The
S.M.A.R.T Journal
Students for Medical Audits, Research & Teaching
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CONTENTS
___________ The
S.M.A.R.T Journal
——————————————————————— What is S.M.A.R.T? pg 3 ——————————————————————— How to use this Journal pg 5 ——————————————————————— How to complete an Audit pg 7
Our Audit of the Month
pg 9
Audit Fact Sheet pg20 ——————————————————————— Human Evolution Pullout pg21 ——————————————————————— Research—Is it for you & how to get started pg23
Editor: Christopher Taylor (5th year student intercalating in MRes Neuroscience)
Others: All Team Members
Associated Societies: Newcastle University Medical Education Society
Research Project of the Quarter
pg25
Research Fact Sheet pg27 ——————————————————————— Body Tricks pg28 ——————————————————————— Medical Education—a society’s view point pg29
Speciality in Focus pg31 ——————————————————————— Book Review pg33
Horses & Zebras—when you hear hoof beats pg34 ——————————————————————— Our Guinea Pig Column pg36
Newcastle University Academic Medicine Society
A word from our Editor: I would like to express many thanks to all members of the team for contributing to this issue and hope that you find this journal essential during your studies. Providing you with examples of how audits & research projects are done. What you can do in your Medical School and the hard work many students put into their societies.
Students for Medical Audits, Research and Teaching Journal
The
S.M.A.R.T Journal Students for Medical Audits, Research & Teaching
SMART is created by medical students for medical students and aims to help students publish their work in a widely read and respectable journal. I accumulates the knowledge and experience of medical students in Medical Audits, Research and Teaching. The audits provide a chance for students to get their work published in a national journal that can be read by peers and professionals alike. Medical Audits are an expected skill of a junior doctor, by collecting and learning from others work students can get a feel for what a good audit consists of covering various fields, providing essential grounding in audts and reviewing journal articles Research allows students to learn about cool new facts and interesting research at the front of its field. It will demonstrate to students how to get invoelved in research, how to get the most out of a placement and get publsished... Medical Teaching is something every medical student should know about. It effects how a student learns, their attitude to education and something which they must themselves experience. Many medical students leave medical school with no idea how to teach, yet this is an expected skill of a junior doctor,. As any medical student will tell you there are good teachers and bad teachers and by sharing students experiences they can collect and learn from these and take them with them into their future careers.
Christopher Taylor
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S.M.A.R.T.
How did SMART come about? As a medical student in my fourth year at Newcastle Upon Tyne I was asked to do an audit as part of my 1st Student Selected Component. I had a brilliant tutor who helped me develop an audit project from previous years audits and aim for a project that was publishable. During my time I heard of many colleagues audits being delayed or relatively small, partly due to the motivation / training of the tutor and partly the audits available. As a result I have included my audit as an example case to demonstrate what a student is able to do during a six week project and produce something that is important and hopefully publishable. During a long train journey to a conference in Edinburgh I was running through concepts for Graphics and Projects to do for the societies I was part of. As a result my mind wandered back to my audit and the time / effort it was taking to write it up (in contrast to the poster we had presented). It struck me that there were several journals out there that allowed students to publish small articles and present them with interesting materials but there was nothing to help students get their work published. As a result this journal took shape in my mind and with a little fun with Graphics and a days work in my Reading week this first concept issue was developed to provide a basis for future projects. I hope you enjoy reading this journal, bearing in mind it is a concept journal and that the full range of possibilities available from this journal will come when a team is recruited :D
Students for Medical Audits, Research and Teaching Journal
How to use t
This Journal is divided into several
Introduction articles - key learning articles / po Audit projects - audit of the month & a useful p
Also scope for contributions from the Medical
Research projects - project of the month & a usef
Also scope for contributions from Academic Me
There will be some non-curricular articles / fun dents ‘wider’ knowledge & maybe stimulate inter
Also scope for contributions from Other Medica
Medical Education / Teaching - projects from w what lectures/projects students like vs. dislike..
