Haematology Outreach Nurse Specialists Helen Walker and Claire Beevis look back on 20 years of the outreach service at James Cook University Hospital and tell us how they adapted the service to meet patient needs during COVID-19.
Helen Walker (Lead Haematology Outreach Nurse Specialist), Leah Sherry (Haematology Outreach Support Sister), Claire Beevis (Haematology Outreach Nurse Specialist), Vicki Pengilley (Haematology Outreach Health Care Assistant/Phlebotomist)
Why did the service start?
The haematology outreach nursing service was developed in 2003 to offer expert holistic support to patients in the community who had been diagnosed with haematological malignancies. The move was prompted by the increasing intensity of treatments, clinical time constraints, and, at the time, a limited psychological service. It was felt that support in the community from a clinical nurse specialist (CNS) would improve holistic needs assessment and signposting to relevant support services. Another issue was attendance to the unit; patients would visit with non-specific illness, and it was felt that they needed more support in the community.
How has the service developed since 2003?
The service has developed over the last 20 years in several ways. In 2012, we began offering a chemotherapy at home service, which was a significant step for the hospital, and allowed patients to have treatment in the comfort of their own homes. Prior to this, patients were required to attend hospital for 10 days consecutively and some patients were refusing treatment as a result. As the treatment would both give patients more time with family and improve quality of life, we were determined to provide an alternative.
How did the service change in response to COVID-19?
As both day unit capacity and general practice appointments were reduced due to social distancing measures, our patients were also advised to shield. As a result, patients were unable or understandably unwilling to attend the hospital for review and blood tests prior to treatment. We needed to ensure our vulnerable patients were seen at home for pre- and post-chemotherapy assessments, transfusion assessments, and blood tests to allow informed decision-making before any change in treatment. We also needed to maintain our existing and well-established chemotherapy at home service and prevent interruption in the treatment pathway. Finally, our medical and nursing colleagues were relying on us to ensure up-to-date information was gathered to enable safe and accurate remote reviews. It was not feasible to request all our home reviews be taken on by district nursing colleagues due to their increase in workload from general practice.
In response to the news of COVID-19 in March 2020, we, like colleagues across the UK, adapted our practice rapidly to maintain service delivery. The MDT identified vulnerable and shielding patients who could transfer out of our main outpatient and day unit setting into the outreach team for ongoing review, management and treatment administration. Outreach activity increased by over 75%. In order to meet the increased demand, we extended our working days, and a health care assistant and assistant practitioner were redeployed to the outreach service. The skills of these valuable team members allowed us to introduce phlebotomy and COVID-19 screening services in the community, which also reduced the number of patients needing to attend general practice for blood tests.
We collaborated with pharmacy colleagues to introduce home delivery of oral chemotherapy (which was well received by patients and continues to this day). The medical team and nurse specialists moved to telephone reviews, which allowed decisions to be made regarding administration of chemotherapy treatments both in the community and outpatient setting without any interruption to the treatment pathway. The support of colleagues, including haematologists, day unit staff, volunteers, pharmacy team, clinical psychologists and our dedicated haematology cancer care coordinator, enabled continuity of care in the community setting. Patient-centred care is at the core of everything we do as a team, and we were determined to continue to deliver safe and effective care and provide reassurance to our patient population, whilst mitigating their risk of infection with COVID-19. The expansion of the service promoted patient health and wellbeing, education, and enabled us to provide support to patients on treatment, newly diagnosed, or receiving end-of-life care. One patient told us:
“Without this service I would have not undertaken my chemotherapy for fear of having to come into the hospital setting due my risk of possibly getting COVID-19.”
What impact has the service had on patients, families and carers?
Any diagnosis of cancer has a profound impact on the health and wellbeing of patients, families and carers. Multifaceted support is required, including emotional, psychological, social and spiritual, and all of the above can change throughout the patient journey. The outreach service has been highlighted as essential in providing support to patients, families and carers throughout that journey. Patients, families and carers recognise the service as a link between home and hospital, which is particularly helpful if they were previously attending the day unit with non-specific illness. Patients have requested they continue with telephone reviews and blood testing at home, as otherwise they have to travel to hospital via the patient transport services (which can be time-consuming and exhausting). If family members or carers have underlying health issues, the home chemotherapy service can alleviate concerns about infection for them as well as patients.
The clinic, day unit and ward environment can inhibit patients, families and carers from talking about their concerns freely, whereas they will share more information in a familiar setting. This is particularly helpful with our patients who are socioeconomically deprived and have chaotic lives. Our patients cannot afford heating or basic home appliances; they cannot afford the cost of public transport to reach the hospital. Without the outreach service, we would not be aware of their living arrangements or (lack of) support networks. We can only signpost and refer for support if we’re aware of such complex needs.
What advice would you give to other hospitals planning a similar project?
Do it, just do it. COVID-19 has repeatedly reminded us, as nurses, of the way we need to constantly revaluate our ways of working to suit the greater needs of the patient. Use established services that are already being provided in the day unit and reallocate that quota of staff to deliver the services in the community. Speak to finance and business managers for budget support. Network with other hospitals with established outreach services. We were unique in 2003 but since COVID-19 lots more teams have begun working this way.
What are your future plans for the service?
COVID-19 reminded us as nurse specialists of the way we keep the needs of the patients, their families and carers at the forefront of everything we do. As a team we will continue to reassess the measures we have in place to sustain patient-centred care across our cohort. We will continue to engage with, and be guided by, our patients, their families and carers, and work alongside our MDT to continue delivering care closer to home. We now know we can adapt to emerging issues and grapple with quick decision-making on delivery of patient treatment whilst providing safe, effective care. We aim to share our ideas through networking with other like-minded nursing teams, produce an article for publication, and continue to expand our existing outreach service.