The Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (Ƶ) are delighted to lend our enthusiastic support to the sixth World Patient Safety Day (WPSD). This event, established by the World Health Organisation (WHO) in 2019, takes place on 17 September every year. It helps to raise global awareness amongst all stakeholders about key Patient Safety issues and foster collaboration between patients, health care workers, health care leaders and policy makers to improve patient safety. Each year a new theme is selected to highlight a priority patient safety area for action.
The theme set by the WHO for this year’s WPSD is “Improving diagnosis for patient safety”, recognising the vital importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.
Streamlining of services is part of the initiatives within Otolaryngology Head and Neck Surgery(Ear Nose and Throat Surgery or ENT)to improvediagnostic safety,patientcareandpatientjourneythrough earlier diagnosis.Thisleaner wayof working makes the diagnostic pathway faster, more efficient, more sustainable as it reduces unnecessary steps in the pathwayandunnecessarily waste of resourceswhich can be redirected elsewhere. It reduces the need for multiple appointments as all the relevant diagnostics such as a flexiblenasolaryngoscopyand an ultrasound scan of the neck or a cone beam CT scan of the sinuses followed by starting the consent process for surgery can all be done in one sitting. There is less risk of loss of investigations(less so now that most of these are digitised), less risk of patients missing appointments if their letter does not arrive on time,and less delay in treatment pathways.
I will illustrate my point by giving you twoexamplesof streamlined processes in the ENT department of theNortheastof England.
The introduction of therapid access neck lump clinicwithin the ‘Adult with Suspected Head and Neck cancer pathway’ has led to a significantimprovementin the cancer patientjourney. A patient referred on the cancer pathway with a neck lump will be seen in the ENT clinic by a senior clinician for a clinical assessmentwithin 14 days of referral by their GP.Mostpatients referred by GPs with a neck lump do not have a sinister mass and can be reassured and dischargedon the same day. If clinicallyappropriate,somewill have an ultrasound scan withor without afine needle aspiration cytology or core biopsy for histology on the same dayfrom the clinic.Theultrasoundfindings willdetermineif the patient isreassured and dischargedon the same dayoroffered an urgent staging CT scan which is done within 48-72 hours in our unitor other investigation. Within a week, thesepatients will havebeen given a diagnosis of cancer which allows closure of the 28-day faster diagnosis pathway(introduced in April 2020).They can thenmove forward on their cancerjourneywith further investigations followed by MDT recommendation of a treatment plan.
Prior to introducing thisrapid diagnosticpathway, we noted that GPs were organising neck ultrasound scans in the community where there isno access to FNA or core biopsy. Thesepatients werenot under any ENT clinician so could not be flagged to secondary care directly by the radiologist if an abnormal resultwasobtained. The patients, when GPs managed to get results of scans, would then be referred to and seen in secondary care by an ENT surgeon who would organise another ultrasound with targeted FNA or core biopsy. There has been a lot of pressure on radiology teams to provide duplicate scans and as you can see there are so many unnecessary steps and anxiety in thepatient’s journey.
WithinENT,we have introduced similar streamlined pathwayforpatients referred withchronicrhinosinusitiswho have not responded tomaximum medicaltreatment in primary care setting despite advice and guidance to GPs by the ENT teams.Chronic rhinosinusitis is very commonly seen in the ENT clinics.In hospitals with access to acone beam CT scan(CBCT), the patients whorequirea non-contrast CT scan of their sinusescan have the scan on the day, the imagesare reviewedwith the clinician and ifappropriate beconsented for surgeryon the day. Another example of use of the CBCT is for patients referred with suspected partial blockage of a salivary gland clinicallywhocan be consented to have a floor of mouthCBCT to accurately localise the calculus or stone. Those with significant symptoms can be referred there and then for consideration of asialendoscopy.Cone beam CT scansthat can be done in the outpatient settingandhas revolutionised the pathway of our non-cancer patients too. There is no need to wait on long radiology diagnosticwaitinglists fora CT scan of the sinuses or floor of mouth.
Our goals as clinicians are to ensuretimelyandaccuratediagnosis of our patients, use of limited NHS resources judiciously with no duplication of investigations,to allowthese diagnostic resourcestobe redirected to other patientsandultimately,we allwant toensure provision of safe care to all patients.