Also scope for contributions from Medical Edu
There will be articles looking at different specia future careers Book reviews will highlight interesting / contro Horses and Zebras aims to be a 1-2page article tions to keep students ‘in the know’ The Guinea Pig column will be posts from our F
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How to use
this Journal
l key parts:
oints of interest peer review (from the team)
School
ful peer review (from the team)
edicine Society
articles to break the continuity and help improve sturests‌
al Society [surgical, wilderness, Skip]
within medical education, reviews of teaching styles, ..
ucation Society
alties to help students make more informed choices for
oversial / fun books for readers on a single common condition and uncommon condi-
Facebook & Twitter pages about what’s important to you
Students for Medical Audits, Research and Teaching Journal
How to do an Audit Explain the Audit cycle:
Get across the key messages Interests Do’s Don’ts How to create a poster How to get published
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Audit Cycle
Students for Medical Audits, Research and Teaching Journal
A retrospective re-audit of the role of Neuro-oncology Specialist Nurses as Key Worker in the care pathway of suspected brain tumours C TAYLOR, PJ KANE, V MCGOWAN, G HENDRY, J MCKEE, M STAUSS
Abstract Guidance published by the National Institute for Clinical Excellence states that all patients should have an identified Key Worker, normally the Neuro-Oncology Specialist Nurses (NOSpN), who are present at key stages of the patient care pathway to provide continuous care and coordinate other Health Care Professionals (HCPs). The patient should also be provided with contact details and literature regarding treatment/diagnosis. Assess the NOSpNs involvement in the management of all patients with suspected brain tumour. Data was collected retrospectively from all new patients’ nursing notes from 01/01/2010 to 31/12/2010 using a trialled pro-forma and compiled on Microsoft Excel for analysis. The previous audit, with a single NOSpN, showed 66% of all patients; 87% of High Grade Gliomas and 53% of other tumour types had Key Worker/NOSpN involvement. This audit shows 89% of all patients, 94% of High Grade Gliomas and 86% of all other tumour types had Key Worker/NOSpN involvement. Low Grade Gliomas had the highest average number of contacts with patients and HCPs. Of 169 patients; 37% received contact details, 14% received literature about their diagnosis, 14% received post-treatment literature and 12% received a follow up call. A second NOSpN has led to a 23% increase in Key Worker/NOSpN involvement. Documentation needs to change to follow NOSpN team dynamics and gap analysis performed on low input cases. Re-audit in 12 months.
Introduction Primary brain tumours originate from the brain tissue itself, they cause a range of symptoms and have associated morbidity and mortality with malignant tumours having a 5 year survival rate of 15.7% men and 17.9% women. Primary brain tumours account for 1.6% of cancers in England and Wales and have an incidence of 8.0/100,000 for men and 5.6/100,000 for women in the UK1. Primary brain tumours have various pathologies depending upon their cell type of origin, examples include; gliomas, meningiomas and pituitary adenomas and are classified according to WHO guidelines.
Neuropsychologists, Occupational Therapists, Speech and Language Therapists and the patient’s G.P. These HCPs may be distributed over several sites and communications may become disjointed and uncoordinated.
Guidance published by the National Institute for Health and Clinical Excellence (NICE) recommends that a Key Worker should be assigned to each patient throughout their care pathway [Figure 1] to provide coordinated and high quality care1,. This responsibility may be taken on by any member of the MDT through the patient’s care pathway; however, it is typically Typical symptoms include headaches, epilepsy, neuro- taken on by the Neuro-oncology specialist nurses logical changes and cognitive / behavioural changesi. (NOSpNs). The NOSpN / Key Worker provide several imDue to the wide range of complications experiportant services: they coordinate all the services and enced by patients a multidisciplinary team (MDT) is commonly established within a Neuroscience depart- HCPs to personalise an individual’s care and support ment to provide specialist centred care. This relies on any needs from the family. They act as a central figure many healthcare professionals (HCPs) to ensure a ho- for all HCPs to communicate with using knowledge listic service is given to each patient and typically in- and experience to support any complications the pavolves Neurosurgeons, Oncologists, Specialist Nurses, tient meets throughout their care pathway4.
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AUDIT This article looks at the affect hiring a second NOSpN has on a single Neuroscience Department at
James Cook University Hospital, Middlesbrough, South Tees Hospitals Trust, United Kingdom.
