SMART issue 1

The

S.M.A.R.T Journal

Students for Medical Audits, Re-search & Teaching

___________ The S.M.A.R.T

Journal

Editor: Christopher Taylor (5th year student

intercalating in MRes

Neuroscience)

Others: All Team Members

Associated

Societies:

Newcastle University

Medical Education Society

Newcastle University

Academic Medicine

Society

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What is S.M.A.R.T? pg 3

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How to use this Journal pg 5

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How to complete an Audit pg 7

Our Audit of the Month pg 9

Audit Fact Sheet pg20

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Human Evolution Pullout pg21

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Research—Is it for you & how to get started pg23

Research Project of the Quarter pg25

Research Fact Sheet pg27

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Body Tricks pg28

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Medical Education—a society’s view point pg29

Speciality in Focus pg31

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Book Review pg33

Horses & Zebras—when you hear hoof beats pg34

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Our Guinea Pig Column pg36

A word from our Editor:

I would like to express many thanks to all members of the team for contribut-

ing to this issue and hope that you find this journal essential during your stud-

ies. Providing you with examples of how audits & research projects are done.

What you can do in your Medical School and the hard work many students put

into their societies.

CONTENTS

Visit www.students.ncl.ac.uk/christopher.taylor2

Visit www.students.ncl.ac.uk/christopher.taylor2 Students for Medical Audits, Research and Teaching Journal

The

S.M.A.R.T Journal

Students for Medical Audits, Research & Teaching

SMART is created by medical students for medical students and aims to help students publish

their work in a widely read and respectable journal. I accumulates the knowledge and experi-

ence of medical students in Medical Audits, Research and Teaching.

The audits provide a chance for students to get their work published in a national journal that

can be read by peers and professionals alike. Medical Audits are an expected skill of a junior

doctor, by collecting and learning from others work students can get a feel for what a good au-

dit consists of covering various fields, providing essential grounding in audts and reviewing

journal articles

Research allows students to learn about cool new facts and interesting research at the front of

its field. It will demonstrate to students how to get invoelved in research, how to get the most

out of a placement and get publsished...

Medical Teaching is something every medical student should know about. It effects how a stu-

dent learns, their attitude to education and something which they must themselves experience.

Many medical students leave medical school with no idea how to teach, yet this is an expected

skill of a junior doctor,. As any medical student will tell you there are good teachers and bad

teachers and by sharing students experiences they can collect and learn from these and take

them with them into their future careers.

Christopher Taylor

S.M.A.R.T.


How did SMART come about?

As a medical student in my fourth year at Newcastle Upon Tyne I was asked to do an audit as

part of my 1st Student Selected Component. I had a brilliant tutor who helped me develop an

audit project from previous years audits and aim for a project that was publishable.

During my time I heard of many colleagues audits being delayed or relatively small, partly due

to the motivation / training of the tutor and partly the audits available.

As a result I have included my audit as an example case to demonstrate what a student is able

to do during a six week project and produce something that is important and hopefully pub-

lishable.

During a long train journey to a conference in Edinburgh I was running through concepts for

Graphics and Projects to do for the societies I was part of. As a result my mind wandered back

to my audit and the time / effort it was taking to write it up (in contrast to the poster we had

presented). It struck me that there were several journals out there that allowed students to pub-

lish small articles and present them with interesting materials but there was nothing to help

students get their work published. As a result this journal took shape in my mind and with a

little fun with Graphics and a days work in my Reading week this first concept issue was de-

veloped to provide a basis for future projects.

I hope you enjoy reading this journal, bearing in mind it is a concept journal and that the full

range of possibilities available from this journal will come when a team is recruited :D


How to use this Journal

This Journal is divided into several key parts: Introduction articles - key learning articles / points of interest

Audit projects - audit of the month & a useful peer review (from the team)

Also scope for contributions from the Medical School

Research projects - project of the month & a useful peer review (from the team)

Also scope for contributions from Academic Medicine Society

There will be some non-curricular articles / fun articles to break the continuity and help improve stu-

dents ‘wider’ knowledge & maybe stimulate interests…

Also scope for contributions from Other Medical Society [surgical, wilderness, Skip]

Medical Education / Teaching - projects from within medical education, reviews of teaching styles,

what lectures/projects students like vs. dislike...

