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153: Experiences of setting up a pre-operative optimisation ‘pre-hab’ service for patients being considered for lung cancer surgery
Poster abstracts of the 15th Annual BTOG / Lung Cancer 103S1 (2017) S1–S81
Larger numbers will be required to determine clinical significance. This quality improvement project has highlighted the benefits of a collaborative approach to guideline development. Recommendations: 1. Incorporation of modified POT proforma into Trust guidance; 2. Education on POT at clinicians’ oncology induction; 3. Re-audit in 6 months to assess long-term impact. Reference: [1] BTS Guidelines for Home Oxygen Use in Adults June 2015. Disclosure: All authors have declared no conflicts of interest. 152
Using the ambulatory care unit for admission avoidance and enhancing care for patients with lung cancer
L. Holland 4th Floor Thorpe House, Kettering General Hospital, Kettering, United Kingdom Introduction: Initial audit findings at KGH showed that 16% of patients referred on the 2ww pathway for lung cancer were admitted to hospital, having deteriorated prior to their clinic appointment (1 in every 6 patients referred). Data from Dr Foster for KGH for a 12 month period from July 2012 showed a total of 1253 bed-days were occupied by patients with lung cancer. Patients requiring CT lung biopsies could wait up to 2 weeks for a slot to be available. Methods: The lung cancer MDT redesigned and streamlined the patient pathway using the ambulatory Care Unit (ACU). All lung cancer patients at risk of being admitted to KGH were identified for review by the lung cancer medical and nursing teams on the ACU and respiratory team developed an innovative lung cancer diagnostic service utilising Ultra sound to facilitate early diagnosis. Results: Number of Emergency lung cancer admissions dropped from 108 to 67 in the following year audit; Improved quality of care for patients by better symptom management/support; Faster diagnosis leading to faster treatment; Significant financial savings of up to £170,000 per year for the local health economy; Substantial reduction in the number of CT lung biopsies, which expose patients to unnecessary radiation; No more waiting list for those patients requiring CT lung biopsies. Conclusion: This is a cost effective service that improves outcomes for patients and reduces emergency admissions. It is an easily adoptable model and could offer significant benefits across the NHS. Disclosure: All authors have declared no conflicts of interest.
Surgery 153
Experiences of setting up a pre-operative optimisation ‘pre-hab’ service for patients being considered for lung cancer surgery
K. Bollard1, K. Lau2, B. De Luca3, C. Hornby4, W.M. Ricketts5 1 Physiotherapy, Barts Health NHS Trust, London, United Kingdom; 2 Thoracic Surgery, Barts Health NHS Trust, London, United Kingdom; 3 Adult Respiratory Care And Rehabilitation Team (tower Hamlets), Barts Health NHS Trust, London, United Kingdom; 4Public Health, Barts Health NHS Trust, London, United Kingdom; 5Respiratory Medicine, Barts Health NHS Trust, London, United Kingdom Introduction: The 2015 National Lung Cancer Audit highlighted that, despite being a thoracic surgical centre, resection rates in our hospital were below the national average. Respiratory comorbidities were cited as a reason for a patient being deemed inoperable in 38.7% of cases, more than any other reason (data submitted separately). Methods: In an attempt to improve resection rates a pre-operative optimisation ‘pre-hab’ programme has been initiated. Here the experiences of our early cases are described.
S69
Results: The characteristics of each patient referred thus far are described in Table 1 overleaf. Conclusion: Which patients to refer to maximise outcomes without saturating capacity has been discussed at length, with some patients being too good, whilst with others there was a degree of nihilism about their potential. All patients have spirometry and gas transfer at their first clinic appointment and we are increasing our use of cardiopulmonary exercise testing. We also discussed the optimal point in the pathway to refer to maximise pre-hab time without delaying surgery, but also without referring patients later diagnosed with either benign or inoperable disease. Despite our resection rate it is unusual for a patient referred for surgery to be turned down and our post-operative complication rate is low, making the choice of outcome measures difficult. As the programme has progressed we have been able to appoint a dedicated physiotherapist, initially patients were either referred urgently for standard pulmonary rehabilitation or advised on self-directed home exercise. With this appointment we have created the capacity to lower the referral threshold, but appreciate that some patients may prefer a more local service, a reason to maintain links with our community pulmonary rehabilitation team. We also now offer a walk in smoking cessation clinic and a ‘cardio-oncology’ clinic to optimise other comorbidities. Disclosure: All authors have declared no conflicts of interest. 154
Uniportal VATS lobectomy and lymph node sampling; Does the lack of ports affect the number of nodes sampled?
