Dr. Rebecca Croft SpR Palliative Medicine. An Audit looking at the use of the Palliative Medicine out-patient clinic. Dr. Rebecca Croft SpR Palliative Medicine.

Reasons for doing the audit. Perceived high DNA rate. Perceived variable attendance rates. Uncertainty in my own mind whether out-patient clinics have a role in palliative medicine.

Standards. No reference to palliative medicine out-patient clinics on Pubmed. 80% available slots should be filled. General oncology DNA rate – 7.7% ( OP CE Meeting 2003)

Introduction Weekly clinic – Thursday am. 1 Consultant and 2 SpR’s. New Patient – 40 minutes. Follow-up patient – 20 minutes. Range of referrers. Patients – palliative neuropathic pain with no active disease

Introduction Methods of patient review in Velindre hospital by the palliative medicine team: Palliative medicine out-patient clinic In-patient review on ward SOS review in oncology clinic SOS review in chemo/radiotherapy

Method Retrospective look at clinic lists for 6 months. Old clinic lists on file Patient information from ISCO. Data entered onto Excel database.

Dataset per clinic Number of 20 minute slots available. Number of slots filled. Number of new patients. Number of follow-up patients. Number of DNA’s. ? Documented reason for DNA.

Dataset per clinic Diagnosis. Oncology consultant. Outcome of consultation re: follow up.

Clinic Slots Utilised

Incidence of DNAs

DNA’s Total number of DNA’s = 26 4 DNA – too unwell to attend. 2 DNA – died. 1 DNA – in-patient in HT. 1 DNA – in-patient elsewhere. 1 DNA – mistake with booking of appts. 17 DNA’s – unexplained.

Patient Types New/Follow up Diagnosis

Lead Oncology Consultant

Diagnoses Post mastectomy pain Colo-rectal ca Breast ca Malignant melanoma Lung ca Neuropathic pain with no active disease Sarcoma

Follow up arrangements

Problems encountered. Areas I had intended to look at: Referrer Time from referral to clinic appt. BUT required hospital notes. Absent hospital numbers – unable to identify 3 patients.

Information I wish I had recorded. Proportion of DNA’s who were new/follow up. Patient only registered once under diagnosis and oncology consultant – although consultant not a guide to the referrer.

Discussion. Are people aware of the out-patient clinic? Clinic vs review in oncology out-patient clinics. Pall. med. patients - ? Dom visit more appropriate.

Palliative Medicine clinic Cons An extra visit to Velindre. Time. May be unwell. - Financial cost. Pros Specific set-aside time to deal with all the problems. Appointment time. Alternative form of follow up if oncology follow up no longer required. Continuity of care.

Review in Oncology clinic Cons Patient may have to be kept waiting until team able to see them. Pressure of time in a busy day. May be seen by different members of the pall. med. team. Pros Discussion with the oncology team. All problems dealt with on one visit.

Domiciliary visit Pros Review of patient in their home environment. Cons Additional time travelling between patients. Unable to carry out investigations,e.g. x-rays. Reliance on primary care team to prescribe. Pros Review of patient in their home environment. No need for patient/family to travel. Good for patients if not well.

Similarities between all methods of patient review All require communication with the primary care team.

Further discussion Does the make-up of the community team affect the need for an out-patient clinic?

Ideas to explore the issue further Ascertain awareness of the clinic using staff questionnaire +/- primary care team questionnaire. Survey other palliative medicine teams – do they offer an out-patient clinic? Patient satisfaction questionnaire. Prospective look at clinics for similar data including referrer and time from referral to clinic appt. ? Performance status Further exploration of reasons for DNA.

Audit conclusion Only 46% slots filled – not met our set standard of 80% DNA rate 16% (10%) – seems higher than oncology but ? comparing like with like. Priority should be looking at increasing the number of slots filled, if it is felt that clinic is the optimum method of palliative medicine follow-up.

Audit conclusion Could only have one SpR list BUT - loss of training opportunity - patients often take longer than allocated slot time Further exploration of demand for out-patient clinic

My personal conclusion Still unsure of appopriateness of out-patient setting in palliative medicine Probably depends on the services available locally Issues require further exploration Outpatient clinic was rewarding and provided good continuity of care for patients and doctors