Also scope for contributions from Medical Education Society

There will be articles looking at different specialties to help students make more informed choices for

future careers

Book reviews will highlight interesting / controversial / fun books for readers

Horses and Zebras aims to be a 1-2page article on a single common condition and uncommon condi-

tions to keep students ‘in the know’

The Guinea Pig column will be posts from our Facebook & Twitter pages about what’s important to you

How to use


How to use this Journal

This Journal is divided into several key parts: Introduction articles - key learning articles / points of interest

Audit projects - audit of the month & a useful peer review (from the team)

Also scope for contributions from the Medical School

Research projects - project of the month & a useful peer review (from the team)

Also scope for contributions from Academic Medicine Society

There will be some non-curricular articles / fun articles to break the continuity and help improve stu-

dents ‘wider’ knowledge & maybe stimulate interests…

Also scope for contributions from Other Medical Society [surgical, wilderness, Skip]

Medical Education / Teaching - projects from within medical education, reviews of teaching styles,

what lectures/projects students like vs. dislike...

Also scope for contributions from Medical Education Society

There will be articles looking at different specialties to help students make more informed choices for

future careers

Book reviews will highlight interesting / controversial / fun books for readers

Horses and Zebras aims to be a 1-2page article on a single common condition and uncommon condi-

tions to keep students ‘in the know’

The Guinea Pig column will be posts from our Facebook & Twitter pages about what’s important to you


How to do an Audit

Explain the Audit cycle: Get across the key messages

Interests

Do’s

Don’ts

How to create a poster

How to get published

Audit Cycle



Introduction

A retrospective re-audit of the role of Neuro-oncology Special-

ist Nurses as Key Worker in the care pathway of suspected

brain tumours

C TAYLOR, PJ KANE, V MCGOWAN, G HENDRY, J MCKEE, M STAUSS

Abstract

Guidance published by the National Institute for Clinical Excellence states that all patients should have an

identified Key Worker, normally the Neuro-Oncology Specialist Nurses (NOSpN), who are present at key

stages of the patient care pathway to provide continuous care and coordinate other Health Care Professionals

(HCPs). The patient should also be provided with contact details and literature regarding treatment/diagnosis.

Assess the NOSpNs involvement in the management of all patients with suspected brain tumour.

Data was collected retrospectively from all new patients’ nursing notes from 01/01/2010 to 31/12/2010 us-

ing a trialled pro-forma and compiled on Microsoft Excel for analysis. The previous audit, with a single

NOSpN, showed 66% of all patients; 87% of High Grade Gliomas and 53% of other tumour types had Key

Worker/NOSpN involvement. This audit shows 89% of all patients, 94% of High Grade Gliomas and 86%

of all other tumour types had Key Worker/NOSpN involvement. Low Grade Gliomas had the highest aver-

age number of contacts with patients and HCPs. Of 169 patients; 37% received contact details, 14% re-

ceived literature about their diagnosis, 14% received post-treatment literature and 12% received a follow

up call. A second NOSpN has led to a 23% increase in Key Worker/NOSpN involvement. Documentation

needs to change to follow NOSpN team dynamics and gap analysis performed on low input cases. Re-audit

in 12 months.

Primary brain tumours originate from the brain tissue

itself, they cause a range of symptoms and have asso-

ciated morbidity and mortality with malignant tu-

mours having a 5 year survival rate of 15.7% men and

17.9% women. Primary brain tumours account for

1.6% of cancers in England and Wales and have an

incidence of 8.0/100,000 for men and 5.6/100,000 for

women in the UK1.

Primary brain tumours have various pathologies de-

pending upon their cell type of origin, examples in-

clude; gliomas, meningiomas and pituitary adenomas

and are classified according to WHO guidelines.

Typical symptoms include headaches, epilepsy, neuro-

logical changes and cognitive / behavioural changesi.

Due to the wide range of complications experi-

enced by patients a multidisciplinary team (MDT) is

commonly established within a Neuroscience depart-

ment to provide specialist centred care. This relies on

many healthcare professionals (HCPs) to ensure a ho-

listic service is given to each patient and typically in-

volves Neurosurgeons, Oncologists, Specialist Nurses,

Neuropsychologists, Occupational Therapists, Speech

and Language Therapists and the patient’s G.P. These

HCPs may be distributed over several sites and com-

munications may become disjointed and uncoordi-

nated.

Guidance published by the National Institute for

Health and Clinical Excellence (NICE) recommends

that a Key Worker should be assigned to each patient

throughout their care pathway [Figure 1] to provide

coordinated and high quality care1,. This responsibility

may be taken on by any member of the MDT through

the patient’s care pathway; however, it is typically

taken on by the Neuro-oncology specialist nurses

(NOSpNs).

The NOSpN / Key Worker provide several im-

portant services: they coordinate all the services and

HCPs to personalise an individual’s care and support

any needs from the family. They act as a central figure

for all HCPs to communicate with using knowledge

and experience to support any complications the pa-

tient meets throughout their care pathway4.

