The One Stop Head and Neck Lump Clinic David Courtney Consultant Maxillofacial Surgeon Derriford Hospital, Plymouth

Background Set-up process / Difficulties Configuration of the one stop clinic Audit results Patient Satisfaction Questionnaire Summary

Literature Atula TS et al - ” Study of early assessment of head and neck cancer patients”-1994 McIvor et al - “Efficiency of the one stop clinic “-1996 A Murray et al – “One stop clinic”-2000 T.P Witcher et al –” One stop clinics in the investigation and diagnosis of head and neck lumps”-2006

Background November NICE document- ‘Improving Outcomes In Head and Neck Cancer – The Manual’

Recommendations (NICE) Patients with persistent head and neck lumps: Rapid access referral Designated head and neck lumps clinic MDT if cancer diagnosed

Summary Background Set-up process / Difficulties Configuration of the one stop clinic Audit results Patient Satisfaction Questionnaire

Requirements Clinical space where participants could work alongside or in adjacent clinical rooms Capital for a microscope to remain in the clinic- £8000 Capital for a portable US machine –Titan US unit and probe - £20000+

Requirements The capital costs of new equipment Difficulties in allocation of session time in consultant job plans Holiday cover for participating clinicians-3 radiologist and cytologists required Identifying a clinical space to house the clinic Recurring costs for ancillary staff and consultant time

Clinician Availability Relied completely on goodwill of Radiology and Cytology colleagues at beginning Justification for funding for radiology and cytology on site reporting came by way of positive audit The session to be included in the job plan when new appointments are made

Funding The average cost of seeing a pt in a normal clinic-£56 The average cost of seeing pt on the one- stop clinic-£78 The FNA results yield rose from 50%->90% thereby reducing the need for a repeat visit and the reduction in the number of review appointments - Estimated saving of £14,122 per annum

Summary Background Set-up process / Difficulties Configuration of the one stop clinic Audit results Patient satisfaction Questionnaire

The Derriford Configuration Fast track H&N lumps clinic set up in Derriford in December 2004 Weekly from 11a.m-1p.m 8-10 patients per clinic block booked at 11a.m.

Configuration continued….. Sited in the ENT department 4 clinic rooms available for clinical examination / nasendoscopy Nursing staff Ultrasound scan +/-FNA On site reporting both USS and Cytology Results discussed with patient

Participants 2 Consultant Maxillofacial Surgeons (2) 1 Consultant ENT Surgeon (2) 1 Consultant Radiologist (2) 1 Consultant Histopathologist (3) Varying numbers of SPR’s from different specialities 1 Pathology technician

USS Scan

Cytology Processed on Site

Summary Background Difficulties / Hurdles Configuration of the one stop clinic Audit results Patient Satisfaction Questionnaire

Audit Results 277 patients seen over a 10 month period 154 females : 123 males Average age - 53 years old Average age of patients with a malignancy - 60 years Average age of patients with benign disease - 51 years old

Referral source week wait GP letter 18 - Maxillofacial 6 - ENT 4 - Haematology 1 - Plastics 24 - Other

Outcomes 82 (30%) patients were discharged on the first visit 2 patients re-referred – (2.4%). Again reassured and discharged

Outcomes continued benign lymphadenopathy - 42% 48 malignancies % 39 salivary tumours % 32 thyroid % 15 lipomas - 5.4% 10 cysts - 3.6% 17 no abnormality detected - 6%

Analysis of the cytology 139 pts had an FNA % 100% adequacy achieved at one-stop clinic appointment Inconclusive cytology in 9 cases-6.5% Of these:- 6 diagnosed on open biopsy as Lymphoma 3 metastatic cancer :- 1 breast :- 1 tonsillar :- 1 unknown primary

Cytology continued….. Our study shows a significant improvement in the adequacy in FNA’s on the one stop clinic compared to a previous audit. This may be due to:- FNA’s now ultrasound guided Immediate on site reporting More senior and experienced clinicians performing the FNA’s

US Scans 264 pts were scanned with USS % 13 patients (4.7%) were not scanned because there was no abnormality clinically USS 100% sensitive in diagnosing malignancy

Summary Background Difficulties / Hurdles Configuration of the one stop clinic Audit results Patient Satisfaction Questionnaire

Patient Satisfaction Survey 58 patients returned a satisfaction survey at the end of the clinic 100% preferred to attend a one-stop clinic rather than individual appointments 51 patients confirmed they were given a diagnosis at the end of the clinic-87.9%

Patient Comments 14 patients (24.1%)- commented that more information regarding a biopsy could have been given. 2 patients commented on the extended length of the appointment 1 patient commented that the ability to chose his clinic date would have been an improvement.

Conclusions One stop clinic advantages- 1) US guided FNA’s increase adequacy. 2) Patient satisfaction is 100%. 3) Clinician team working in real time resulting in a more accurate diagnosis. 4) The service is cost effective in the long term.

Improvements for the future Increase the availability of tru-cut biopsies. Increase the time allocated for the clinic. Choose and Book? Re-audit Extend use of USS to H&N clinic

Thank you. Any Questions?

References McIvor et al study of 203 patients with head and neck pathology confirmed one stop clinic as an efficient assessment system Atula et al study of 105 patients-86 with clinically normal necks on palpation -13 confirmed with cervical metastasis after US and FNA in one stop clinic

Cytology continued…. Pathology audited 92 pts in first 6 months of the lumps clinic Reported adequacy of 92.4% on first FNA 2% overall inadequate after 2 nd attempt Earlier audit at Derriford in Adequacy rate of 50%

Literature Atula TS et al - ” Study of early assessment of head and neck cancer patients”-1994 McIvor et al - “Efficiency of the one stop clinic “-1996 A Murray et al – “ One stop clinic”-2000 T.P Witcher et al –” One stop clinics in the investigation and diagnosis of head and neck lumps”-2006