Direct Access CT Lung Pathway V3 Updated 13/06/2016 ACE Direct Access CT Lung Pathway V3 Updated 13/06/2016

What are we trying to achieve by implementing the new pathway? A more appropriate screening system for the increasing number of people presenting with lung cancer – raising by around 1000 per year A higher survival rate for patients with lung cancer – due to late presentation, 40% of patients are first seen via the emergency route We have a robust 2WW pathway with referrals based on abnormal imaging, red flag symptoms and clinical suspicion. This is being widely used and has expanded over the years. The alternate pathway is trying to incorporate the low risk cohort with normal CXR and some clinical suspicion as a direct access to enable efficient management and triaging of these patients. This is aimed at decreasing the ever growing demand for the 2ww pathway referrals. Patient satisfaction without the increased anxiety that a ‘potential’ cancer referral is a big benefit and the pathway is resource friendly.

How the new pathway differs from the previous pathway The new pathway saves consultant time. The patient can present to the GP, who can request a CT scan without having to attend a 2ww clinic .

Describe new forms, tools or systems that have been developed to facilitate the new pathway Requests and results Requests are electronic and are received in Radiology at NUH via paper print out. All requests are reviewed, justified and protocolled by 1 of 3 Consultant Radiologists specialising in lung. This involved ensuring our The protocol is a standard plain low dose scan of the chest. The images are also reviewed by the same Thoracic Consultant Radiologists and a report is made which automatically goes onto the electronic system and viewed by GP referrers as well as relevant NUH staff. NUH operate a Radalert system so that any unexpected or serious findings are highlighted by the reporting Radiologist to a member of the Radalert administrative team and an email sent to the relevant personnel. Incidental findings of COPD, Bronchiectasis, airways disease are advised to be referred as OP to specialist clinics. Incidental nodules are discussed automatically at the local Nodule MDT at the City Hospital Campus.

When did the new pathway start? This pilot study started in January 2015 and involves Nottingham GP practices directly requesting CT scans of the chest for patients who meet agreed criteria. This criterion is set out below and has been agreed with NUH lung physicians, Consultant Radiologists and General Practitioners. There have been 274 patients referred on the pathway to date

What happened to the referral Number of patients Attended & Performed 224 Appointed - diary 11 Appointed - Special 3 Hospital Cancel 5 Hospital Cancel - Duplicate request 9 Hospital cancel - No longer required 7 Patient DNA 4 Rejected Patient - Cancel 1 Requested 6 Grand Total 274

TAT’s The Request to Attend turnaround times have dropped significantly in Feb 2015 it was taking an average of 23 days from request to attend now , Jun 2016 the average time has dropped to 17 days The Attend to Report turnaround times average 2.7 days ( Feb 15 - Jun 16, in June 2016 the average time from Attend to Report was 1.0 days

TAT’s The Request to Report turnaround times average 25.6 days ( Feb 15 - Jun 16), in June 2016 the average time from Attend to Report was 18.1 days

NUH Lung suspected cancer referrals - 2ww patients seen Jan 15 – Apr 16 Month Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 Patients seen 74 86 101 77 90 73 85 88 52 94 67 51 82 75 81 78

Emerging findings

Case1

Case2

Analysis Nine cases alerted for findings as abnormal Four cases of obvious Lung cancer Two nodules,not necessarily cancer One liver lesion,benign haemangioma on Inv One case of known myeloma,no lung lesion Two CXR were reported as abnormal with RUL lesion and Pleural effusion,both malignancies.

Emerging findings This project has been in place now for over 12 months and has been shown to support GP’s with patients who have a normal CXR but have suspicious symptoms. The pathway is designed to improve the TAT’s for these patients who otherwise would need an out-patient referral to NUH with subsequent delays for imaging. 274 patients were referred with 224 receiving a CT scan (14 waiting appointment date in June 2016). 93% of these patients had normal results; 2% (3 patients) had a reported cancer, one of which had an abnormal CXR and should not have been referred on this pathway.

Challenges Factor Comment Impact on ACE project Action ICT Issue with requests not printing out so staff unaware of request Delays in request to attendance Staff to check Webhiss daily Reporting capacity National shortage of radiologists; limited number involved with this project/specialising in lung meant annual leave impacted on TAT’s Delays in attendance to report Use of specific reporting box on Radiology IT system meant patients more readily identifiable and prioritised; annual leave coordinated Data collection Project needed specific allocation of data analyst to ensure correct data collected and support management and Radiologists Initial delays in roll out to more CCG’s as numbers and impact unknown Part time data analyst funded by ACE to support both Nottingham lung projects   CT capacity Demand in CT up 7% year on year; prioritisation to meet targets Delays in request to attendance due to lack of capacity within 2 weeks Additional weekend and evening lists

GP Survey 95% of GPs said they would use the pathway again 95% of GPs said “Yes” Comments included “ it allowed me to check I was doing the best for the patient”, "The direct access CT saved a 2ww referral, saving the NHS money” All of the replies were Yes, comments included "Quick, easy not so threatening as having to see a cancer specialist“ and "Reassurance / diagnosis without needing 2ww care referral"

All of the replies were Yes, comments included "Quick, easy not so threatening as having to see a cancer specialist“ and "Reassurance / diagnosis without needing 2ww care referral" If you could change anything about the Direct Access CT Lung Pathway what would it be? "More help with interpreting results as pts have lots of questions relating to CT reports that I am not necessarily qualified to answer." "Nothing - it's really good" "nil" " open it up a little, perhaps to include non-smokers in certain situations." " to open up for direct access to CT abdomen as well" "There were some problems initially with getting the referral through to the system and doubts that they had received it. Their staff were saying that they would not be alerted when a referral came in and that we should have phoned them to let them know. I think this has now been ironed out" " as have only used once, unsure as to current CT scan wait time and whether that may hold up a necessary 2ww??" " some teething troubles initially - took weeks for 1 pt to get a scan but now seems much better"

Learning points to date/ advice to others What happens next? Further review of patients referred on this pathway to look at symptoms and outcomes Feedback from CCG’s required to inform any changes/improvements to pathway Support from CCG’s to sustain and embed this pathway into normal practice Continue data collection to support and provide evidence of benefits The feedback has been helpful in reflecting on the issues raised ,i.e., reporting template that’s friendly to interpret and enable further referral and management ,maintaining timeframes, regular audit and feedback to maintain set standards. Generic emails for Lung Cancer MDT and ILD MDT that can be incorporated into the reports that help the GP’s to refer with ease.