Implementation of the first Nurse Led Triage Clinic for Suspected Head and Neck Cancer Referrals
by Sian LouiseParker, Lead Clinical Nurse Specialist for Head and Neck, Lung and Gynaecology Cancers
(pictured above)
In June 2022, a novel Nurse-led triage service for suspected Head and Neck Cancer referrals was implemented at Epsom and St Helier University Hospitals using the Symptom Based Risk Calculator for Head and Neck Cancer Referrals v21. Whilst the risk calculator tool was widely used by doctors during the COVID-19 Pandemic, this was the first pilot in the country to integrate the risk calculator in an entirely nurse-led clinic, without there being bias from prior triaging by clinicians. Previously, patients being referred on a suspected H&N Cancer pathway would have their referral reviewed by a doctor within the H&N service and then booked into an appropriate clinic. This relied on the GP providing accurate information including any known risk factors for H&N cancers, as well as selecting the correct site of symptoms that make up a “Head and Neck” referral. The five sites included on the referral are Laryngeal/Pharyngeal including neck lumps, Ear/Nose/Sinus, Oral/Lip, Salivary and Thyroid.
During the early planning stages of the pilot it was agreed that although the tool has so far only been validated for use with patients presenting with symptoms affecting the larynx and pharynx, that we would use the tool to triage all referrals for any of the five sites listed above. Patients would then go through a telephone assessment of their presenting symptoms as well as a thorough medical and social history, before being triaged into one of three categories – High Risk ENT review, Low Risk ENT review and Oral and Maxillofacial (OMFS) review. All patients were then seen within 7-10 days of their telephone triage; the risk stratification allowing us to allocate resources more appropriately with the high risk patients being seen by the Head and Neck Cancer consultants working within ENT and OMFS. Patients presenting with a neck lump would also have an Ultrasound Scan (with or without a biopsy) requested from triaging. This is known as a straight to test (STT) pathway and means that at the first face to face appointment, patients are seen with the results of the test and gives a greater chance for them to be given a diagnosis of cancer, or have cancer ruled out, within 28 days. This is the new Standard for Cancer Diagnosis set by NHS England2.
It was agreed that as part of using my clinical judgement, if there were any patients whose symptoms sounded concerning but were scoring as low risk on the calculator, I would override the calculator and triage those patients into the high risk category. There was also excellent support from both the ENT and OMFS consultants if I had any queries or concerns, and I was very much encouraged to follow my clinical judgement.
Within the first eight weeks of running the telephone triage, there were 283 patients who underwent a telephone assessment, ranging in age from 16 to 99 years old, with 61% of the patients being female and 39% being male. Of these 283 patients, 19 people were found to have a cancer, 16 of which were Head and Neck cancers with the remaining three being diagnosed with types of blood cancers. It also showed that of the confirmed cancers, none of them had been triaged to the low risk clinic.
The telephone triage was re-audited after running for six months. This re-audit showed that a total of 355 patients had been referred into the service, with 15 people receiving a diagnosis of Head and Neck cancer. Over this time period, there had been 2 patients found to have cancer who had been triaged into the low risk category. However as they were seen within 7 days of their telephone triage, there were no delays in getting them a confirmed diagnosis or in them starting treatment. Interestingly both of these patients were found to have presented with a neck lump. After further analysis it was recognised that we are seeing an increasingly younger patient population, who have fewer risk factors, being diagnosed with HPV related H&N cancers, where their only symptom at presentation is that of a neck lump. Subsequently we made a decision to implement a local protocol that all patients presenting with a neck lump should have their risk calculator score overridden and be seen in the high risk clinics. It is also noted that people presenting with thyroid lumps rarely score highly on the risk calculator, therefore this override protocol takes this patient group into account also.
When looking at the amount of patients who were having their low risk score overridden into high risk, during the first eight weeks of the clinic running there were 44 patients whose score was overridden, making up around 16% of referrals. This figure then dropped to 13 patients (8.6%) at the re-audit, indicating an increased confidence in using the tool. When analysing the reasons for the score being overridden, the common themes noted were:
- A history of cancer in this area with suspicion for recurrence
- Thyroid nodules/increased size in known thyroid nodules
- Incidental activity seen on other unrelated diagnostic scans (mostly PET scans)
- New lateral neck lump.
The telephone clinic has now been in place for 18 months, with nearly 3000 patients having been referred into the service, and 80 confirmed cancer diagnoses between June ’22 and August ’23. Having spent my entire career working within Head and Neck Cancer, piloting this novel nurse-led triage service has been extremely exciting, and I feel very privileged to have been at the forefront of it. Reflecting on the last 18 months I can see how much I have developed as a diagnostician, being able to do the triaging alongside my role of being a Clinical Nurse Specialist, and how my assessment of patients has evolved beyond simply using the risk calculator. It has also helped me to support patients’ right from the beginning of the pathway, helping them to understand what is happening and what to expect, as well as providing psychological support from a much earlier stage than if I was meeting them only once they had received a diagnosis. Being involved in this pilot has reaffirmed for me everything that I love about being a Clinical Nurse Specialist working with this incredible patient group!
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