allow more patients to undergo potentially curative surgery.

Vicki’s mission is for patients to receive an earlier diagnosis to improve their chance of earlier intervention and survival. She has designed and implemented a rapid diagnostic pathway using jaundice as a marker of potential pancreatic cancer. This rapid-access jaundice pathway has been operational since March 2017 and the number of patients referred for surgery has increased.

“Every day in the UK, 27 people are diagnosed with pancreatic cancer and 24 people die from it. Almost 50% of all patients with pancreatic cancer receive their diagnosis after having attended the emergency department (Public Health England, 2017). Once they are diagnosed, 90% of patients already have advanced disease and surgery is no longer an option (Public Health England, 2018).

In patients found to be inoperable at diagnosis, the mean survival rate is four to six months. Five-year survival is less than 7% and the figure has not improved significantly in almost 40 years. Surgery remains the only curative treatment option and is viewed as the best possibility of improving long-term survival. An earlier diagnosis would allow more patients to undergo potentially curative surgery.”

Could we start by talking about your project that lead you to winning the Nursing Times award?

 

At WWL, we work with Manchester Royal Infirmary for any surgical input. Anything to do with the pancreas, liver, bile duct or gall bladder that is expected to be cancerous and requires surgery, goes to them. Manchester Royal had started to offer ‘fast track surgery’; offering timely surgery to those patients with a suspicion of pancreatic cancer.

Historically, if a patient presented with jaundice (a common indicator of pancreatic cancer), the jaundice would be treated first, and then the patient would be evaluated to see whether surgery was required.  ‘Fast track surgery’ enabled patients with jaundice to be operated on, prior to the jaundice itself being treated (by having a stent inserted into their bile duct).

However, although we had this team of surgeons offering this surgery on a fast track basis, we were not finding the patients quickly enough to get them over for this surgery- and this became my starting point for the project.

Some organisations within Greater Manchester had implemented a jaundice clinic one day a week, for all patients referred with jaundice who had a suspicion of cancer. But this still left patients with a potential delay of up to one week as they waited for action, in an already time critical period.

So I set about an idea where we could have a more flexible pathway, whereby if a patient presented with jaundice and a suspicion of cancer, then they would come straight through to me.

I would do a telephone consultation in the first instance, and then get them booked in for a scan as quickly as possible. This meant that the patient did not have to wait for a clinic appointment with a gastroenterologist, and to then be referred for a scan. They could be assessed much quicker than before.

 

What made you want to get involved in a project like this? How did you come to taking the lead?

 

I am a specialist nurse for any cancer of the pancreas, liver, bile duct and gall bladder. The pancreas, as a tumour site, carries a very poor prognosis, so anything that we could try to improve that was worth doing- and the key really is getting an earlier diagnosis.

There isn’t a screening programme for pancreatic cancer like there is for others, you can’t self-examine, and you can’t give your pancreas a prod or a poke to see if it feels alright. So often the thing that people present with is jaundice, and that can be quite late in the day.

Over the years I’ve done so much to try and raise awareness and money; I’ve done Tough Mudder, dyed my hair purple, and dressed head-to-toe in purple (purple is the colour for raising awareness of pancreatic cancer, and I try to do so much during pancreatic cancer awareness month which is November). I’ll do anything, I really will, to try and improve that horrendously poor survival rate. So even if we didn’t achieve what we have done, it certainly wasn’t going to do any harm; it had a chance to make a real difference.

 

What was the hardest thing about the project?

 

Initially, we were concerned about the potential volume of referrals each day, and whether we’d be able to accommodate scans as required. But, everyone has worked together. Without radiology giving us the scanning slot, getting the scan reported quickly, ambulatory, gastroenterology… it really has been everyone coming together.

So, I think the hardest thing has just been trying to relay those fears – to make people think, let’s give it a go, let’s try it, even if it’s just for a few weeks.

 

On the flip side, was there anything that really surprised you with how successful it was? Was there any part of the project that was a particular success?

 

When I began the project, I was a Quality Champion at WWL. My aim was to improve and increase the number of patients that we were able to refer to surgery by 10% in the first year. I had reservations about the 10% increase, I was unsure as to whether this was achievable. However, in the first year we increased the number of patients referred to surgery by 31%.

I could never have dared to hope that we could achieve such success, but we have, and just that difference- getting them scanned quicker, could make a difference to someone’s diagnosis.

I’m not saying that a week can always make a difference to someone’s diagnosis, in that not everybody will be eligible for surgery, but it’s that early diagnosis and intervention that then allows us to provide palliative treatment earlier, to give a patient a better chance at a prolonged prognosis.

 

After having such success in the first year, what is next? Will it be about trying to sustain your success?

 

Yes, we will definitely be trying to sustain it. We’re still collecting data as we go, and at the moment it is sustained.

If we could get other places to adopt the pathway, even if they make small modifications, then we have a chance to make a big difference to this patient group.

It’s going to take us years to properly understand the long term impact of this pathway. But, we know that we’re getting more people the chance of curative surgery. So yes, the cancer might come back, and maybe it was always going to come back, but we’re giving people that chance and maintaining hope which is invaluable.

NHS Quest would like to thank Vicki for taking the time to speak to us about her work. The WWL Quality Champions programme allowed Vicki to achieve positive change through improvement science, and we can’t wait to see what she does next!

If you would like to hear more about Vicki’s work, then she can be contacted at @vicks31 or via email.