1. Neuro Oncology Therapy Update
15th November 2017

2. Pre-Pilot Service Ward based: post operative Holistic assessment of:
Function
Physical performance
Cognition / communication / mood
Physio, OT, SLT, neuropsychology (on request)
Aim to:
Anticipate needs on hospital discharge
Highlight areas of vulnerability
Highlight areas of potential for improvement (could be remedial or compensatory)
Identify patient and family awareness of condition, prognosis etc.
Inform MDT of assessment outcomes to enable treatment decision making

3. Pre-Pilot Service Therapy treatment:
Education for patient and family (e.g. management of cognitive impairment, strategies to manage visual/functional deficits). At present, this education focuses on short term management (immediately post discharge).
Onwards referrals and liaison with community services to support discharge planning.
Provision of necessary equipment for discharge.
Rehabilitation as resource allows.
No follow up service. No phone call follow up, therefore for low grade tumours this is particularly difficult.

4. What have we changed?
Started 1 session / week pre-op therapy clinic in August 2017
Initial referral criteria:
Location of tumour indicates likely functional impairment
Pre-operative symptoms identified with:
Power/sensation
Swallow
Communication
Cognition
Complex discharge planning needs identified (e.g. comorbidities, social circumstances)
6 patients seen  2 did not have surgery
Average of 80 minutes per patient required for clinical assessment and interview. Additional pre-op input non-clinical time (e.g. referrals, phone calls) = 100 minutes average per patient
Post op time variable and difficult to compare given that all disciplines reviewed patient separately post op rather than one single assessment pre-op

5. Pilot patient outcomes:
Insufficient data thus far for accurate interpretation of outcomes.
4 surgical patients = 2 patients were repatriated for further rehab, 2 patients discharged directly home.
Average bed days minus weekend days (no therapy service) = 6 days, 3.6 days (excluding patient with post op hemiplegia).
Average bed days = 9
Average bed days minus patient with post op hemiplegia = 5.6

6. Pre-operative interventions
Baseline cognitive, physical and language assessments
Patient and family education to assist symptom management
Signposting to support agencies
Referrals to community services including rapid response, rehabilitation teams, equipment prescription
Discussions with GPs and members of hospital neuro-oncology MDT re medical management of patients (e.g. seizure control)
Anxiety management
2nd point - Education regarding preparation for surgery

7. Positive reflections
Access to therapy input achieved earlier in cancer pathway
Achieved increased rapport building and anxiety management around condition (this needs to be captured with a quality tool)
Observed increased MDT working and trusted assessment
Observed increased efficiency in discharge decisions from completion of baseline assessments
More timely assessments completed for patients not coping at home pre-admission
Hospital admission prevented for 1 patient
Improved family/carer satisfaction and engagement observed (this needs to be captured with a quality tool)
Quality of therapy input increased by having more contact with some patients along each stage of diagnosis, treatment etc.
Baseline assessment comment – to understand social supports and coordinate appropriate preparations for surgery, to understand individual patient strengths and weaknesses, facilitates/informs decision making in inpatient environment. Increases clinician confidence for progressing discharge and managing risks.

8. Challenges
Insufficient numbers to accurately interpret results thus far;
Logistical complications with timely appointment bookings, transport, room availability (especially difficult for high grade tumours and coordinating on other clinic dates);
Emotional impact of diagnosis and preparation for surgery increased length of time of appointments and interventions required (role for Macmillan – needs to be developed);
Lack of inpatient 7 day service impacts LOS;
Patients may opt not to have surgery.
Insufficient numbers – we were anticipating more referrals.
Logistical examples - Variability in patient/family awareness of diagnosis and surgical options which impacted on
Discussions and questions asked. Difficult to fit appointment in prior to surgery for high grade. Difficult to coordinate with nursing colleagues timings of their pre op assessment and pre op planning scans. People not wishing to travel twice.

9. Recommendations Continue pilot
Increase joint MDT assessments post operatively
Re-define referral criteria to be more specific:
Must be for surgery;
Patient demonstrates current impairments which would benefit from early therapeutic management;
Patient highly likely to have post-operative impairment which indicates need for baseline assessment and review of social supports.
Joint assessment post op – continuing to work on our efficiences and resource allocation.

10. Questions?