Working as a Colorectal Nurse Specialist in Great Britain

2. Working as a Colorectal Nurse Specialist in Great Britain Liz Coni Colorectal Nurse Specialist Queen Alexandra Hospital Portsmouth Hospitals NHS Trust UK

3. Aim To demonstrate how the roles and responsibilities of the Colorectal CNS contribute to the effective working of a multidisciplinary team (MDT)

4. Introduction • Service background • Pre-operative/treatment phase • Per-operative • Post-operative • Follow-up • Future

5. Service-1999 • Commenced post August 1999 • Four surgeons • One full time colorectal nurse specialist • One part time MDT coordinator/research coordinator • Two secretaries • Three stoma care nurses • Monthly MDT meeting held over lunchtime

6. Service-2010 • Five surgeons • Three full time colorectal nurse specialists • One nurse endocopist • One full time MDT coordinator • One research coordinator • Three secretaries • Four stoma care nurses • Weekly MDT meeting held in designated time • Increase in number of core members

7. Profile • 300 new patients per year • 170 elective operations • 70 emergency operations • 50% of all patients require oncological treatment • All major services on site, except TEMS and PET imaging • One surgical ward • Surgical high care unit • Laparascopic Colorectal Training Centre

9. Role of MDT • Rapid and high quality diagnostic service • Identify and review all new patients • Patient information • Advice • Point of contact • Appointment system • Communication • Audit • Training • Service improvement • Adherence to local and national guidelines

10. Role of Colorectal Nurse Specialist • Comprehensive service • Effective management • Efficient management • Excellent communication • Information, support and advice to all • Audit • User groups • Service improvement • Key worker • Continuity • MDT discussion

11. Elements of role Colorectal Nurse Specialist • 30 hours per week • Colorectal Cancer and Stoma Care Manager Associate Nurse Specialist (2006) • 30 hours per week • Colorectal Cancer Associate Nurse Specialist (2009) • 37.5 hours per week • Role split between colorectal cancer and enhanced recovery Advanced communication skills course Psychological distress course

12. Areas covered • MDT meeting • Weekly diary meeting • Two week wait clinics • Outpatient department new referrals-colorectal, gastroenterology, bowel screening • Endoscopy department • Treatment centre • Inpatients/enhanced recovery • Virtual follow-up clinics • Team meetings • Phone calls • Trouble shooting!

13. Pre-operative/treatment phase New referrals • Meet patient and carers • Assess knowledge/understanding • Initial assessement • Support • Arrange diagnostic tests • Patient information • Questions/advice • Contact information

14. MDT • MDT coordinator prepares agenda on spreadsheet, available to each prior to and at the meeting-35 approx • Hospital notes and Colorectal Nurse pack available on all patients • Surgeon presents patient • Discussed by team-surgeon, radiologist, oncologist, pathologist and nurses • Outcomes recorded by surgeons and nurses • Purple history sheet-surgeon • Proforma-nurse • Hand written notes of all patients by nurses

15. Review outcomes for each patient MDT coordinator notes tests/procedures and tracks for future meetings Nurses identify patients to be seen in clinic Arrange appointments Telephone other patients discussed Post MDT

16. For surgery For oncoloogical intervention and surgery For oncological intervention only Active monitoring Patients to be seen

17. Often already known to nursing team Need further test/procedure Awaiting treatment decision still Patients to be telephoned

18. Colorectal MDT Clinic Proforma Patient Details: Name: DOB Hospital number Case Details: Site of tumour Stage/TNM Metastases? Histology MDT Meeting MDT Decision Resection / Stoma only / Stent / TEMS / Chemotherapy / Radiotherapy Other test / treatment Type of resection ?Extended / joint op ?Additional specialists Ureteric stents Metastases / indeterminates to be managed? Site of indeterminate lesions If yes, re-scan due Need to be examined by surgeon (e.g. for decision re APR /AR)? Need flexible sigmoidoscopy Referral to other MDT Specify team Date done Comments MDT Clinic Proforma

19. Date:……………………………………………………………………………………………………Date:…………………………………………………………………………………………………… Seen by: (delete as appropriate) CNS – Liz Coni Associate Nurse Specialist - Rosie Hopping Associate Nurse Specialist - Lesley Worrall OPD / WARD ATTENDER (delete as appropriate) DISCUSSION: (circle as appropriate) Surgery Radiotherapy Chemotherapy No intervention Other test / treatment PATIENT UNDERSTANDING MDT Assessment: nature and extent of disease? Treatment options Ye MDT advice/decision PATIENT ACCEPTANCE proposed treatment FOR NON-OPERATIVE PATIENTS / MANAGEMENT WITH OTHER SPECIALITY Oncology OPA date OPA date for other consultant / team Comments

20. FOR OPERATIVE PATIENTS: Nature of operation proposed: Type Height Weight BMI Previous abdominal surgery: (excluding hernia repairs/caesarean sections) FITNESS: Fully independent? Limitations How far can you walk on the flat at normal pace Smoker Cardiac Angina Frequency What precipitates? MI Arrhythmia?: Valve disease / replacement?: Hypertension: CVA/TIA If yes, details…………………………………………………………………………………………. Respiratory: Asthma COAD SOBOE? Diabetic?: Insulin / Oral agents / Diet controlled (delete as appropriate) Medications (NB Clopidigrel and Warfarin):

21. ASPECTS OF OPERATION DISCUSSED: Major surgery discussed Potential complications: death heart attack pneumonia ITU care anastomotic leak reoperation stoma abscess infection bleeding blood clots damage to nerves working bladder or sexual function (please tick if discussed) Suitable for laparoscopic? Stoma: temporary or permanent Enhanced recovery programme FURTHER ASSESSMENT: Anaesthetic opinion: Referral date…………………………………………………………………………….. OPA date:………………………………………………………………………………... ECHO Referral date…………………………………………………………………………….. OPA date:………………………………………………………………………………... ITU opinion Referral date…………………………………………………………………………….. OPA date:………………………………………………………………………………... Stoma care Referral date…………………………………………………………………………….. OPA date:………………………………………………………………………………... SURGERY: PLANNED OPERATION DATE:…………………………………………………………………… SHCU / ITU?:........................................................................................................................... Admission procedure explained………………………………...……………………………….. Discharge planning:………………………………………………………………………………... Preclerking date…………………………………………………………………………………….. OPA WITH COLORECTAL SURGEON(specify):……………………………………………… (AS / DOL / ACP / JSK)

22. Pre-clerking to assess fitness Anaesthetic review if required Identify appropriate theatre list Allocated to consultant Consenting appointment Pre-operative phase

23. Admit on day Surgical high care unit post-operatively ERP nurse visits twice daily Home day 4-6 maximum Inpatient stay

24. Follow up appointment with colorectal nurses for histology results Oncological referral, if required, completed by colorectal nurses together with consultant letter Surgical follow up appointment with consultant, ideally at 6-8 weeks Referred to Nurse Led Virtual Follow-up clinic, if appropriate Post-operative phase

25. Referred by consultant Usually colonic cancers Telephone clinic weekly 20 spaces at 10 minute intervals Follow imaging protocol Assess progress Book tests Symptom leaflet Contact details Virtual Follow-up Clinic

26. User groups Feedback Amalgamate stoma care team Information-web based Develop Enhanced Recovery Programme Future