A new community thoracic specialist nurse role for post-operative care

Introduction

Patients undergo thoracic procedures for diagnostic, therapeutic and palliative intent for both benign and malignant diseases, and the thoracic department at South Tees Hospitals NHS Foundation Trust cares for around 800 patients a year who are undergoing these interventions.

In July 2020, the department, in collaboration with Macmillan Cancer Support and South Tees Cancer Services, created a new role for a community thoracic specialist nurse, with the aim of providing holistic care to thoracic patients. The role was intended to actively support patients and their families by providing continuity of care throughout the thoracic surgical pathway. The need for specialised thoracic care had been identified prior to July 2020, but the project began at this point because the Covid-19 pandemic increased the demand for community-based thoracic care to reduce both the length of patients’ hospital stays and their hospital readmission rates.

Addressing gaps in service provision

Our department had already identified a gap in service provision before the pandemic began: patients were discharged following thoracic surgery and often not reviewed until their routine six-week post-surgery clinic check-up. The spread of the coronavirus in 2020 meant it became imperative to discharge post-operative patients as quickly as possible; patients with lung cancer are at an increased risk of becoming infected with Covid-19 and there were concerns they would experience higher rates of morbidity and mortality than the general population (Passaro et al, 2021).

Our department, therefore, faced the risk of the gap we had identified widening. To address this and improve patient care, we developed the role of a community thoracic specialist nurse to visit patients at home 24-48 hours after discharge. The nurse’s specialist knowledge in thoracic surgery would enable them to:

• Review patients;
• Manage their symptoms;
• Provide reassurance and support for patients and their families.

Setting up the service

Our team worked closely with South Tees Cancer Services and Macmillan Cancer Support to write a proposal for a community thoracic specialist nurse service, which was quickly approved. Macmillan Cancer Support provided a grant of £50,000 in 2020, and this was renewed in 2021. South Tees Hospitals NHS Foundation Trust funded costs for things such as a laptop, telephone and travel expenses, and we arranged to have a pool car used only for this service. Additionally, the trust agreed to take over responsibility for funding the service in the future.

The process was not without challenges, such as obtaining the correct equipment quickly and developing an integrated database that linked to GP, hospital and community care services. This database links to all thoracic services, including pre-assessment, surgery, discharge and all follow-up reviews (both in the clinic and in the community); it also facilitates the specialist nurse role being covered during annual leave and other staff absences. With the trust’s support, we were able to overcome these challenges, ensuring we had adequate equipment and supplies available to manage patients in the community.

Running the service

Funding for one Macmillan community thoracic specialist nurse was introduced and the post is now fully incorporated into the team, with four nurses providing thoracic patients with community support on rotation. As the Covid-19 pandemic has restricted hospital visits for inpatients, the ability to care for patients in the community – where they can see their families and carers – dramatically improves patient care and satisfaction. In addition, the community thoracic specialist nurses are able to examine and manage each patient’s condition at home in a more personalised way than they could previously.

This new role allows the nurse to:

• Support patients during their transition to community care following early discharge;
• Provide expertise – including early intervention for psychological and emotional support – in the patient’s own home;
• Answer questions relating to surgery and expected recovery;
• Manage symptoms, for example, by optimising analgesia;
• Support patients to manage their own symptoms, such as breathlessness;
• Identify and treat wound problems;
• Provide patients with their post-operative histology results and inform them of any onward referrals for further treatment.

The service takes a holistic approach to patient care and our specialist nurses follow each patient’s journey from pre-assessment through to treatment and recovery.

“The judges were impressed by this service, which was clearly focused on patients, and the team were inclusive in their involvement of both patients and staff in service development” (Judges’ feedback)

Outcomes

This service aimed to support not only thoracic patients’ physical health but also their psychological wellbeing. The community thoracic specialist nurses have identified ways to improve patients’ quality of life and comfort at home; for example, they have arranged Macmillan Grants to enable patients who were struggling with basic care to buy essential equipment, such as beds or kitchen appliances.

The introduction of this role has led to a significant reduction in thoracic patients’ length of hospital stay: it is now an average of 4.1 days in our department, compared with the pre-pandemic national average of 6.6 days (Richens, 2018). We believe this could reduce further over the coming year, because during the Covid-19 pandemic the majority of patients have been admitted on the day before surgery, whereas our department is beginning to return to its common practice of admitting them on the day of surgery.

Additionally, our initial data shows a reduction in hospital readmissions from 36% in 2019 to 11% in 2021 (Lim, 2022). We acknowledge that readmission rates will never be zero; however, when complications that require inpatient care are recognised during home visits, the thoracic specialist nurses can arrange direct admission to the thoracic ward, thereby avoiding patients having to visit high-risk areas, such as the emergency department and admission units.

Patient feedback

Since the initiative began in 2020, 400 new patients have been supported by this specialised nursing service. We have made 520 home visits, 460 telephone calls and 80 pre-assessment or clinic reviews. Patient feedback has been overwhelmingly positive; in particular, patients say how invaluable they find the service in terms of reassurance and support. One said:

“It is important to have a sense of follow-up after major surgery, because it’s unknown territory and one can feel anxious.”

Conclusion and future plans

An unexpected difficulty we encountered during this project was that several patients’ physical and mental health was worse than anticipated. We recognised that these lower levels of health needed to be addressed urgently, as many patients were also struggling with isolation caused by the pandemic. A benefit of our service is its ability to provide face-to-face support and care, which we hope will encourage positive recovery.

Since introducing this specialised nursing service, we have constantly adapted to a fast-changing world, achieved our primary goals in improving patient care, and surpassed our initial expectations. As we continue to push through the pandemic, we will ensure we continue to support patients after thoracic surgery to the best of our abilities. We plan to disseminate our project both locally and nationally as an example of good practice, and other teams have already expressed an interest in replicating this service.