Method One hundred and sixty nine patient’s records were examined in a cross-sectional retrospective casenote review as part of an audit registered within the Trust Audit Department. These patients were all initially referred to a single Consultant Neurosurgeon with suspected brain tumours between 1st January and 31st December 2010. During this time there were two NOSpNs working whereas the previous audits and before July 2009 there had only been one NOSpN in the department. A proforma was developed for data collection and piloted on 10 random patients successfully. The information was recorded from patient nursing records, NOSpN referral books and E-records/referral letters and was compiled and analysed using Microsoft Office Excel. Information was collected on recorded Key Worker assignment and if the NOSpNs were present at the key points of the Patient Care Pathway [Figure 1]. Patients were then divided into several categories: High and Low Grade Gliomas, Meningiomas, Pitui-
tary Adenomas, Metastases, Other Cancers (tumours not previously mentioned) and ‘Others’ (non-intracranial/CNS tumours at diagnosis despite suspicion at referral). Patients were excluded if they had been referred before 1st January as the second NOSpN was only hired in July 2009 and previous audits had already included those patients looking at the role and workload of a single NOSpN. Other patients referred to the Consultant Neurosurgeon were also excluded as they were not referred with suspected brain tumours. Information was also collected on whether the NOSpNs provided contact details, literature regarding diagnosis, literature regarding treatment, if they made a follow-up phone call for support and treatment coordination and the number of contacts made to different HCPs. This was to assess if there was a change in the workload and role of the Key Worker after hiring a second NOSpN.
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Figure 1:
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AUDIT Results Table 1: Patient Demographics Age
All patients referred to the Consultant Neurosurgeon with primary brain tumours were included in this study [n=169].
Male:Female ratio 18-29 30-39 40-49 50-59 60-69 70-79 80+
5:7 5:10 11:16 14:21 25:18 10:17 5:5
Tumour Categories
Number of Patients
High Grade Glioma Low Grade Glioma Pituitary Adenoma Meningioma Metastases Other Cancers ‘Others’
50 (30%) 14 (8%) 24 (14%) 40 (24%) 12 (7%) 12 (7%) 17 (10%)
There were 75 men and 94 women included in the audit with a mean age of 56 years. The most common tumour type recorded was High Grade Glioma, followed by Meningioma and Pituitary Adenoma [See Table 1]. Other Cancers of the brain and central nervous system (CNS) and Metastases were the least common Guidelines published by NICE state that all patients (100%) with suspected brain tumours should be assigned a Key Worker who must be present at all stages of the patient’s care pathway.
Table 2: Involvement of Key Worker at important stages of care pathway Total Number of Contacts
NOSpN involvement Key Worker Assigned Initial Consultation Diagnosis Treatment Discussion Post Treatment Review
High Grade Glioma
Low Grade Glioma
Pituitary Adenoma
Meningioma
Metastases
Other Cancers
‘Others’
Total
47
14
20
32
11
12
14
150
31
8
9
10
4
4
0
66
46
13
18
29
10
12
14
142
45
14
19
29
10
11
13
141
46
13
19
24
10
11
13
136
30
10
8
8
9
7
1
73
NOSpN involvement per number of patients in each tumour type High Grade Glioma
Low Grade Glioma
Pituitary Adenoma
Meningioma
Metastases
Other Cancers
‘Others’
Mean
Initial Consultation
0.92
0.93
0.75
0.73
0.83
1
0.82
0.85
Diagnosis
0.9
1
0.79
0.73
0.83
0.92
0.76
0.85
Treatment Discussion
0.92
0.93
0.79
0.6
0.83
0.92
0.76
0.82
Post Treatment Review
0.6
0.71
0.33
0.2
0.75
0.58
0.06
0.46
Average
0.84
0.89
0.57
0.67
0.81
0.86
0.60
0.75
Students for Medical Audits, Research and Teaching Journal
Between July 2008 and June 2009 when there was only one NOSpN in the Neuroscience Department during a previous audit showed that only 66% of patients had an assigned Key Worker. Between January and December 2010 a second NOSpN had joined the department. Table 2 demonstrates that 150 patients (89%) had a NOSpN involved at least once through their care pathway but only 66 patients (39%) had an assigned Key Worker. Low Grade Gliomas have the greatest input (89%)
from the NOSpNs, followed by High Grade Gliomas and Other Cancers of the brain and CNS, with ‘Others’ (initially suspected as brain tumour) showing the least amount of input. Table 2 also shows that a patient with suspected brain injury, on average, is likely to meet the NOSpN through only 75% of their care pathway. Figure 2 shows that overall all tumour types are receiving similar levels of input from the NOSpNs
Table 3: Services provided by Key Worker throughout patient’s care pathway Total of services provided per number of patients in each tumour type
Contact Details Provided Literature Provided Phone Call Made Post Treatment Literature Provided
High Grade Glioma
Low Grade Gliom a
Pituitary Adenoma
Meningioma
Metastases
Other Cancers
‘Others’
Mean
0.67
0.64
0.29
0.18
0.17
0.33
0.06
0.33
0.37
0.14
0.13
0
0
0.08
0
0.1
0.27
0.07
0.08
0.05
0.08
0.17
0
0.1
0.27
0.21
0.8
0.05
0
0.33
0
0.13
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AUDIT High Grade Gliomas are documented as receiving more contact details, phone calls and literature regarding diagnosis or treatment options than any other tumour group. Other Cancers of the brain and CNS received the second most services while Metastases, Meningiomas and ‘Others’ received the least levels of services from the NOSpNs [Table 3].
