Patients diagnosed with and treated for Head and Neck Cancer (H&NC) require management from the MDT including Dietitians and Speech and Language Therapists (SLTs) to maintain health and wellbeing and optimise their function before, during and after treatment. The NICE guidelines – Improving outcomes in head and neck cancers (CSG6); Cancer of the upper aero- digestive tract: assessment and management in people aged 16 and over (NG36); Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32) support this concept, and recommend SLT and dietitians from diagnosis to discharge. For patients with H&NC this support includes screening for malnutrition and required support from health care professionals able to manage their nutrition, hydration and wellbeing. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32)also states that patients who need nutritional support should receive coordinated care due to risk of developing refeeding symptoms. This project is able to identify and describe the impact of increasing the resources of SLT and dietetics to the on treatment oncology H&NC group and identify the specific benefits to the patients and the service.
The project was a joint initiative - a collaboration between:
- Kate Reid - Head of Speech and Language Therapy (SLT)
- Susan Price - Head of Nutrition and Dietetics
- Camilla Dawson - Clinical Lead SLT
- Susan Duff - Specialist Registered Dietitian (RD)
- Improving outcomes in head and neck cancers (CSG6)
- Cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over (NG36)
- Head and neck cancer (QS146)
- Nutrition support in adults (QS24)
- Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32)
Aims and objectives
This project describes the benefits of patients being seen by Speech and Language Therapists and Dietitians whilst they have radiotherapy (plus or minus chemotherapy) to minimise the morbidity associated with oncology treatments to the head and neck. The paper describes the individual and operational benefits of this clinical intervention, including reduced weight loss, and admissions to hospital as well as a shortened length of stay for patients who were admitted.
Patients diagnosed with and treated for H&NC require management from the multi-disciplinary team (MDT) that includes Dietitians and Speech and Language Therapists (SLTs) to optimise their function and to maintain their health and wellbeing, before, during and after treatment. The NICE clinical guidelines CSG6 (2004), NG36 (2016) and head and neck quality standard 146 support this concept, and detail the requirement for SLT and dietitians from diagnosis to discharge. NICE CG32 (2006) and QS24 make recommendations for adults requiring oral nutritional support, enteral and parenteral nutrition in both the hospital and community setting. For patients with H&NC this support also includes screening for risk of malnourishment and required support from health care professionals able to manage their nutrition, hydration and wellbeing. NICE CG32 also states that patients who need nutritional support should receive coordinated care as they are at risk of developing refeeding symptoms.
Reasons for implementing your project
Prior to August 2018, our cancer centre provided two sessions (7.5 hours) of dietetic support and no SLT service to patients during radiotherapy (plus or minus chemotherapy) as their main or combined treatment for H&NC. The dietitians providing this limited service noted that patients deteriorated quickly during treatment and the main point of intervention for both services was as patients were admitted to hospital. The SLT support and intervention was crisis driven and reactive, only assessing patients when they were admitted to the ward during treatment. The dietitians, SLT and wider MDT were aware that this was a gap in the service and left patients vulnerable to poor nutrition and hydration and impacted on swallow function, leading to reduced oral intake, potential weight loss, increased complications and poor rehabilitation post-radiotherapy. When patients were admitted to hospital during and post-treatment it was possible to identify weight-loss of more than 10% from baseline as a concerning factor. The therapy team believed that by providing proactive clinical interventions during their radiotherapy treatment, it would be possible to reduce the number of patients who would require admitting to hospital, and for those who were to shorten the length of stay.
How did you implement the project
Therapy services wrote a business case that sought dietetic and SLT funding to manage patients during their oncology treatment for H&NC, describing the potential benefit to patients’ care. Financial modelling based on predicted activity included 1.2 whole time equivalent (wte) dietitians and 0.6 wte SLT band 6 should be funded. The 1.2 wte dietitians and 0.6 wte SLT would be reabsorbed into the establishment if no positive benefit could be demonstrated after a year’s pilot of this intervention.