J.S. Shin, S.S. Avtaar Singh, A. Al-Adhami, S. Das De, M. Klimatsidas Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, United Kingdom Introduction: Minimally invasive surgical procedures have been associated with reduced length of stay and increased patient Table 1 (abstract 154) Details of patients undergoing uniportal lobectomy for primary non-small cell lung cancer at our unit Pre-operative characteristics Uniportal (n=48) Age (mean±SD) Side (right:left) Height (cm) Weight (kg) Transfer factor (DLCO) (%) Forced expiratory volume in 1 second (FEV1) (%) Gender (M:F) Thoracoscore (median (Q1, Q3)) Intraoperative details Number of lymph nodes Dissected (median (Q1, Q3)) Operative time (mins) Postoperative details Stage 1a Stage 1b Stage 2a Stage 2b Stage 3a Compliant to ESTS 2006 Length of stay (days) Histopathological classification Adenocarcinoma Squamous cell carcinoma Large cell carcinoma Post-operative complications Atrial arrhythmias Air leak Respiratory compromise (NIV or Reintubation) Infection Other
70.0±6.65 40:18 162.7±8.30 67.5±13.53 68.6±16.81 90.1±21.32 23:25 0.660 (0.425, 1.398) 4 (3, 5) 158.5±42.2 21 (43.8%) 15 (31.3%) 4 (8.3%) 7 (14.6%) 1 (2%) 45 (93.8%) 5.00 (3.25, 10.75) 33 (68.8%) 13 (27.1%) 2 (4.1%) 2 (4.1%) 5 (10.4%) 2 (4.1%) 2 (4.1%) 1 (2.1%)
Despite the minimal access, the lymph node dissection rate was 93.8%. The median length of stay was also 5 days.
Larger numbers will be required to determine clinical significance. This quality improvement project has highlighted the benefits of a collaborative approach to guideline development. Recommendations: 1. Incorporation of modified POT proforma into Trust guidance; 2. Education on POT at clinicians’ oncology induction; 3. Re-audit in 6 months to assess long-term impact. Reference: [1] BTS Guidelines for Home Oxygen Use in Adults June 2015. Disclosure: All authors have declared no conflicts of interest. 152
Using the ambulatory care unit for admission avoidance and enhancing care for patients with lung cancer
L. Holland 4th Floor Thorpe House, Kettering General Hospital, Kettering, United Kingdom Introduction: Initial audit findings at KGH showed that 16% of patients referred on the 2ww pathway for lung cancer were admitted to hospital, having deteriorated prior to their clinic appointment (1 in every 6 patients referred). Data from Dr Foster for KGH for a 12 month period from July 2012 showed a total of 1253 bed-days were occupied by patients with lung cancer. Patients requiring CT lung biopsies could wait up to 2 weeks for a slot to be available. Methods: The lung cancer MDT redesigned and streamlined the patient pathway using the ambulatory Care Unit (ACU). All lung cancer patients at risk of being admitted to KGH were identified for review by the lung cancer medical and nursing teams on the ACU and respiratory team developed an innovative lung cancer diagnostic service utilising Ultra sound to facilitate early diagnosis. Results: Number of Emergency lung cancer admissions dropped from 108 to 67 in the following year audit; Improved quality of care for patients by better symptom management/support; Faster diagnosis leading to faster treatment; Significant financial savings of up to £170,000 per year for the local health economy; Substantial reduction in the number of CT lung biopsies, which expose patients to unnecessary radiation; No more waiting list for those patients requiring CT lung biopsies. Conclusion: This is a cost effective service that improves outcomes for patients and reduces emergency admissions. It is an easily adoptable model and could offer significant benefits across the NHS. Disclosure: All authors have declared no conflicts of interest.
