Author: Duncan Stevenson (Graphic Designer)

Life in the Fast Lane: Reducing the waiting time of PEG Removals for Head & Neck Patients who have completed their cancer treatment.
Laura Kent Macmillan Head & Neck Specialist Dietitian
Vicky Poole Macmillan Head & Neck Clinical Nurse Specialist (CNS)

Background
A Head & Neck cancer diagnosis can have a profound effect on all aspects of patient quality of life. It can cause functional difficulties, changes in appearance, psychological distress, financial burden, anxiety and much more (Bristol-Myers Squibb, 2019).
It is important to look at ways to improve the aftercare of patients to support their recovery and improve their quality of life.
A recurring issue raised by patients was the time waiting for their PEG tube to be removed, often seen as the last visual reminder of their cancer treatment.
Personal impacts on patients:
Currently the Average wait for PEG removal for Head & Neck Cancer patients is 62 days, with a range of 7 to 240 day wait.
*based on 33 PEG removals over the last year & average Salaries, not including overheads

Unable to swim or take part in water sports activities with children

Impacting on sleep , tube gets caught and in the way

I have a manual job and it keeps getting caught

Can’t wear a swimming costume comfortably

The tube is in the way when I carry my child

The tube gets in my way when I am gardening.

Impact on personal relationships with partner

Results
81.5 % reduction in average waiting time for PEG removal by end of 6 months with a range of 8 to 29 days wait, once the backlog of patients waiting for removal was cleared.
100% Satisfaction with PEG removal procedure by CNS.
Improved patient quality of life and satisfaction on waiting times
Cost savings
*based on 33 PEG removals over the last year & average Salaries, not including overheads

Costing Breakdown	Average Expense for a year *
Previous removal pathway includes: / Clinical Time / Head & Neck Team / Home enteral feeding team / Administration / Endoscopy staff / Ancillaries / Stoma site treatment	£2967
New removal pathway	£427
Total Savings	£2540

*based on 33 PEG removals over the last year & average Salaries, not including overheads

Currently the Average wait for PEG removal for Head & Neck Cancer patients is 62 days, with a range of 7 to 240 day wait.

Intervention
To set up a Clinical Nurse Specialist PEG removal clinic for Head & Neck cancer
patients.
Aim
50% reduction in the time waited for PEG removal in Head & Neck Cancer patients within 6 months following service set up.
Outcome Measure = Number of days between MDT decision for PEG removal and
Removal day.
Method
Process Mapping was completed for the current PEG removal pathway for insight into the process and identify where the delays were. A new process was then mapped out.
A Driver Diagram was created to breakdown our idea into projects which needed to be achieved to allow a service to be set up.
A Competency for PEG removals was developed and approved.
PEG removal training was provided by a Gastroenterology consultant and
competency signed off.
Clinic space was identified and a clinic created on Trak
MDT PEG removal form to sign off and approve removal
Patient Questionnaire developed for feedback
Patient information leaflet adapted for post PEG removal to reflect change in
pathway.

Future Plans
Cascade training of PEG removals to establish a reliable service.
Continue to closely monitor need for PEG re-insertion (Balancing Measure)
Acknowledgements: Dr Di Mambro, Mr Wheatley, Home Enteral Feeding Team, Endoscopy Booking Team & Rebecca Handley Head & Neck Cancer Unit Co-ordinator.
Reference: Bristol-Myers Squibb (2019) Beyond Clinical Outcomes: UK Patient experience in head & neck cancers Available at: https://www.theswallows.org.uk/wp-content/uploads/2019/08/APPROVED-HN-Report-final-1.pdf [Last Accessed 18.09.20]