Lymphoedema Service Referral and Discharge Clinical Guideline V2.0 July 2018
Summary Patient develops oedema Other causes investigated and treated (including DVT and Malignancy) Oedema remains Referral to Lymphoedema Referral triaged within 2 working days Declined Referrer contacted Urgent Patient offered an appointment > 2 weeks Accepted Cancer Patient offered an appointment > 6 weeks Non-cancer Patient offered an appointment > 8 weeks Assessment, Treatment and Review at the Lymphoedema Clinic Patient stable and able to self-manage Patient declines treatment or does not attend Patient discharged Page 2 of 12
1. Aim/Purpose of this Guideline 1.1 This policy clarifies the criteria for referral of patients to the Lymphoedema Clinic at the Royal Cornwall Hospital (RCH) and the discharge process that will be followed. 1.2 This guideline applies to anyone wishing to make a referral to the Lymphoedema service and to healthcare professionals in primary care who will provide continuing care for patients discharged from the service. 1.3 This version supersedes any previous versions of this document. 2. The Guidance Referral guidelines for the Lymphoedema Service 2.1 The RCH Lymphoedema Clinic is an outpatient clinic based solely at Treliske and is unable to provide domiciliary visits. 2.2 Patients will need to be able to travel to RCH Treliske to attend their outpatient appointment. Patients who are unable to travel to RCH should be managed by the Community Nursing team; the lymphoedema team can provide advice. Patients referred with lower limb or truncal oedema will need to be able to transfer onto the couch for assessment. If the patient needs hoisting or specific transfer aids for transfers please make this clear on the referral, failure to do so may mean that the patient cannot be assessed at their planned appointment. 2.3 The lymphoedema team can provide telephone advice for inpatients within the Royal Cornwall Hospital Trust, however management will need to be undertaken by the ward team. Inpatients may be referred for outpatient appointments using the lymphoedema clinic referral form if the condition is related to the patients existing condition. Referrals for unrelated lymphoedema need to be made via the GP. 2.4 The RCH Lymphoedema Clinic will assess and treat patients with oedema that has been present for more than 3 months. This includes: Primary Lymphoedema Secondary Lymphoedema related to cancer and other causes, Lipoedema Obesity related oedema Chronic oedema 2.5 Patients with cancer related oedema will be accepted prior to the 3 month threshold, however acute causes must be ruled out prior to referral. In addition patients with cancer and lower limb oedema must have been screened for DVT and this must have been ruled out prior to referral; this must be stated clearly on the referral. 2.6 Patients with oedema associated with known or suspected arterial insufficiency should be referred to the vascular service for further advice regarding lymphoedema management prior to referral to lymphoedema. Page 3 of 12
2.7 Patients with a BMI over 40, with bilateral lower limb oedema, should be referred to a weight management programme prior to referral to lymphoedema. Clinical evidence provides a strong link between obesity and chronic oedema and unless the primary cause of the obesity is addressed treatment will be ineffective. 2.8 Only written referrals will be accepted. Referrals should be made using the Referral Management Service or sent to the Lymphoedema Team, Therapy Department, PAW, Royal Cornwall Hospital, Truro TR1 3LJ or rchtr.lymphoedema@nhs.net Referrals will not be accepted if the information is incomplete, this may delay the patient being offered an appointment. If the referral is urgent please state the reason for urgency clearly on the referral. (the referral form is available http://www.royalcornwall.nhs.uk/services/therapies/lymphoedema/). 2.9 Referrals will be accepted from all Healthcare Professionals: Referrals are accepted directly from the GP or Practice Nurse. Referrals will be accepted from the patient s medical Consultant when the lymphoedema directly relates to the condition they are under their care for, referrals for new and unrelated lymphoedema must be made via the GP. For referrals from other Healthcare Professionals, once the referral is accepted by the lymphoedema service, the GP will be contacted by letter to confirm that they agree with and support the referral. 2.10 Referrals will be accepted for children (of any age) and adults with lymphoedema. Referrals for children will be discussed on a case by case basis with the multi-disciplinary team and may be referred on for further assessment to a regional centre of excellence. 2.11 Referrals will be accepted for patients from Cornwall and the Isles of Scilly. Patients who meet the criteria of the following neighbouring services, Cornwall Hospice Care, St Luke s Hospice and North Devon Hospital will be given the choice of where they wish to attend. 2.12 Referrals will be triaged within 2 working days of receipt and urgent referrals contacted to agree an appointment. We aim to see urgent or palliative patients within 2 weeks and all other patients in 8 weeks. 3. Discharge guidelines for the Lymphoedema Service 3.1 The lymphoedema service offers a specialist outpatient service for persons with lymphoedema. It is the aim of the service to enable patients to selfmanage this long term condition. A well-controlled lymphoedema or chronic oedema, will be maintained by the patient with the support of primary care. Page 4 of 12
3.2 These guidelines outline which patients will be discharged and the procedures to be followed when discharging patients from the Lymphoedema service at the Royal Cornwall Hospital. This will ensure that within the confines of available resources, all patients are treated in an equitable manner and all members of the team, patients, family and relevant others understand the procedure to be followed. 3.3 Appropriate discharge planning will be arranged for all patients who meet the requirements for a safe discharge from the Lymphoedema Service. The requirements for safe discharge are: The patient has reached the agreed outcomes for intervention. The patient is stable, is able to self-manage and does not require further treatment or has been stable and maintained for 12 months on their current treatment regime. The patient/carer must be able to understand their condition and the necessary action if any abnormalities should occur. The patient will be wearing garments available on prescription, or if this is not possible supplied by the appliances department on receipt of an annual request from the patients GP. Patients with lympho-venous or gravitational oedema can be managed within primary care initially. However, if referred to the Lymphoedema Service the patient will be assessed, treated and reviewed and then discharged for maintenance by primary care. In addition the followings patients will also be discharged: Patients who are deemed non-adherent and do not accept prescribed treatment following consultation. Patients with no evidence of lymphoedema or chronic oedema at assessment. Patients who it is not safe to offer treatment to, due to their comorbidities. Patients with obesity related lymphoedema who have not met their agreed weight-loss goal. 3.4 Patients who DNA will be discharged in line with the Patient Access Policy (2013). Patients who do not attend their initial assessment will be discharged. Patients under the age of 18 will be discharged in line with the RCH Did Not Attend, Cancellation and refusal of Appointments Policy for Children and Young People up to the Age of 18 Years Policy. Patients who do not attend a review appointment will be contacted and requested to rebook their appointment within 4 weeks, if the patient does not contact the clinic then they will be discharged Patients who cancel 2 or more appointments within an active course of treatment. The patient and their GP will be informed by written correspondence. Page 5 of 12
