mdt improvement project - uclh internet · •mdt improvement workshop – july 2016 •mdt visits...
TRANSCRIPT
1995 “..assessment and management of rare cancers in multi-
disciplinary teams..”
2000 “…the care of all patients with cancer should be
formally reviewed by a specialist team…”
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2011-12 2012-13 2013-14 2014-15
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Activity (patient discussions)
Challenges for cancer MDTs
• Time - increasing case-load & complex case-mix
• Increasing treatment options
• Demands on time of MDT Lead & members
• Preparation and attendance of MDMs
• Annual review meetings
• Leadership
• IT support
• Video links
• Data
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1995 assessment and management of rare cancers in multi-
disciplinary teams
2000 the care of all patients with cancer should be
formally reviewed by a specialist team
2015 2017
Streamlining & more effective
working
• MDT discussions should focus more on difficult cases and processes should be put in place to enable swifter decisions on patients going through standard treatment pathways.
• Recommendation 38: NHS England should encourage providers to streamline MDT processes such that specialist time is focused on those cancer cases that don’t follow well-established clinical pathways, with other patients being discussed more briefly.
• Identify protocolised treatment pathways.
• ‘pre-MDT triage meeting’ to apply protocolised
pathways.
• Minimum attendance based on quoracy. NHS England
to run pilots to determine optimal attendance
requirements.
• Develop referral proforma template to include
minimum dataset including HNA, patient preferences,
suitability for trials
• Real-time documentation of outcomes.
• Ensure regular morbidity & mortality meetings and
quarterly operational meetings – time in job plans
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UCLH Cancer Collaborative MDT Improvement project
• MDT Improvement workshop – July 2016
• MDT visits (5 local, 8 specialist) – Nov 2016 to March 2017
• Questionnaires to MDT leads and co-ordinators
• Develop JD for MDT lead & co-ordinator
• Report published – April 2017
Differences in MDTs
Content Number of cases in the time available
Information about the patient & preferences
Stratification of cases
Combination of benign & malignant
Infrastructure Room, seating, screens, video-conferencing
Process – preparation and who does what • Presentation of cases
• Recording of outcomes
• Consideration of cases for trials
Chairing • Involving team members
• Summarising discussion & outcomes
Evidence of operational/review meetings 10
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Length of meeting and number of cases
Dur (mins)
21 Recommendations
• Leadership, infrastructure and attendance
• MDT lead & MDT co-ordinator JDs • Quoracy
• Process • Information about patient – performance
status & wishes • Protocolised pathways • Clear outcomes
• Governance & Improvement • Morbidity & mortality – SACT data • Operational meetings
• Support • Mentorship, support & development 12
Do MDT chairs have the time to prepare & lead?
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0%10%20%30%40%50%60%70%80%
No Partly Yes Preperation isminimal due to theuse of proformas
Does your job plan allow time for MDT preparation?
0%
10%
20%
30%
40%
50%
60%
70%
80%
Yes no It would havebeen useful
when I started
JD would bebeneficial butrecruitment
process wouldnot
We alreadyhave one
(PAH)
Do you feel your role as MDT lead would benefit from a structured job description and recruitment
process?
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0%
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120%
Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17
% cases submitted with complete dataset
RLH BHRUT WXH HUH PAH Other/Private Total
Tumour Site
Percentage in favour
What percentage of patients do you feel could be resolved outside of the meeting - for example,
through clearly defined treatment protocols and review by a smaller group?