The business case was agreed in part (0.8.0 wte Dietetics and 0.6 wte SLT). The appointed therapists were able to identify the key clinics, days and members of the MDT to work with, to improve communication, joint working and identifying critical time-points in the week to influence how patients on treatment were supported. New members of staff established observation and collaborative working with other HCPs oncologists, radiographers, clinical nurse specialists and administrative teams who had managed until this point without the specific therapies being part of the team. Establishing real clinical space, IT access, means of documenting efficiently key information, and respect for one another’s professional boundaries was vital and actively acknowledged by the dietetic and SLT teams.
The total number of patients treated by the oncology centre for H&NC has remained constant (n=220) over the last two years. The oncological treatments offered, the technical way of delivering them and the consultants caring for the patients has also remained unchanged. Figure 1 and 2 describe the pre and post investment numbers of patients referred and their average length of stay. See attachment for details.
Table 1 (see attachment) demonstrates a 54-82 bed days saved per month because of the dietetic and SLT input to the on treatment H&N radiotherapy outpatient clinics. It is not possible to combine both services saving in bed days because some of the patients are known to both services.
Dietetic health care professionals will aim to minimise the amount of weight loss that patients have to 10% or under. If this is possible there is evidence that patients have an improved quality of life and a better functional recovery. Table 2 demonstrates (see attachment) that in the pre-investment group 45% (n=33) of the patients who were admitted had lost more than 10% of their baseline weight this reduced to 39% of a smaller total group (n=22) in the post-investment group.
The work has highlighted the value of consistently collecting anthropometric measures on patients as a way of identifying the functional impact on patients’ recovery.
Feedback from the health care professionals include:
Encouraging patients to maintain their swallow function even if just by drinking water rather than stopping any swallowing of oral intake is vital. We have been able to notice sudden changes in pain levels and react quickly to this.
It means that if a tube is needed it’s in a planned way rather than as an urgent hospital admission.
Working with SLT colleagues we have been able on numerous occasions to identify those patients who have swallowing difficulties and therefore at a greater risk of not meeting their needs orally. This helps early discussion and allows concerns to be discussed and has enabled NG tube placement to take place pre-emptively rather than as an emergency.
It keeps patients out of hospital and helps to keep them “well” to carry on with their treatment rather than just “falling across the finish line.”
Before the on treatment support from the two services patients were not able to come to the post treatment clinics within the first month of finishing their treatments because they were too unwell to attend. More patients are less frail at their first presentation in the post-treatment clinics. These clinics have fewer patients needing to attend per clinic which means those that are attending you can see more holistically.
Feedback from patients includes:
“The service was brilliant, everyone was involved from the off and I felt totally supported throughout.”
“Having you as a team, always available, compared to just coming in and out of the treatment room each day, ………..if we had any questions you made yourself available for us. You feel someone is there for you every day.”
“There weren’t any surprises, everything you said would happen did happen”
Key learning points
When dietetics and SLT work collaboratively, benefits to the individual patient and the service can be demonstrated. There are individual benefits associated with not being admitted to hospital and a reduced length of stay, along with a reduction in percentage reduction of body weight loss. This has the potential to impact positively on nutrition, hydration, quality of life, well-being and recovery from treatment.
It is important to appreciate the specific value of each individual therapy team, and the collaboration with the MDT to develop practice ensuring safe effective care that is of a high quality.
To the knowledge of the team there is no previous work that has demonstrated the impact of investing in dietetic and SLT services concurrently, to improve parameters including individual patient outcomes and operational parameters such as length of stay and number of admissions.
It is a reasonable assumption that the introduction of the two therapy groups at this point in the patient pathway can influence both the individual care of the patients and their overall pathway by reducing the number of emergency admissions and allowing services to continue with their elective planned oncology admissions. As a therapy team we can attribute the reduction of the inpatient admissions and length of stay to the introduction of the two services.
Report to clinical, operational and financial trust leads that the investment has had a positive impact on the care of patients and their care pathway.
Discuss the service impact with the oncology service, and analysing the data further to consider impact on other specific patient groups such as those with palliative disease. A review of the data associated with the H&NC patients admitted has started now to show that those patients had prolonged length of stay are palliative patients. Our teams believe if they could review patients whilst they are on their palliative treatment there may be an influence on a patient’s length of stay.