The introduction of a nurseled, one stop, suspected prostate cancer service

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The introduction of a nurse-led, one stop,
suspected prostate cancer service

• Nicola James, MSc, BA (hons)RGN
• Nurse Consultant

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3 Main Aims

• 2)To demonstrate that a nurse-led service can
  perform at least as well as a conventional,
  medically-led service offering higher quality at
  lower cost.

• 1)To improve the experience of men with
  suspected prostate cancer and address inequities
  experienced by them.
• 3)To address waiting times.

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WHY?

• NURSE-LED ASPECT?
• CWT
• EWTD
• NHS cash limited service reasonable to expect
  value for money (increase activity, make savings)
• 18 week wait issues frees consultant urologists
  for other activity
• Job satisfaction of nurse consultant
• Increasing pressure on specialist nurses to
  justify roles.

• ONE STOP ASPECT?
• Men with suspected prostate cancer have same
  needs and fears as anyone else with suspected
  cancer. Breast v prostate?? Inequity?
• Uncertainty
• Need for clear explanation
• Need for fast track diagnosis
• Continuity of care (same person)
• Previous published work showed patients very
  happy with nurse led assessment and results
  giving.

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What used to happen?

• GP referred patient to urologist
• Urologist or Nurse Consultant would see in
  out-patients and book a biopsy
• Waiting time for biopsy varied. Certainly not
  same day.
• CWT led to adhoc arrangements and crisis
  management.
• Consultant urologist (or SPR) would perform
  biopsy
• Nurse consultant would give results
• Time from referral to diagnosis approx 21-31
  days.
• Patient may have seen 3 different people in this
  time.

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What happens now?

• GP e-books patient into one stop clinic.
• Takes place every Friday.
• At clinic, Nurse Consultant takes history,
  assesses and counsels for biopsy. She then
  performs the biopsy and sees the patient 5 days
  later with results.
• Time from GP referral (ie patient sitting in GP
  surgery) to diagnosis no longer than 11 days and
  patient sees same person throughout.

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Challenge

• Nurse led assessment and results giving already
  established (see earlier published work James,
  2005, 2006,Cancer Nursing Practice).
• Next step was for nurse to learn Transrectal
  Ultrasound and Prostate Biopsy.
• Once competent, logical step was to offer all
  three aspects (assessment, biopsy and results) as
  quickly as possible.

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What happens now?

• Nurse led 2-week-wait suspected prostate cancer
  clinic
• Nurse led transrectal ultrasound and prostate
  biopsy
• Nurse led histology giving clinic.
• Nurse led prostate cancer follow up

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How did we get from where we were to where we are?

• Training of nurse in TRUS and biopsy.(Took 6
  months)
• Competencies involvement of patient safety team
  and clinical governance committee.
• Goodwill and support of all involved (urologist,
  pathologist, radiologist and oncologist)
• Support of Trust and PCT
• Audit, audit, audit

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Financial issues

• Consultant urologist costs 110 k per annum
• Level 7 nurse costs 39 k per annum
• Level 8 nurse (Nurse Consultant) costs 42k per
  annum. Using the example of a suspected prostate
  cancer clinic
• One clinical session of consultant time 211.54
• One clinical session of nurse consultant time
  80
• One clinical session of level 7 time 75
• (NB-In local model, nurse sees as many patients
  in per session as medical consultant)

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Robust evaluation?

• Audit and evaluation is the cornerstone of good
  clinical practice.
• Nurse led practice must be as safe as medically
  led practice.

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AUDIT RESULTS

• One stop service
• Rated very highly
• Patients very happy with pathway times
• Patients very happy to have all aspects of
  diagnostic pathway offered by nurse

• Nurse led biopsy
• Safe. Cancer pick up rates at least as good as
  those published by medical staff.
• Quality of tissue excellent
• Complication rate comparable to published medical
  rates.

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Conclusion

• This innovation has significantly improved the
  experience of men with prostate cancer (or
  suspected prostate cancer)
• It has dramatically cut waiting times
• It has proved that nursing roles can be safely
  extended.
• Principles can be extended into other areas