Overall 74% 31.00% Skin 89% 37.80% Urology 87% 35.30% Other (please specify) 81% 28.50% Children and Young People 79% 31.40% Lung 78% 26.90% Gynaecology 78% 28.20% Upper GI 75% 30.70% Breast 75% 33.70% Haematology 75% 32.90% Brain 74% 26.70% Sarcoma 73% 21.10% Palliative Care 67% 42.90% Colorectal 63% 27.90% Head and Neck 50% 25.00% CUP 43% 12.20%
Analysis of single OG Cancer sMDT meeting
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Clinical details Question for MDT MDT outcome Suitable for pre-MDT triage
Next step after pre-MDT
Metastatic gastric adenoca, CT scan Treatment options Palliative care Yes Palliative care
Adenoca oesoph, neoadjuvant chemo Review CT Liver lesion - for MRI ? Adenoca stomach, CT - T3N1, staging lap Results of staging lap Cytology - positive, for palliative chemo Yes Refer to oncology OPC
Perforated adenoca oesoph, CT & PET Case review For neoadjuvant chemo-rad No
Metastatic SCC oesoph treated with chemorad CT to determine disease progression Disease progression Yes Oncology review
SCC oesoph treated with chemorad, OGD ? Recurrence Review histology Recurrent disease, discuss salvage surgery No
Perforated adenoca oesoph, SCLN biopsy Review histology Benign, consider oesophagectomy No
Metastatic SCC oesoph treated with chemorad, interval CT CT to determine disease progression Stable disease Yes Oncology review
SCC oesoph treated with chemorad, surveillance PET CTExclude recurrence No recurrence Yes Continue surveillance
SCC oesoph, CT - T3N2M0 Next step PET scan Yes PET scan
Referral from sarcoma MDT - oesophageal nodules biopsied Histology Repeat OGD with mapping biopsies No
Adenoca oesoph, CT- T3N1M0, PET - staging lap clear Next step Neoadjuvant chemo Yes Refer to oncology OPC
Adenoca oesoph, CT - R adrenal mass & suspicious liver lesions Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC
Adenoca oesoph, CT/PET - T3N2M0, co-morbidities Case discussion Review in surgical clinic to discuss optiona No
Resected gastric cancer Review histology For adjuvant chemotherapy No
High grade dysphasia on surveillance OGD for Barretts Review histology Repeat biopsy but patient not keen for further invx No
Adenoca stomach, CT - T3N1M1, bleeding Review case & imaging For palliative DXT No
Adenoca oesoph, CT - T3N2M0 Review CT For PET scan Yes PET scan
Adenoca oesoph, CT - T2N1M0 Review CT For PET scan Yes PET scan
Adenoca stomach, CT - TxN1M1 Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC
Elderly patient with gastric outlet obstruction from gastric ca Review CT T3N2M1 disease - stenting ? Elderly patient with early adeno oesoph, EMR Review histology Complete resection, for surveillance OGD No
Resected gastric cancer Review histology ypT3N2R1, for adjuvant chemo No
Cases suitable for protocolised pathway
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Clinical details Question for MDT MDT outcome
Suitable for pre-MDT triage Next step after pre-MDT
Metastatic gastric adenoca, CT scan Treatment options Palliative care Yes Palliative care
Adenoca stomach, CT - T3N1, staging lap Results of staging lap Cytology - positive, for palliative chemo Yes Refer to oncology OPC
Metastatic SCC oesoph treated with chemorad CT to determine disease progression Disease progression Yes Oncology review
Metastatic SCC oesoph treated with chemorad, interval CT CT to determine disease progression Stable disease Yes Oncology review
SCC oesoph treated with chemorad, surveillance PET CT Exclude recurrence No recurrence Yes Continue surveillance
SCC oesoph, CT - T3N2M0 Next step PET scan Yes PET scan
Adenoca oesoph, CT- T3N1M0, PET - staging lap clear Next step Neoadjuvant chemo Yes Refer to oncology OPC
Adenoca oesoph, CT - R adrenal mass & suspicious liver lesions Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC
Adenoca oesoph, CT - T3N2M0 Review CT For PET scan Yes PET scan
Adenoca oesoph, CT - T2N1M0 Review CT For PET scan Yes PET scan
Adenoca stomach, CT - TxN1M1 Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC
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12 cases for discussion
7 patients for oncology review
1 patient for palliative care
3 patients for PET scan
Pre-MDT meeting
7 patients for oncology review
1 patient for palliative care
3 patients for PET scan
AT LEAST – 2 DAYS IN TIMED PATHWAY FEWER CASES FOR DISCUSSION
Introducing protocolised management
• Develop pathways with MDTs & Pathway Boards
• Each MDT to determine who will triage? • E.g. MDT lead, MDT co-ordinator, radiologist
• Ensure ’direct to next step’ patients listed on MDT agenda
• Systematic study & audit