Slide 1 Supporting Early Diagnosis in cancer in primary care Improving GP Coding&Safety Netting The key to quality data with quality outcomes in cancer and beyond. Dr Afsana Bhuiya Macmillan GP Improvement Lead LONDON CANCER Contact: afsana.bhuiya1@nhs.net *London 5 year cancer commissioning strategy
Slide 2 Why Coding and Safety-Netting? High quality coding and safety netting in primary care would mean up-to-date, relevant and connected information about the patient (independent of how long you have known them) Enables more MEANINGFUL results from risk assessment tools, like QCancer. Potential to: reduce misses, lead to earlier cancer referrals and early detection, as well as improved screening and care for patients who have survived cancer. QI response to scoping: • No agreed guidelines/standards for coding or safety netting and there is little agreement on how to interpret or apply safety netting. • No formal training for GPs for coding/using computer systems (many computer systems too) • GP VTS trainees do not have standard teaching on this and it often depends on their individual trainers knowledge. The quality of input – determines the quality of the output.
Slide 3 What is Safety Netting? The term ‘safety - netting’ was introduced to general practice by Roger Neighbour – central to GP consult. A process where people at low risk, but not no risk , of having cancer are actively monitored in primary care to see if the risk of cancer changes. Safety Netting can go wrong! little agreement on how to interpret or apply safety netting. Good safety netting is dependent on good continuity of information and record keeping/coding. NICE guidance July 2015 and the Cancer Task Report (achieving world class cancer outcomes) both recommend establishing rigorous safety netting processes and support training in this.
Slide 4 The NICE guidance introduce new risks and require BETTER and more STRINGENT SAFETY NETTING Guide – Emis focus – TODAYS workshop on the principles behind good quality coding/safety netting – which are system transferable. But on the premise that we have: • Awareness of NICE guidance changes - threshold of invx reduced /PPV reduction to 3% • Importance of vague symptoms (RED FLAGS too late) • Terminology like direct access and straight to test – awareness not widely available • QCancer – interface • Investigations like FBC very important – HB, Thromobocyctosis, Leucocytosis
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Slide 7 Case Study – New Patient Consultation • 64 year old lady caucasian lady seen for simple left shoulder pain for 1/12 – no hx of trauma. She reports its painful to use the shoulder in general. • O/E: Tender to palpate over the shoulder , painful/reduced abduction • Differential: OA of ACJ / bursitis • Note - Patient recently joined the surgery – first consultation with you. • Quick history overview - NO significant history seen on active/past significant problem list. • Ex-smoker. • Due to see nurse next for her ‘new patient screen’ • You send her for an XR of shoulder and prescribe analgesia. • Report: Abnormal apical shadow in the left lung! • GP arranges an urgent recall of the patient to discuss the results!
Slide 8 • GP2GP electronic notes follow quite soon. • Undertake a review of her history: • Seen by several different clinicians in the last 12/12. ‘e’ appointments. • Notes were very difficult to follow as the consultations had not been problem coded, many generic symptoms at different times. • Seen by nurse 6/12 ago and had a cough – with flecks of blood once – haemoptysis wasn’t coded. • CXR was requested but there was not result ? Was it done? • Breast cancer was documented in one consult – the problem list checked – and it has been coded as ‘minor – past’ problem. • You reflect and do an SEA and feedback to your surgery. You realise learning points would probably benefit the previous surgery.
Slide 9 Case Study: Waste of Resources • A patient with known myeloma was seen by a locum in clinic for a minor illness. • The patient had her recent blood test results as the last recorded information and all were commented on as – ‘abnormal – speak to dr ’ • The locum seeing the results did an FAST TRACK CANCER ref. • Few weeks later a letter was received from a confused Haematologist asking why a patient with known Myeloma (stable disease) being referred. • Myeloma was NOT coded anywhere. The letters from the haematologist were not coded. • Lesson: Problem coding imperative. Appropriate pathology commenting – ‘known myeloma’ or ‘consistent with known disease’. Why did the patient not know?
