Summary
The Trust developed a bespoke outreach fibroscan and testing service for the assessment of Hepatitis C and liver disease. It is a quick, painless and non-invasive examination used to assess liver stiffness, taking between 10 to 15 minutes.
The results are immediate, allowing assessment of underlying stiffness, counselling, health education and the ongoing monitoring of improvement or progression of disease. The Liver Treatment Unit at Imperial College Healthcare NHS Trust at St Mary’s Hospital has substantial resources and an expert team which manages and cares for all forms of liver disease - and currently performs one of the largest nurse-led assessment clinics in London, reducing the need for liver biopsies. The aim is to utilise the skills and experience gained in order to expand the service to more diverse settings.
Challenge
The hepatitis C outreach services were initiated in April 2012 at North Westminster Drug & Alcohol service (NWDAS) under the umbrella of the PREVENT Project (PREvention of Blood borne Viruses through education, clinical networks, testing and treatment in substance misusing populations). LTU were providing hepatitis C treatment at NWDAS - but clients had to attend St Mary’s Hospital for the fibroscan before they started the medication. In order to bridge the gap, the first outreach fibroscan session was held at NWDAS on 16 April 2014.
Objectives
To enable clients to access to diagnostic equipment and specialist assessment in an environment in which they felt safe, while enhancing the CNWL and St Mungo’s staff to support clients within their own environment - thereby improving the treatment journey and client experience since clients could be assessed for fibrosis or cirrhosis without the need for a liver biopsy. To provide a seamless pathway from diagnosis to treatment or monitoring of liver disease.
Solution
Access to location and rooms were secured, the portable fibroscan was made available and safely transported to the clinics. In order to promote attendance at the fibroscan sessions, flyers were created and emailed together patient information leaflet to the relevant services. All clients were encouraged to attend the session in order to ascertain whether the virus had caused any damage to their liver. Fibroscan drop-in sessions were carried out in St Mungo’s Broadway Hostel (St Mungo’s): The Broadway St Mungo’s, Market Lane and The Old Theatre St Mungo’s, King Street. Central Northwest London NHS Foundation Trust (CNWL): North Westminster Drug & Alcohol Service, Hammersmith & Fulham Community Drug & Alcohol Service, Blenheim Kensington & Chelsea North Hub and Ealing RISE Southall and West hubs.
The fibroscan clinics were performed by an experienced fibroscan practitioner and clinical nurse specialist. A hepatology consultant was present, allowing clients to have a medical consultation at the same time. Clients with elevated fibroscan scores were given their results and counselled appropriately by the clinical nurse specialist and hepatology consultant. Occasionally, immediately after an elevated fibroscan clients accepted blood tests, the results of which were sent to the GP. Clients who needed follow-up appointments were offered appointments into either the cirrhosis clinic or hepatology outpatients for further management.
Results
Between February 2014 and April 2015, nine fibroscan sessions were held in seven community clinics across London: in total, 110 clients received a fibroscan within outreach clinics. All sessions were attended by clients many of whom had never previously accessed specialist services; highly positive feedback was received about these sessions. In those who had no previous fibrosis assessment, 79% of clients had minimum or no fibrosis and 21% had evidence of damage: of these, 8% of clients had moderate fibrosis, 6% of clients had severe fibrosis and 7% of had cirrhosis.
Patients are have reduced anxiety as liver biopsy is no longer required for many and even where this has been required engagement remains high as they are already familiar with the team.
Of those patients testing positive with fibroscanning for HCV in one these bespoke clinics, 29% have already accessed treatment. Treatment for is now ongoing for the majority in the same community settings within the outreach clinics, attendance to appointments and completion of the treatment course is high, which maximise their chance of cure.
Learnings
Staff and client involvement in organising and facilitating the fibroscan session was very important, with access to this programme enhanced care and information is able to be given to the clients by their key workers. Barriers between drug and alcohol services and specialist services in secondary care can be transcended to provide patients access to the care that they need and require. With the increase in portable fibroscan equipment and the introduction of more palatable medications, the ability of nurse specialists and hepatologists to treat in the local settings of those infected with hepatitis C will increase. More barriers which prevent patients attending secondary care - and therefore not gaining access to treatment or care - will be removed.
Evaluation
The success of the clinics are measured by client attendance, outcome, follow-up testing and engagement in treatment. Imperial College Healthcare participates in the ‘friends and family’ audit: patients in the drug and alcohol units attending the sessions are offered the opportunity to rate the service. Responses have all been extremely positive with no negative or poor ratings received.