Surgery 153
Experiences of setting up a pre-operative optimisation ‘pre-hab’ service for patients being considered for lung cancer surgery
K. Bollard1, K. Lau2, B. De Luca3, C. Hornby4, W.M. Ricketts5 1 Physiotherapy, Barts Health NHS Trust, London, United Kingdom; 2 Thoracic Surgery, Barts Health NHS Trust, London, United Kingdom; 3 Adult Respiratory Care And Rehabilitation Team (tower Hamlets), Barts Health NHS Trust, London, United Kingdom; 4Public Health, Barts Health NHS Trust, London, United Kingdom; 5Respiratory Medicine, Barts Health NHS Trust, London, United Kingdom Introduction: The 2015 National Lung Cancer Audit highlighted that, despite being a thoracic surgical centre, resection rates in our hospital were below the national average. Respiratory comorbidities were cited as a reason for a patient being deemed inoperable in 38.7% of cases, more than any other reason (data submitted separately). Methods: In an attempt to improve resection rates a pre-operative optimisation ‘pre-hab’ programme has been initiated. Here the experiences of our early cases are described.
S69
Results: The characteristics of each patient referred thus far are described in Table 1 overleaf. Conclusion: Which patients to refer to maximise outcomes without saturating capacity has been discussed at length, with some patients being too good, whilst with others there was a degree of nihilism about their potential. All patients have spirometry and gas transfer at their first clinic appointment and we are increasing our use of cardiopulmonary exercise testing. We also discussed the optimal point in the pathway to refer to maximise pre-hab time without delaying surgery, but also without referring patients later diagnosed with either benign or inoperable disease. Despite our resection rate it is unusual for a patient referred for surgery to be turned down and our post-operative complication rate is low, making the choice of outcome measures difficult. As the programme has progressed we have been able to appoint a dedicated physiotherapist, initially patients were either referred urgently for standard pulmonary rehabilitation or advised on self-directed home exercise. With this appointment we have created the capacity to lower the referral threshold, but appreciate that some patients may prefer a more local service, a reason to maintain links with our community pulmonary rehabilitation team. We also now offer a walk in smoking cessation clinic and a ‘cardio-oncology’ clinic to optimise other comorbidities. Disclosure: All authors have declared no conflicts of interest. 154
Uniportal VATS lobectomy and lymph node sampling; Does the lack of ports affect the number of nodes sampled?
J.S. Shin, S.S. Avtaar Singh, A. Al-Adhami, S. Das De, M. Klimatsidas Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, United Kingdom Introduction: Minimally invasive surgical procedures have been associated with reduced length of stay and increased patient Table 1 (abstract 154) Details of patients undergoing uniportal lobectomy for primary non-small cell lung cancer at our unit Pre-operative characteristics Uniportal (n=48) Age (mean±SD) Side (right:left) Height (cm) Weight (kg) Transfer factor (DLCO) (%) Forced expiratory volume in 1 second (FEV1) (%) Gender (M:F) Thoracoscore (median (Q1, Q3)) Intraoperative details Number of lymph nodes Dissected (median (Q1, Q3)) Operative time (mins) Postoperative details Stage 1a Stage 1b Stage 2a Stage 2b Stage 3a Compliant to ESTS 2006 Length of stay (days) Histopathological classification Adenocarcinoma Squamous cell carcinoma Large cell carcinoma Post-operative complications Atrial arrhythmias Air leak Respiratory compromise (NIV or Reintubation) Infection Other
70.0±6.65 40:18 162.7±8.30 67.5±13.53 68.6±16.81 90.1±21.32 23:25 0.660 (0.425, 1.398) 4 (3, 5) 158.5±42.2 21 (43.8%) 15 (31.3%) 4 (8.3%) 7 (14.6%) 1 (2%) 45 (93.8%) 5.00 (3.25, 10.75) 33 (68.8%) 13 (27.1%) 2 (4.1%) 2 (4.1%) 5 (10.4%) 2 (4.1%) 2 (4.1%) 1 (2.1%)
Despite the minimal access, the lymph node dissection rate was 93.8%. The median length of stay was also 5 days.