Team approach to cancer prehabilitation leads the way

 

A new expanded prehabilitation service that includes allied health at Australia’s only public hospital solely dedicated to caring for people affected by cancer could challenge what is considered ‘normal practice’ for cancer patients, both nationally and internationally.

Jess Crowe, has been working as a senior physiotherapist at the Peter MacCallum Cancer Centre for the past three and a half years in a role that allows her to combine her passion for acute cardiorespiratory physiotherapy and oncology. For the past year, Jess has also been wearing another hat—that of Allied Health Coordinator of the hospital’s newly expanded prehabilitation service.

Jess understands well the substantive role that physiotherapy and other allied health disciplines, working together in a multidisciplinary environment, can play in the prehabilitation of the patient with cancer facing surgery or stem cell transplant.

Growing local and international evidence, including guidelines from the United Kingdom, a site-specific audit and the alignment of prehabilitation with the hospital’s strategic plan led to a successful business case to expand the Peter MacCallum Cancer Centre’s prehabilitation service with dedicated allied health support.

The ground-breaking service, which expanded in March 2019, brings together the medical teams of anaesthetists, surgeons, haematologists and nurses with the allied health teams of physiotherapists, exercise physiologists (EPs), psychologists and dietitians under one multidisciplinary umbrella. The teams function as one to guide eligible patients through the prehabilitation service from diagnosis to preparing for major gastrointestinal cancer surgery and autologous stem cell transplants.

The aim of the allied health service is to improve patients’ physical fitness as well as nutritional and psychological wellbeing with a view to reduce postoperative complications, length of stay in hospital and to mitigate functional decline and deconditioning. But, importantly, the team want to embed this clinic into usual care for patients.

Part of Jess’s role, together with the prehabilitation team, is to evaluate the implementation of this expanded allied health service at both the six- and 12-month mark—the former of which was detailed in an e-poster presentation at the APA TRANSFORM Conference in Adelaide late last year. Jess says the poster highlighted some key findings of the service that was created with very specific service aims in mind.

The poster highlighted many successes of the service, including analysis at the six-month mark which showed that over 90 per cent of patients referred were accepting of the service and utilisation of allied health services by patients who had participated was high. The attendance rate was higher than 90 per cent for individual appointments. Jess says the new service has attracted ongoing hospital funding and has now become an integral part of the management for patients at Peter MacCallum Cancer Centre.

‘The results that I found really powerful were that, of the patients that were eligible for our service, 93 per cent of them took up the service, and then of the 93 per cent who took it up, over 90 per cent were attending individual sessions,’ Jess says. ‘So already our clinic utilisation is really strong, and our uptake is outstanding. Referral numbers were high also—for the first five months we had over 170 referrals into the service.

‘We also had some really positive results in terms of reduction in length of stay for our surgical patients, and a minor reduction in stay for our stem cell transplant patients. The patient sample size was small because at the five-month mark, the number of patients who had been referred to our service, completed four to eight weeks of prehab, had their procedure and then discharged from hospital was around 50.

‘The other 120 on our books were still receiving prehabilitation. However, there were some really positive results there from the six-month evaluation and it’s going to be really interesting to see the results of our 12-month evaluation where we have more patient data to analyse.’

Jess says there are amazing stories of success for the patients emerging from the data evaluation. She says some of the hospital’s high-risk patients have been able to reach their surgery or transplant goals but wouldn’t have otherwise been fit enough or physically or mentally well enough to do so previously.

‘And that’s a really special cohort of patients,’ Jess says ‘But the other side  of things is we’ve also been able to really improve patient education, and in the lead-up to their procedure we can give them something to focus on so that they have control over aspects of their treatment regime while they’re awaiting a procedure date and might feel there is a lot of uncertainty.’

‘Giving them an exercise program to do and achievable goals that they can focus on helps patients feel more in control of their health and hopefully improves their quality of life as well,’ she says.

‘Because we had such strong results from the six-month evaluation, everyone within the service benefits too. It raises the profile of allied health services within the hospital and also really benefits the patients, because we can continue with the service and look to expansion in the future.’

This month, Jess and the team will complete the 12-month evaluation of the program, and she anticipates further positive results for the patients but also for the clinicians who are delivering the service. For physiotherapists, that comes in the form of education and exercise prescription, including education about forthcoming surgery or transplant and aerobic and resistance exercise training to improve outcomes. For the surgical patient cohort, which involves predominately gastrointestinal cancer surgery, the physiotherapy education focus is on respiratory exercises and importance of early mobilisation.

Exercise sessions are run in the hospital’s gym with supervision or at the patient’s home individually, or a mix of the two. They can also be conducted via telehealth. The exercise programs are risk stratified and prescribed based on the cardiopulmonary exercise test (CPET) results from the anaesthetic assessment and results of the initial physiotherapy assessment.

‘With our assessments we’re completing standardised objective and self-reported outcome measures with these patients to assess their risk of complications with their procedure as well as their fitness,’ Jess says.

‘We also use these outcomes to decipher how intense that intervention needs to be, and also the level of supervision these patients require for exercising. These assessments are completed by the physios and EPs in the program, but for the surgical cohort they are in conjunction with the CPET results provided by the anaesthetists for risk stratification.

‘We are completing regular outcome measures with our patients; outcome measures are completed initially and then immediately pre-procedure and again at 30 days after the procedure. This allows us to monitor the results of the program and how we may need to adapt its components. The nutrition team is looking at a number of different outcomes for their patients too. We use standardised nutritional outcomes at the same time points as above.’

Jess says the plan for the next 12 months is to increase the service’s external profile and develop tools and resources to support other exercise professionals who want to introduce prehabilitation in the community.

‘I think that’s a really big gap at the moment. Many of our patients are from rural or regional Australia, and would benefit from supervised exercise programs in the community. We want to be able to create packages for these physiotherapists and exercise professions to help them deliver prehabilitation in a safe and effective manner’.

‘The main message that I’ve learnt with 12 months in the job is how important  a role physios have in prehabilitation, in exercise prescription as well as respiratory education,’ Jess says.

‘But without the multidisciplinary team, prehabilitation is just not going to be anywhere near as effective. It’s been an amazing year working with all the different disciplines involved; I think the key is having a really strong multidisciplinary team and having champions in all disciplines to make it work from the consultant level down.’ 

Jess says the results will be compared against previous care where there was no standard allied health prehabilitation, and outcome measure results will be examined in-depth to adjust the service appropriately for patients. The 12-month evaluation, now underway, will examine the program’s effectiveness and allow changes to be made to the model of care based on the findings.

The service has been attracting plenty of interest internally at the hospital as well as nationally and internationally, through the APA and at conferences. Jess says the hospital’s anaesthetists and senior physiotherapy researchers are providing expert advice about prehabilitation at conferences all over the world. ‘Now it’s wonderful that we can also include our allied health experience to that,’ she says.

‘[The service] is a massive win for Peter MacCallum Cancer Centre. It came through a lot of hard work from our leaders, from consultant level through to the researchers and our allied health director,’ Jess says. ‘I think the reason why we have such great uptake to the service is the support we have from the medical and nursing staff. Prehab is now “standard care at Peter Mac”.’

 

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