3.5 The assessing therapist will make the final decision to discharge. 3.6 Discharge planning should be discussed with the patient as soon as they become stable and will form part of the patient s education, enabling selfmanagement. 3.7 When the discharge process has been discussed with the patient, their views are noted and it may be necessary to liaise with relevant others. 3.8 The following discharge advice will be discussed with the patient and / or carer prior to discharge and written information will be provided. Patients will be made aware of potential complications of their condition, and will be advised what to do and who to contact if a problem should occur. Patients will be provided with the relevant patient information they require to manage their condition. Any resource required by the patient should be issued or ordered and explained how to obtain subsequent orders 3.9 The discharge will be documented in the patient s notes and a letter will be sent to GP, patient and relevant others with details of the necessary follow up care. 4. Monitoring compliance and effectiveness Referral Guideline: Element to be Appropriateness of referrals received. monitored Number of incomplete referrals. Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Clinical Leads Lymphoedema Team Compare each referral with this guidance Each referral received will be monitored Referrer to be contacted with the reasons the referral has been declined or is incomplete. Clinical Leads in Lymphoedema to address any persistent nonconformance (if identified) with specific referrers Required changes to practice will be identified and actioned within 6 months of implementation. A lead member of the team will be identified to take these changes forward where appropriate. Lessons will be shared with all the relevant stakeholders. Page 6 of 12
Discharge Guideline: Element to be monitored Patients meeting the discharge criteria are discharged appropriately Number of re-referrals to the service Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Clinical Leads Lymphoedema Team Peer review of case load and discharges Review of re-referrals and monitor reason for re-referral Annual peer review Ongoing monitoring of re-referrals Action plan following above to be reported back to Outpatient Team Lead Clinical Leads in Lymphoedema to establish any variance in implementing the policy and work towards ensuring there is a consistent and equitable approach Required changes to practice will be identified and actioned within 6 months of implementation. A lead member of the team will be identified to take these changes forward where appropriate. Lessons will be shared with all the relevant stakeholders. 5. Equality and Diversity a. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. b. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 7 of 12
Appendix 1. Governance Information Document Title Lymphoedema Service Referral and Discharge Clinical Guideline V2.0 Date Issued/Approved: 17 th July 2018 Date Valid From: 17 th July 2018 Date Valid To: 17 th July 2021 Directorate / Department responsible (author/owner): Emma Underwood, Lymphoedema Specialist (OT) CSCS Contact details: 01872 252885 Brief summary of contents Guidance for those wishing to refer to the Lymphoedema Clinic RCHT on referral procedure and criteria and the discharge process Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: 20/06/2017 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Lymphoedema, Referral and Discharge RCHT CPFT KCCG Lymphoedema Referral and Discharge Policy v1.0 Therapies Clinical Governance Forum Dec 2017 Therapies Clinical and Quality Assurance Group Jan 2018 CSCS Governance DMB approval July 2018 Karen Jarvill Associate Director CSCS Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Not Required {Original Copy Signed} Name: Kevin Wright CSCS Clinical Governance Lead {Original Copy Signed} Page 8 of 12
Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Internet & Intranet Intranet Only Clinical/Occupational Therapy Links to key external standards Related Documents: Training Need Identified? None No Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) May 2014 V1.0 Initial Issue Emma Underwood Lymphoedema Specialist (OT) 20/6/17 V2.0 Policy reviewed, contact details updated, appendices removed as available on the website as stand-alone leaflets and link to new referral form added. Emma Underwood Lymphoedema Specialist (OT) All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 9 of 12
Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. Name of Name of the strategy / policy /proposal / service function to be assessed Directorate and service area: Clinical Support and Cancer Services - Therapy Is this a new or existing Policy? Existing Name of individual completing assessment: Telephone: 01872 252885 Emma Underwood 1. Policy Aim* To provide information on the referral and discharge process Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* 3. Policy intended Outcomes* To raise awareness of the referral process To ensure a safe and equitable discharge process 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. Number of incorrect or incomplete referrals received Number of re-referrals due to poor access to ongoing care in the community Patients Workforce Patients Local groups External organisations Other Therapies Clinical Governance Forum Dec 2017 Therapies Clinical & Quality Assurance Group Approval June 2018 CSCS Governance DMB approval July 2018 Page 10 of 12
What was the outcome of the consultation? Request for assurance over the exclusion criteria and rationale sought and for this to be clarified in the wording of the document. 7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development Page 11 of 12
8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Emma Underwood Date of completion and submission 1/2/18 Names and signatures of members carrying out the Screening Assessment 1. Emma Underwood 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Emma Underwood Date 01/02/18 Page 12 of 12