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Working as a Colorectal Nurse Specialist

in Great Britain
Liz Coni
Colorectal Nurse Specialist
Queen Alexandra Hospital
Portsmouth Hospitals NHS Trust
UK

Aim

To demonstrate how the roles and responsibilities of the


Colorectal CNS contribute to the effective working of a
multidisciplinary team (MDT)

Introduction

Service background
Pre-operative/treatment phase
Per-operative
Post-operative
Follow-up
Future

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

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

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

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

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

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

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!

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

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

Post MDT

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

Patients to be seen

For surgery
For oncoloogical intervention and surgery
For oncological intervention only
Active monitoring

Patients to be telephoned

Often already known to nursing team


Need further test/procedure
Awaiting treatment decision still

MDT Clinic Proforma


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

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
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

Ye

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):

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)

Pre-operative phase

Pre-clerking to assess fitness


Anaesthetic review if required
Identify appropriate theatre list
Allocated to consultant
Consenting appointment

Inpatient stay

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

Post-operative phase
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

Virtual Follow-up Clinic

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

Future

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