One Patient, Many Teams
In this article, Dr Anna Fowler and Dr Emilie Hoogenboom, Consultant Anaesthetists at University College London Hospitals and The Royal National Throat Nose and Ear Hospital, describe how patients with Head and Neck (H&N) pathologies can benefit from a multidisciplinary team approach to perioperative care.
First consider the following scenario, you may well have come across a similar situation in your own practice:
An elderly lady presents with left facial palsy and a lump in the left parotid region. An ultrasound-guided biopsy finds a squamous cell carcinoma of the parotid gland. The MRI scan shows a large lesion that is infiltrating the muscles. She has a past medical history of hypertension, breast cancer treated 10 years ago and a stroke 5 years ago. The multidisciplinary team decides that a a PET-SCAN is needed to determine the extent of the disease and further assessment of the patient’s general medical status and fitness for surgery is necessary. These will inform the discussion with the patient about different treatment options.
The Head and Neck Multidisciplinary Team Meeting
Multidisciplinary team (MDT) discussions ensure effective coordination of perioperative care, by providing an expert, risk-benefit assessment of treatment options and timing of surgery and an opportunity to plan, optimise and co-ordinate postoperative care, including rehabilitation. This process helps to inform discussions with patients and their families or carers, and should take into consideration patient wishes and expectations. The goal is to design individual care plans, and avoid futile interventions.
The UCLH H&N Multidisciplinary Team Meeting
The National Institute for Health and Care Excellence (NICE), provides clear guidance on the organisation of Head and Neck services, recommending that multidisciplinary teams should be responsible for every patient .
The UCLH Head and Neck Centre is a regional hub for the treatment of cancer and non-cancer conditions. The H&N MDT meeting is attended by specialists from the whole region, including a MDT coordinator, H&N surgeons, radiologists, pathologists, specialist nurses, dieticians, speech and language therapists, adult and paediatric oncologists, dentists, ward nurses and anaesthetists.
The MDT meetings aim to “share expertise, standardise care across the region and facilitate access to the information” discussed in the meeting, says Dr Emma Pelluet, Radiology Consultant.
Thanks to advances in medicine and technology, more patients present for elective or emergency surgery with complex co-morbidities, posing significant challenges for patients and their families, and for the clinicians looking after them. The case-mix includes patients with complex tumours, whose airway management may be challenging, and a significant number of patients also have associated co-morbidities. Many are smokers and have respiratory or cardiovascular disease and a poor functional status.
The MDT reviews the nature of the pathology, the imaging and the possible outcomes of different treatment modalities, taking into account the patient’s functional status, their preferences and social circumstances. Plans for the immediate postoperative care and rehabilitation as well as the initiation of enhanced recovery programmes are also discussed.
Including the patient in the decision-making process, is part of the NHS Long Term Plan’s commitment to make patient-centered and personalised care the norm across the healthcare system in the UK. The conversation brings together what the patient knows best: their preferences, personal circumstances, goals, values and beliefs, and the clinician’s expertise: treatment options, evidence, risks and benefits.
The importance of shared decision-making is reinforced by the General Medical Council. Their Good Medical Practice guidance states:
‘Whatever the context in which medical decisions are made, you must work in partnership with your patients to ensure good care. In so doing, you must listen to patients and respect their views about their health, discuss with patients what their diagnosis, prognosis, treatment and care involve; share with patients the information they want or need in order to make decisions; maximise patients’ opportunities, and their ability, to make decisions for themselves; respect patients’ decisions.’ 
This statement is echoed by the Nursing and Midwifery Council and the Health and Care Professions Council.
It is important to allow sufficient time for the patient to reflect on the risks and benefits of their treatment, get answers to their questions and have a full and frank discussion regarding their concerns. Decision making is easier in the immediate preoperative, intraoperative and early postoperative period when such conversations have occurred in advance and have been clearly documented.
The H&N Anaesthetic Preoperative Assessment
Anaesthetic Preoperative Assessement Clinic
If surgery is a treatment option, the patient is referred to the H&N anaesthetic preassessment clinic. This is led by a consultant anaesthetist with a clinical nurse specialist and runs in parallel with the H&N surgical outpatient clinics, so patients with complex issues can be assessed by both specialities together and shared-decision making is possible.
The consultation follows the principles and structure of anaesthetic preassessment as outlined in the RCoA “Guidelines for the Provision of Anaesthesia Services for Preoperative Assessment and Preparation 2019”, and the “Guidelines for the Provision of Anaesthesia Services for ENT, Oral Maxillofacial and Dental surgery 2019 and includes taking a full history, examination including an airway assessment, a review of investigations and discussion about patient wishes and expectations.
In Theatre: Multidisciplinary Airway Management in Action
Team Brief on the Day of Surgery
In The 4th National Audit Project (NAP4) 72 (39%) of reported cases involved an airway problem in association with an acute or chronic disease process in the head, neck or trachea. Approximately 70% of these reports were associated with obstructed airways. When difficulty occurred the transition to a surgical airway performed by the surgeon, was often delayed. The report recommends that in patients with increased risk, airway investigations should be reviewed jointly by the surgeon and anaesthetist. We should think about anaesthetising complex H&N cases in the operating theatre, and for a surgeon to be immediately available in case of difficulties.
It is vital that on the day of surgery, a full team brief takes place. The airway management strategy, including plans for failure and plans for extubation and recovery, are reviewed and discussed with the whole team, anaesthetists, surgeons, ODPs and scrub nurses, immediately prior to the procedure.
Teamwork and clear communication are very important in all cases where a procedure with a shared airway is planned.
Sharing the Airways during Bronchoscopy
The development of an airway management strategy, as we discussed in Week 2, is based on all of the above should consider the skill mix of staff, the available equipment and the environment where the airway will be managed. A particular focus in management of the shared airway is the essential co-operation between anaesthetic and surgical team, especially when difficulties are expected, and we will explore this in more detail in the next step.
- NICE Guideline: Improving outcomes in head and neck cancers
- General Medical Council – Good Medical Practice (2009)