AUDIT


This article looks at the affect hiring a second

NOSpN has on a single Neuroscience Department at

James Cook University Hospital, Middlesbrough,

South Tees Hospitals Trust, United Kingdom.

Method

One hundred and sixty nine patient’s records were

examined in a cross-sectional retrospective casenote

review as part of an audit registered within the Trust

Audit Department. These patients were all initially

referred to a single Consultant Neurosurgeon with

suspected brain tumours between 1st January and 31st

December 2010. During this time there were two

NOSpNs working whereas the previous audits and

before July 2009 there had only been one NOSpN in

the department.

A proforma was developed for data collection and

piloted on 10 random patients successfully. The in-

formation was recorded from patient nursing records,

NOSpN referral books and E-records/referral letters

and was compiled and analysed using Microsoft Of-

fice Excel.

Information was collected on recorded Key Worker

assignment and if the NOSpNs were present at the

key points of the Patient Care Pathway [Figure 1].

Patients were then divided into several categories:

High and Low Grade Gliomas, Meningiomas, Pitui-

tary Adenomas, Metastases, Other Cancers

(tumours not previously mentioned) and

‘Others’ (non-intracranial/CNS tumours at diagnosis

despite suspicion at referral).

Patients were excluded if they had been referred be-

fore 1st January as the second NOSpN was only hired

in July 2009 and previous audits had already included

those patients looking at the role and workload of a

single NOSpN. Other patients referred to the Con-

sultant Neurosurgeon were also excluded as they

were not referred with suspected brain tumours.

Information was also collected on whether

the NOSpNs provided contact details, literature

regarding diagnosis, literature regarding treatment,

if they made a follow-up phone call for support

and treatment coordination and the number of con-

tacts made to different HCPs. This was to assess if

there was a change in the workload and role of the

Key Worker after hiring a second NOSpN.


Figure 1:

AUDIT


Table 1: Patient Demographics Age

18-29 30-39 40-49 50-59 60-69 70-79 80+

Tumour Categories High Grade Glioma Low Grade Glioma Pituitary Adenoma Meningioma Metastases Other Cancers ‘Others’

Male:Female ratio

5:7 5:10 11:16 14:21 25:18 10:17 5:5

Number of Patients

50 (30%) 14 (8%)

24 (14%) 40 (24%) 12 (7%) 12 (7%)

17 (10%)

All patients referred to the Consultant Neurosur-

geon with primary brain tumours were included in

this study [n=169].

There were 75 men and 94 women included in the

audit with a mean age of 56 years. The most com-

mon tumour type recorded was High Grade

Glioma, followed by Meningioma and Pituitary

Adenoma [See Table 1]. Other Cancers of the brain

and central nervous system (CNS) and Metastases

were the least common

Guidelines published by NICE state that all pa-

tients (100%) with suspected brain tumours should

be assigned a Key Worker who must be present at

all stages of the patient’s care pathway.

Results

Table 2: Involvement of Key Worker at important stages of care pathway

Total Number of Contacts

High

Grade

Glioma

Low Grade

Glioma

Pituitary

Adenoma

Menin-

gioma

Metasta-

ses

Other Can-

cers ‘Others’ Total

NOSpN involve-

ment 47 14 20 32 11 12 14 150

Key Worker

Assigned 31 8 9 10 4 4 0 66

Initial Consulta-

tion 46 13 18 29 10 12 14 142

Diagnosis 45 14 19 29 10 11 13 141

Treatment Dis-

cussion 46 13 19 24 10 11 13 136

Post Treatment

Review 30 10 8 8 9 7 1 73

NOSpN involvement per number of patients in each tumour type

High

Grade

Glioma

Low Grade

Glioma

Pituitary

Adenoma

Menin-

gioma

Metasta-

ses

Other Can-

cers ‘Others’ Mean

Initial Consulta-

tion 0.92 0.93 0.75 0.73 0.83 1 0.82 0.85

Diagnosis 0.9 1 0.79 0.73 0.83 0.92 0.76 0.85

Treatment Dis-

cussion 0.92 0.93 0.79 0.6 0.83 0.92 0.76 0.82

Post Treatment

Review 0.6 0.71 0.33 0.2 0.75 0.58 0.06 0.46

Average 0.84 0.89 0.57 0.67 0.81 0.86 0.60 0.75


Between July 2008 and June 2009 when there was

only one NOSpN in the Neuroscience Department

during a previous audit showed that only 66% of pa-

tients had an assigned Key Worker.

