Prehabilitation: A multidisciplinary team approach

Dr Rachael Barlow, Lead, Enhanced Recovery, Prehabilitation and

Optimisation, Rachael.barlow2@wales.nhs.uk/barlowr1@cf.ac.uk

Cancelled Treatments

Poor outcomes

Poor survival

Impact of Poor General health status and Poor Preparation

Improving access to surgery

What makes a person eligible for surgery?1. Stage of cancer at diagnosis

– NLCA 2015 - 58% of patients with early stage disease (I-II) undergo surgery – NOGCA 2018 – ~50% not recorded as surgical despite early stage disease

2. Overall health status

3. Patient preference

THE most important member of the team… without them your

outcomes will never be the best they can be!

1. Edwin: The Patient

Many patients have combined treatments across Health Board

and Cancer hospital

Neoadjuvant Surgery Adjuvant

Prehabilitation and Optimisation

Health Behaviours and Surgical Outcome

• Compelling evidence linking unhealthy preoperative behaviours to poor postoperative outcomes

• Links to poor outcome with inactivity, poor weight management, smoking, hazardous alcohol intake

• Many people have multiple unhealthy behaviours

Prehabilitation allows the patient:1.EMPOWERMENT: Take control of their care

and outcome

2.EDUCATION: Understand why prehab and its intervention improve outcome

3.EXPECTATION: A detailed understanding of their treatment pathway, what is going to happen, who is doing what and when

4.CHOICE: An opportunity to be engaged in their care

Using the time when a patient presents with symptoms as a

‘Teachable moment’ – Making every contact count – behavioural

change

May 2012

My own prehab journey

• May 2012 diagnosed stage III breast cancer with lymph node involvement

• Neoadjuvant chemotherapy

• Neuropenic sepsis admitted to Velindre Cancer Centre

• 10 days inpatient

Communication and Education Communication strategy will raise awareness of our

initiative to the public and across the regional workforce.

• Edwin’s GP refers Edwin to rapid access lung clinic and explains that a diagnosis of cancer needs to be ruled out.

At the same time• The GP explains the need to check his

Wellbeing during this stressful time.

A few days later• Edwin attends his nearest Cluster based

Wellbeing Hub where he has his health, social, welfare and housing needs discussed.

• A pharmacist checks his medications and provides advice on lifestyle and health.

• He has a full range of blood tests• He is given ideas to increase his activity and

exercise levels.• He is given basic dietary advice and started on

nutritional supplements• He is enrolled on a local walking groups,

national exercise referral scheme, smoking cessation team, alcohol advice team etc.

• He is also given mindfulness advice to aid his anxiety.

Maximising Opportunities for Wellbeing Bundle

Edwin’s Current Experience… Edwin’s Future Experience…

• Edwin attends his GP for a cough he has had for several weeks.

• He has lost 2 stone in weight due to his poor appetite and anxiety. His wife is very worried.

• He hides his emotions from his wife but he is very frightened.

• He has not slept properly for several months.

• He wants to stop smoking but thinks he cannot do this at the moment due to his stress levels.

• He believes he has to conserve his energy levels by resting, in case he needs treatment in the future.

• GP has not discussed with Edwin, the link between his history of asthma, type II diabetes and high blood pressure and any potential treatment outcome as he does not want to burden Edwin.

• GP refers patient into rapid access lung clinic for investigations

• A bundle used by primary care teams to assess the general health status of people with suspected cancer and to provide treatment for any health problems and signpost to partner services for ongoing information, advice and support. This has two key benefits.

Primary Care Optimisation Bundle

For people subsequently diagnosed with cancer• People presenting with cancer symptoms have

multiple health and social needs• The bundle allows early detection and signposting

for remedial interventions to increase chance of curative treatment which may be too high risk otherwise such as fitness, nutrition and mental health.

• It will also flag up anaemia, cardiovascular disease, frailty, respiratory disease, diabetes ensuring remedial intervention ahead of any incurring treatment, to prevent any delays or cancelled treatments.

For people subsequently not diagnosed with cancer• At this vulnerable time when people are choosing to

engage with health services with worrying symptoms, we consider they may be more receptive to tackling some of these issues and detrimental behaviours.

• We will sign post these people to existing services such as smoking cessation, alcohol support, nutrition services, national exercise referral scheme, welfare support, social prescribing etc.