Table 4 demonstrates that patients with Low Grade Gliomas required the greatest average number of contacts throughout the patient care pathway with Pituitary Adenomas and ‘Others’ receiving the least. On average the NOSpNs contacted Healthcare Professionals (HCPs) (5.09) almost as often as the patient (4.84).
Table 4: Average number of contacts made by NOSpN through patient care pathway
with Patient with Any Carers with HCPs
High Grade Glioma
Low Grade Glioma
Pituitary Adenoma
Meni ngioma
Metastases
Other Cancers
‘Others ’
8.95
9.64
1.96
3.13
5.25
5.33
1.39
5.09
3.67
1.36
0.25
0.40
0.42
0.67
0
0.97
6.80
8.64
2.71
4.10
3.50
5.75
2.39
Mean
4.8 4
Table 5: NOSpN contacts with HCPs HCP
Sum
Range
Mean
% of Total
Neurosurgeon
467
0-9
2.92
56%
Oncologist
114
0-4
1.48
14%
G.P.
103
0-5
1.63
12%
Neuropsychologist
53
0-3
1.13
6%
Speech and Language Therapist
27
0-2
1.04
3%
Occupational Therapist
11
0-2
1.22
1%
Neuroscience SpN
5
0-2
1.25
1%
District Nurse
20
0-5
1.43
1%
Community Macmillan Nurse
13
0-2
1.3
1%
Social Worker
9
0-4
2.25
1%
Physiotherapist
3
0-1
1
1%
Epilepsy SpN
4
0-2
1.33
1%
Neurologist
3
0-1
1
1%
Endocrinologist
5
0-1
1
1%
Students for Medical Audits, Research and Teaching Journal
The Neurosurgeon is the main point of contact for the NOSpNs with up to 9 contacts throughout each patient’s care pathway, making up over half of all contacts made. The NOSpNs also make numerous contacts with the Oncologist (mean 1.48) and patient’s General Practitioner (mean 1.63). Table 5 also shows that the NOSpNs contacted 14 different Healthcare professionals 829 times, mainly contacting the Neurosurgeon, Oncologist, patient’s G.P., Neuropsychologist, Speech and Language Therapist and Occu-
pational Therapist from the Neuroscience Department’s MDT. In a previous audit between July 2008 and June 2009, when there was one NOSpN present, the number of liaisons with HCPs was measured for High Grade Gliomas. Figure 3 compares this data with the number of liaisons made for High Grade Gliomas between January and December 2010 with two NOSpNs present.