Between January and December 2010 a second

NOSpN had joined the department. Table 2 demon-

strates that 150 patients (89%) had a NOSpN in-

volved at least once through their care pathway but

only 66 patients (39%) had an assigned Key Worker.

Low Grade Gliomas have the greatest input (89%)

from the NOSpNs, followed by High Grade Gliomas

and Other Cancers of the brain and CNS, with

‘Others’ (initially suspected as brain tumour) show-

ing the least amount of input. Table 2 also shows that

a patient with suspected brain injury, on average, is

likely to meet the NOSpN through only 75% of their

care pathway.

Figure 2 shows that overall all tumour types are

receiving similar levels of input from the NOSpNs

Table 3: Services provided by Key Worker throughout patient’s care pathway

Total of services provided per number of patients in each tumour type

High

Grade

Glioma

Low

Grade

Gliom

a

Pituitary

Ade-

noma

Menin-

gioma Metastases

Other

Cancers ‘Others’ Mean

Contact

Details

Provided

0.67 0.64 0.29 0.18 0.17 0.33 0.06 0.33

Litera-

ture Pro-

vided

0.37 0.14 0.13 0 0 0.08 0 0.1

Phone

Call

Made

0.27 0.07 0.08 0.05 0.08 0.17 0 0.1

Post

Treat-

ment

Litera-

ture Pro-

vided

0.27 0.21 0.8 0.05 0 0.33 0 0.13

AUDIT


High Grade Gliomas are documented as receiving

more contact details, phone calls and literature re-

garding diagnosis or treatment options than any other

tumour group. Other Cancers of the brain and CNS

received the second most services while Metastases,

Meningiomas and ‘Others’ received the least levels

of services from the NOSpNs [Table 3].

Table 4 demonstrates that patients with Low Grade

Gliomas required the greatest average number of

contacts throughout the patient care pathway with

Pituitary Adenomas and ‘Others’ receiving the least.

On average the NOSpNs contacted Healthcare Pro-

fessionals (HCPs) (5.09) almost as often as the pa-

tient (4.84).

Table 4: Average number of contacts made by NOSpN through patient care pathway

High

Grade

Glioma

Low

Grade

Glioma

Pituitary

Adenoma

Meni

n-

gioma

Metastases Other

Cancers

‘Others

’

Mean

with

Patient 8.95 9.64 1.96 3.13 5.25 5.33 1.39 5.09

with

Any

Carers

3.67 1.36 0.25 0.40 0.42 0.67 0 0.97

with

HCPs 6.80 8.64 2.71 4.10 3.50 5.75 2.39

4.8

4

Table 5: NOSpN contacts with HCPs

HCP Sum Range Mean % of Total

Neurosurgeon 467 0-9 2.92 56%

Oncologist 114 0-4 1.48 14%

G.P. 103 0-5 1.63 12%

Neuropsychologist 53 0-3 1.13 6%

Speech and Language

Therapist 27 0-2 1.04 3%

Occupational Therapist 11 0-2 1.22 1%

Neuroscience SpN 5 0-2 1.25 1%

District Nurse 20 0-5 1.43 1%

Community Macmillan

Nurse 13 0-2 1.3 1%

Social Worker 9 0-4 2.25 1%

Physiotherapist 3 0-1 1 1%

Epilepsy SpN 4 0-2 1.33 1%

Neurologist 3 0-1 1 1%

Endocrinologist 5 0-1 1 1%


The Neurosurgeon is the main point of contact for the

NOSpNs with up to 9 contacts throughout each pa-

tient’s care pathway, making up over half of all con-

tacts made. The NOSpNs also make numerous con-

tacts with the Oncologist (mean 1.48) and patient’s

General Practitioner (mean 1.63). Table 5 also shows

that the NOSpNs contacted 14 different Healthcare

professionals 829 times, mainly contacting the Neu-

rosurgeon, Oncologist, patient’s G.P., Neuropsy-

chologist, Speech and Language Therapist and Occu-

pational Therapist from the Neuroscience Depart-

ment’s MDT.

In a previous audit between July 2008 and

June 2009, when there was one NOSpN present,

the number of liaisons with HCPs was measured

for High Grade Gliomas. Figure 3 compares this

data with the number of liaisons made for High

Grade Gliomas between January and December

2010 with two NOSpNs present.

Discussion

Primary brain tumours are more common in patients

aged 50-70yrs5 with the highest incidence at 75-

79yrs1. The tumour types most commonly seen per

annum are High Grade Gliomas (3550) followed by

Meningiomas (812), Pituitary Tumours (690) & Low

Grade Gliomas (520)1. A similar patient demographic

is represented in this study with peak incidence at 60-

69yrs and tumour types following the same distribu-

tion [Table 1].