Slide 10 Case Study: Knee Pain 45 year old Somalian man seen by your colleague for knee pain. He had requested an XR. You receive an urgent fax reporting a likely bone sarcoma! The fax was slightly odd as it did not on heading paper and did not say where it came from. But the radiologists name was at the bottom. Confirm the result. We rang the patient. Then his wife. Then any other family member at the address. Not trackable. Estranged from wife. Sent him letter. Spoke to the initial dr – patient didn’t report he was going on holiday. Sent TASK to myself to track patient. Two weeks later he has been booked on my list by a different receptionist who wasn’t aware about how hard we were trying to get hold of him? And then DNAs. This time I refer to royal national sarcoma clinic 2ww in the hope he may just go there. What could have been improved? I put an alert on his notes after that. Sent a TASK to all staff to be aware of him. Sent him another letter. What happened: ?
Slide 11 Case study: Dysuria A 60 year old lady attends with dysuria and frequency in emergency GP clinic. No sig PMH. Hx reveals this is the 3 rd occasion that she has been seen in 2 months for these symptoms. Once at the surgery treated empirically with Nitrofurantoin 3 days (urinalysis trace blood) and once at the walk in centre-Trimethoprim 5 days. Her symptoms come and go. No recorded MCS on your system. Nil on hospital ICE system. Urine dip today = Protein trace Leucs+ Blood+. She isn't sure but thinks her urine maybe a pink at times. You decide to treat but realise a urine MCS is needed and you note she has not had her NHS health check so advise her to have some routine blood tests. You have booked her in yourself to be seen at the end of the week. The MSU is negative. No bld. No infection. Dysuria is better. Relief? Look toward blood results for further reassurance/advice…… Hb 110 (115), wcc ,7, Platelets 430 - rest of bloods normal. Explore gynae symptoms – denies PM bleeding – but admits to increase in vaginal d/c. You realise this changes the differential and you use QCancer to help you risk stratify.
Slide 12 Request DIRECT ACCESS Pelvic US and ensure you send a TASK to yourself to follow up the result or ensure it is done in a timely manner. 10 days later an urgent fax from InHealth – Pelvic US report – suspicious of endometrial CA. Request patient sees you that day – relay your concern about the result and discuss cancer as a possibility. Explain the two week ref pathway and discuss the format and what to expect. Supplement with a two week wait information leaflet. You email the referral forms You code this as fast track gynae cancer referral – as you can then track the referrals and in two weeks when search for the referrals you can ensure your staff can chase the patients if there is no evidence of follow up. Patient has treatable endometrial cancer.
Slide 13 Case Study: Tiredness/Language You see a 53 yr old Romanian lady who came with her daughter to see you about tiredness. Language barrier. Daughter translates. Her 3yr old granddaughter is running around the consultation room. Hx – nil. No weight or appetite loss. BP – normal. Weight recorded. Plan : ‘tiredness screen’ bloods. Adv to call back for results. Concern levels: low. Next – 2/12 later she returns, on her own. She did not do her blood tests as you had advised. She looks pale, thinner and c/o of a lump in neck. Language is an issue. Now? Language line. She reports weight loss. and also pruritis. O/e – pallor/excoriations and wide spread lymphadenopathy. Weight today – clear 3 kg loss. Impr – Lymphoma. Action: fast track cancer referral. Concern relayed re cancer and next steps. Address and number checked. Ref emailed. End of month fast track cancers search reveals no letters from hospital – concern – arrange recall. She reports she missed the appointment as she had to baby sit the grandchildren when her daughter was having housing problems with the council. You reiterate how important this appointment is. Leaflet issued in Romanian. Two weeks later – she returns with her daughter – she has come to get the biopsy results and they seem very anxious. You don’t remember receiving anything through docman – you check the notes – NO hospital communication ……………………..
Slide 14 FULL GUIDANCE AT: http://www.londoncancer.org/media/126626/15070 8_Guide-to-coding-and-safety-netting_report_Dr- A-Bhuiya_V3.pdf
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