• We will also review prescribed medication, screen for morbidity and optimise existing comorbidity.

• A member of staff from hospital team contacts Edwin either in person or on the phone and explains what is found.

• He is then contacted or seen by a prehab assistant and the next stage is discussed with Edwin.

• He is booked into the next available appointment suitable for his requirement for prehabilitation in his local wellbeing hub. His information will be obtained from the Primary care optimisation team to prevent any duplication.

• He will receive prehab in line with his needs to improve his health status. This will include (supported by Patient Knows BestTM )

– Structured exercise programme, self management; group

– Nutritional advice tailored to his needs, – Emotional support – Continuous medical optimisation started in

primary care.– Inspiratory muscle training

• He will also be able to see a social worker or welfare officer if needed.

Prehabilitation during the investigation phase

Edwin’s Current Experience Edwin’s Future Experience

• Edwin has a chest X-Ray in his local hospital and it is indicative of lung cancer. He continues to undergo investigation for potential lung cancer. This will take several more weeks until he has the results and if required, a potential treatment plan.

• His anxiety is now even greater and he has lost more weight and is eating very little. He feels out control.

• He is still not sleeping.

People with suspected cancer will be signposted to partner services for information, advice and care support whilst initial investigations take place at their local Health and Wellbeing Centre.

• After a few weeks of prehab at his local prehab hub, Edwin has successful undergone all his tests and is confirmed with an operable lung cancer.

• He attends clinic and is seen by his surgeon and is informed he will be sent a date to come in for his operation. He is asked to attend the pre-operative assessment clinic.

• Since he was told in radiology this may be a lung cancer, he has been reassured and prepared by the community prehab team and is feeling much stronger and more able to cope.

• He has been following the advice of the dietitian, and has managed to maintain his body weight, he feels he may have put some weight on!

• Edwin is seen by the Perioperative anaesthetist and asked to perform 2-4 weeks of high intensity exercise prior to his surgery. He is given a training schedule which is predominantly home based.

• He also needs an IV iron infusion as he is anaemic. He will have this as part of the prehab service, preventing him from requiring a blood transfusion and a longer more complicated stay in hospital.

• He continues with his inspiratory muscle training• He is now walking nearly 10,000 steps every day

and can feel himself getting stronger. He is feeling positive for what lies ahead

Prehabilitation when curative treatment plan confirmed

Edwin ‘s Current Experience

Edwin’s Future Experience…

• Edwin is confirmed with an operable lung cancer. He is seen by his surgeon and is informed he will be sent a date to come in for his operation.

• His anxiety is now even greater and he has lost more weight and is eating very little.

• He is still not sleeping.

People with a confirmed cancer diagnosis will have more intensive support in preparation for treatment and to maximise opportunity for effective post-operative or post cancer recovery. This is likely to take place at their local Health and Wellbeing Centre.

Complex Patient JourneyPresenting Symptoms, anxiety and fear

GP and primary care team + Cluster based team, pharmacist, nurse, phlebotomist

Diagnosing symptoms with investigations

Radiology and endoscopy team

Making every contact count, discussion of healthy lifestyle, signposting to community prehab

Delivering diagnosis outpatient clinic

Surgeon or physician Community prehab – fitness instructors, physios, dietitians, OT, social worker, welfare

Person centred care: Supporting diagnosis

CNS Community prehab – fitness instructors, physios, dietitians, OT, social worker, welfare

Staging of disease Radiology, surgical exploration

Community prehab – fitness instructors, physios, dietitians, OT, social worker, welfare

Staging of the patient: risk assessment

Anaesthetist Community prehab – fitness instructors, physios, dietitians, OT, social worker, welfare

Discussion of treatment options

MDT If curative, secondary care prehab, exercise physiologist

Oncological treatment options

Oncologist If curative, secondary care prehab, exercise physiologist

Preoperativeassessment clinic

Anaesthetist, nurse If curative, secondary care prehab, exercise physiologist

Workforce

• Number of new posts needed• Not enough capacity at present• New roles maybe needed?• Under and postgraduate education • Links with Universities• Health Education Improvement Wales (HEIW)• Research skills for these staff to ensure

outcomes are continuously measured

Samuel H. Golter

“There is no profit in curing the body, if in

the process, we destroy the

soul.”