As data was collected retrospectively it was

expected that some eligible patients could have been

missed, however, due to the inclusion criteria only

patients not referred as primary brain tumours were

excluded. Hence no patients newly referred with sus-

pected primary brain tumours will have been ex-

cluded.

Guidelines published by NICE state that all pa-

tients with suspected brain tumours should be as-

signed a Key Worker. From 169 referrals only 66 pa-

tients (39%) had a documented Key Worker, which

does not meet NICE standards. 150 patients (89%)

had the NOSpNs involved in their care at least once,

which demonstrates a lack of documentation by the

NOSpNs. After observing the team dynamics and

discussions with the NOSpNs it was apparent that

they both acted as the patient’s Key Worker, thus

documenting a single NOSpN was not appropriate

and their actual involvement was under represented.

Hence, NOSpN involvement was examined more

than documented Key Worker involvement.

This results from when a single NOSpN was

present before June 2009 when the Key Worker was

always the NOSpN, however, with two NOSpNs pre-

sent it is more appropriate for both to work as a team

to coordinate communications with the patient and

HCPs throughout the patient care pathway. In con-

trast to a previous audit between July 2008 and June

2009 where only 66% of patients were assigned a

Key Worker / had NOSpN involvement, this demon-

strates an improvement of 23%. This is represented

in Figure 4.

AUDIT


Figure 4: Comparison between One NOSpN and Two NOSpNs on Key

Worker Involvement

NICE guidelines state that assigned Key Workers

should be present at all key stages throughout the pa-

tient’s care pathway [Figure 1] for all referrals of sus-

pected brain tumour. Of the 169 patients 16% were

not seen at the Initial Consultation, 17% at Diagnosis,

20% at Treatment Discussion and 57% were missed

at the Post Treatment Review [Table 2].

This partly reflects the Neurosurgeon’s consultation

style; direct observation showed that during the ini-

tial referral the Neurosurgeon often deferred exami-

nation in favour of extended discussion of Diagnosis

and a Treatment Review, often with the Oncologist

present. As a result the NOSpNs were present at sev-

eral key points in one instance.

It may also reflect the management options

for different tumour types, where some only re-

quire observation with others needing biopsy, de-

bulking and radio/chemotherapy. This audit is also

a snapshot of workload of the NOSpNs between

January and December 2010 so it is important to

consider that some patients may not have reached

the point in their care pathway to allow for a Post

Treatment Review. There is still a significant de-

cline in NOSpN involvement towards the end of

the patient care pathway that still needs to be ad-

dressed.


AUDIT

References:

1. Improving Outcomes for People with Brain and Other CNS Tumours, National

Institute for Health and Clinical Excellence, NICE Guidance on Cancer Services,

London, June 2006. http://guidance.nice.org.uk/CSGBraincns

2. Quinn M, Babb P, Brock A et al. (2001) Brain. Cancer trends in England and Wales

1950–1999: studies on medical and population subjects No. 66. London: The Stationery

Office, p34–9.

3. Kleihues P, Cavenee WK (2000) Pathology and genetics of tumours of the nervous

system. Lyon: IARC Press

4. Excellence in Cancer Care: The Contribution of the Clinical Nurse Specialist National

Cancer Action Team. National Cancer Programme, 2010 Macmillan Cancer Support

5. The Brain Booklet (2010), Brain and Spine Foundation 2010,

www.brainandspine.org.uk

Audit Facts


AUDIT FACTSHEET

Neurosurgeon—job description

Neuro-Oncology Nurse Specialist—job description

Primary Brain Tumour—disease aetiology

Glioma—

Meningioma—

Pituitary Adenoma—

Astrocytoma—

Dendocytoma—

Oligodendrocytoma—

Metastases—

What this Audit did well

Further Questions

What you can take away from this audit


PULL-OUT



RESEARCH



RESEARCH



RESEARCH

Research Fact


Research FACTSHEET

Neurosurgeon—job description

Neuro-Oncology Nurse Specialist—job description

Primary Brain Tumour—disease aetiology

Glioma—

Meningioma—

Pituitary Adenoma—

Astrocytoma—

Dendocytoma—

Oligodendrocytoma—

Metastases—

What this Audit did well

Further Questions

What you can take away from this audit


FUNNY

Education



Visit

www.students.ncl.ac.uk

/christopher.taylor2

Education


Visit

www.students.ncl.ac.uk

/christopher.taylor2


CAREERS

BOOKS



Horse/Zebra

Guinea Pigs


THE END

SMART issue 1

Documents

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medical teaching

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