Discussion Primary brain tumours are more common in patients aged 50-70yrs5 with the highest incidence at 7579yrs1. The tumour types most commonly seen per annum are High Grade Gliomas (3550) followed by Meningiomas (812), Pituitary Tumours (690) & Low Grade Gliomas (520)1. A similar patient demographic is represented in this study with peak incidence at 6069yrs and tumour types following the same distribution [Table 1]. As data was collected retrospectively it was expected that some eligible patients could have been missed, however, due to the inclusion criteria only patients not referred as primary brain tumours were excluded. Hence no patients newly referred with suspected primary brain tumours will have been excluded. Guidelines published by NICE state that all patients with suspected brain tumours should be assigned a Key Worker. From 169 referrals only 66 patients (39%) had a documented Key Worker, which does not meet NICE standards. 150 patients (89%)
had the NOSpNs involved in their care at least once, which demonstrates a lack of documentation by the NOSpNs. After observing the team dynamics and discussions with the NOSpNs it was apparent that they both acted as the patient’s Key Worker, thus documenting a single NOSpN was not appropriate and their actual involvement was under represented. Hence, NOSpN involvement was examined more than documented Key Worker involvement. This results from when a single NOSpN was present before June 2009 when the Key Worker was always the NOSpN, however, with two NOSpNs present it is more appropriate for both to work as a team to coordinate communications with the patient and HCPs throughout the patient care pathway. In contrast to a previous audit between July 2008 and June 2009 where only 66% of patients were assigned a Key Worker / had NOSpN involvement, this demonstrates an improvement of 23%. This is represented in Figure 4.
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AUDIT Figure 4: Comparison between One NOSpN and Two NOSpNs on Key Worker Involvement
NICE guidelines state that assigned Key Workers should be present at all key stages throughout the patient’s care pathway [Figure 1] for all referrals of suspected brain tumour. Of the 169 patients 16% were not seen at the Initial Consultation, 17% at Diagnosis, 20% at Treatment Discussion and 57% were missed at the Post Treatment Review [Table 2]. This partly reflects the Neurosurgeon’s consultation style; direct observation showed that during the initial referral the Neurosurgeon often deferred examination in favour of extended discussion of Diagnosis and a Treatment Review, often with the Oncologist present. As a result the NOSpNs were present at sev-
eral key points in one instance. It may also reflect the management options for different tumour types, where some only require observation with others needing biopsy, debulking and radio/chemotherapy. This audit is also a snapshot of workload of the NOSpNs between January and December 2010 so it is important to consider that some patients may not have reached the point in their care pathway to allow for a Post Treatment Review. There is still a significant decline in NOSpN involvement towards the end of the patient care pathway that still needs to be addressed.
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AUDIT References: 1.
Improving Outcomes for People with Brain and Other CNS Tumours, National Institute for Health and Clinical Excellence, NICE Guidance on Cancer Services, London, June 2006. http://guidance.nice.org.uk/CSGBraincns
2.
Quinn M, Babb P, Brock A et al. (2001) Brain. Cancer trends in England and Wales 1950–1999: studies on medical and population subjects No. 66. London: The Stationery Office, p34–9.
3.
Kleihues P, Cavenee WK (2000) Pathology and genetics of tumours of the nervous system. Lyon: IARC Press
4.
Excellence in Cancer Care: The Contribution of the Clinical Nurse Specialist National Cancer Action Team. National Cancer Programme, 2010 Macmillan Cancer Support
5.
The Brain Booklet (2010), Brain and Spine Foundation 2010, www.brainandspine.org.uk
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Audit Facts
AUDIT FACTSHEET Neurosurgeon—job description Neuro-Oncology Nurse Specialist—job description Primary Brain Tumour—disease aetiology
Glioma—
Meningioma—
Pituitary Adenoma—
Astrocytoma—
Dendocytoma—
Oligodendrocytoma—
Metastases—
What this Audit did well Further Questions What you can take away from this audit
Students for Medical Audits, Research and Teaching Journal
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PULL-OUT
Students for Medical Audits, Research and Teaching Journal
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RESEARCH
Students for Medical Audits, Research and Teaching Journal
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RESEARCH
Students for Medical Audits, Research and Teaching Journal
RESEARCH
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Research Fact
Research FACTSHEET Neurosurgeon—job description Neuro-Oncology Nurse Specialist—job description Primary Brain Tumour—disease aetiology
Glioma—
Meningioma—
Pituitary Adenoma—
Astrocytoma—
Dendocytoma—
Oligodendrocytoma—
Metastases—
What this Audit did well Further Questions What you can take away from this audit
Students for Medical Audits, Research and Teaching Journal
FUNNY
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Education
Students for Medical Audits, Research and Teaching Journal
Vis www.studen /christoph
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Education
sit nts.ncl.ac.uk her.taylor2
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CAREERS
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BOOKS
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Horse/Zebra
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Guinea Pigs
THE END