PenCHORD - Streamlining the bladder cancer pathway at RCHT

South West PeninsulaCancer
Start Date: 18 Feb 2016


The pathway for muscle-invasive bladder cancer pathway patients at Royal Cornwall Hospital is relatively straightforward, but contains numerous delays.  Some delays relate to waiting times for referrals to Derriford Hospital for surgery, but there are also significant delays before this stage, and the collaborators would like to reduce their own delays by looking at the potential benefits of pre-alerts and joint clinics within the pathway.  The reduction of delays could potentially save lives for patients with this time-critical condition.

Project aims and activity

The aims of the project are to answer the following questions:

  1. Where are the bottlenecks within the pathway for muscle-invasive bladder patients at Royal Cornwall Hospital?
  2. How could the introduction of joint clinics and methods to pre-alert specialists to test results reduce delays within the system?

The project will involve the following key steps:

  • A process mapping session to determine the nature of the system to be modelled, and generate discussion to identify “what if” scenarios
  • Conceptual model to be developed from the process map
  • A Discrete Event Simulation model of the current system to be built using Simul8
  • Exploration of “what if” scenarios (including the introduction of a joint clinic to pre-alert) to determine impact on time spent in system (and particularly time between TURBT and delivery of definitive treatment or referral to Derriford for surgery)

Expected outputs and impact

The results of the modelling project will outline the predicted reduction in time from referral to definitive treatment for patients with muscle-invasive bladder cancer. These results will then serve as a motivation to encourage those involved in the pathway to facilitate necessary changes.

This project has potentially significant impact, because the results would be used to inform the redesign of the muscle-invasive bladder cancer pathway at Royal Cornwall Hospital, which could save lives if delays are consequently reduced. We intend to work with the collaborators after any changes have been introduced in order to analyse the muscle-invasive bladder cancer patient data to see if there has been a reduction in time spent in system following the changes.

There is huge research potential from this project, particularly if the impact is significant.  We aim to co-author a paper with the collaborators for publication within a high impact-factor clinical journal.

There is also significant media interest in this area, and the collaborators are keen to publicise the project and the results of our collaboration.

The approach used here could also potentially be rolled out to other sites in the South West. The collaborators also hope to use the evidence generated from this project to discuss with Derriford Hospital the potential gains from reducing delays in referrals for surgery for RCHT muscle-invasive bladder cancer patients (which could, in turn, lead to a further PenCHORD project working with Derriford to reduce their delays). In addition, the collaborators are very keen to pursue a follow-on project that would look at optimising chemotherapy scheduling.

Current activity

After a meeting with consultants and urologists from the Royal Cornwall Hospital to discuss initial results from the bladder cancer model, two new ideas arose:

1) To fast-track suspected muscle-invasive patients to the TURBT test (which is where the biggest delay is currently).

2) To get specialist nurses to speak to the patient about their diagnosis whilst they’re on the ward on the same day as their TURBT (currently there is a delay as patients wait to be contacted by phone). 

Once these changes were put through the model it was predicted, if implemented, that there would be a 5.5 week reduction in the time from referral to treatment for muscle-invasive bladder cancer patients - representing a 35% reduction in the time a patient spends in the RCHT system.

These initial findings resulted in Mark Mantle, Cancer Lead for Urology writing a protocol for suspected muscle-invasive patients based on the modelling evidence.

Following on from this, data will be collected from the Royal Cornwall Hospital which will allow the PenCHORD team to analyse the impact of these changes to their system to determine the actual extent of the reduction in time from referral to treatment.

Dr Daniel Chalk