Multidisciplinary Approach in a Peritoneal Surface Malignancy Program
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How to build a multidisciplinary team in delivering cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)
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Multidisciplinary Approach in a Peritoneal Surface Malignancy Program
- 1. { Multidisciplinary Approach in the Management of Peritoneal Surface Malignancies Mary Ondinee Manalo Igot, MD, FPCP, FPSMO Medical Oncologist / Neuro-Oncologist “NONE OF US, IS AS SMART AS ALL OF US.” 26 August 2017 Southern Philippines Medical Center
- 2. If you are not the right doctor to do a particular task, you might lose patients because of inexperience, not being up to date, and lack of foresight.
- 3. PATIENTS. AT THE HEART OF ALL WE DO.
- 4. The best way to start a peritoneal malignancy program is to have a MULTDISCIPLINARY TEAM composed of doctors, who are EXPERTS in their OWN field, who will be DEDICATED enough to give their TIME and EFFORT to the advancement of the program.
- 5. The importance of effective teams in health care is increasing due to some factors such as: (i) the increasing complexity and specialization of care; (ii) increasing co-morbidities; (iii) increasing chronic disease; Teamwork in Healthcare (WHO)
- 6. The better the members of a healthcare team are able to work together, the better they are able to provide the best quality patient care possible. Here are some ways that teamwork works in healthcare: 1. SEEKS THE SAME GOAL. 2. FOSTERS COMMUNICATION. 3. PREVENTS MEDICAL ERRORS. 4. CREATES A BETTER WORK ENVIRONMENT. Importance of Teamwork in Healthcare
- 8. The dream is to have a PSM program here in Mindanao so that we can serve more patients.
- 9. We need a group of people with diverse abilities to work though that goal.
- 10. TEAM LEAD : Colorectal Surgeon / Surgical Oncologist CO-TEAM LEAD : Another surgeon who is able to do peritonectomy HIPEC FACILITATOR : Medical Oncologist trained in HIPEC OTHER SURGEONS : Gyne Onco, HPB, urologists, TCVS ANESTHESIOLOGIST : Preferably who has handled HIPEC cases and willing to handle HIPEC cases INTENSIVIST : Pulmo or Surgical PRIMARY ATTENDING : If not one from the above SPECIALIZED NURSES : HIPEC Onco Nurse, ICU nurses PERFUSIONIST Who are the CORE TEAM MEMBERS?
- 11. Pathologist Cardiologist Infectious disease specialist Nephrologist Pulmonologist Gastroenterologist Geneticist and Genetic Counselor Palliative Care doctors and nurses Psychiatrist Stoma and wound nurse Physiotherapist Oncology nutritionist Social Services Representative / Financial Counsellor Who are the SUPPORT TEAM MEMBERS?
- 12. CLINICAL PATHWAY for CRS-HIPEC Referral for CRS- HIPEC Notify Team Lead / Medical Oncologist for eligibility screening If eligible, schedule for an MDT together with the other attendings of the patient and other relevant people Usual requirements for screening: 1. Histology 2. CT scans of the chest, abdomen, pelvis 3. Bone scan 4. Crea, AST, ALT, ECG, 2D Echo, tumor markers 5. Physical examination of the Team Lead / Medical Oncologist for functional status assessment and history
- 13. PGH : Every Thursday morning at 7AM SGH : 5PM every Thursday (for Surg Onco) 7PM every Thursday (for Colorectal) Multidisciplinary Team Conference
- 14. CLINICAL PATHWAY for CRS-HIPEC Admit patient for completion of work up and pre-op / anesthesia evaluation Pre-operative evaluation, procurement of blood, and notification of the OR and chemo infusion team CRS-HIPEC Recovery room Pre-op evaluation minimum: 1. CBC 2. PT/PTT 3. Blood type 4. FBS 5. Creatinine, BUN, Na, K, Ca, Alb, Mg 6. AST, ALT, ALP 7. TB, DB, IB 8. HBsAg, anti-HBs 9. CEA, CA-125, CA 19-9 (whichever is applicable) 10. Baseline CXR PA/L upright 11. Urinalysis and pregnancy test for premenopausal females *If the patient has a lot of comorbidities, other diagnostics can include PFT, stress test, GFR scan, HBA1C, lipid profile, FT4/TSH, etc… Blood Requirements: 4 units of PRBC HIPEC Requirements: 3 bags of 2 liters 1.5% dextrose peritoneal dialysate fluid plus chemotherapy (mitomycin, cisplatin, oxaliplatin, etc…) Additional procedures that may be done inside the OR which will require other subspecialties: 1. Insertion of a central line 2. THBSO 3. Liver resection 4. Ureteral stenting 5. Nephrectomy, etc…
- 15. For stable patients: Telemetry room for at least 1 day For unstable patients: ICU for 1- 3 days Regular room for 5-7 days Discharge Usual post-operative labs until discharge: 1. Serial CBC, creatinine, AST, ALT, Na, K, Ca, Alb, Mg 2. ABG 3. ECG 4. CXR 5. Abd xray 6. Urinalysis 7. CBG monitoring 8. CEA, CA-125, CA 19-9 (whichever is applicable) CLINICAL PATHWAY for CRS-HIPEC
- 16. HIPEC COORDINATOR : acts as a liasion for the PSM, guides and directs the patient through treatment and surveillance. Reminds doctors of schedules and coordinates with the perfusionists. Also is in charge of arranging MDT conferences. Helps with the scheduling of OR and follow-up appts. HIPEC DATABASE MANAGER : in charge of collecting data needed for research and quality purposes. In charge of calling up patients from time to time so that PFS and OS can be computed. Who are the other SUPPORT TEAM MEMBERS?
- 20. AD HOC MEMBERS : Director of the Cancer Center Chief of Surgery Chief of Oncology Other heads of relevant departments Publicity and Special Events Who are the other SUPPORT TEAM MEMBERS?
Editor's Notes
- Good morning. This is actually quite a hard topic. This is not GOOGLE-able. There is nothing on this in UpToDate. Im a medical oncologist and went to singapore to train on neuro oncology / CNS malignancies. However, CNS malignancies were grouped with GI cancers so I spent more than a year treating CNS and GI cancers in SG. I also immersed myself immensely with HIPEC, because I know that the Philippines is ready for this treatment and I can share what I learn with other doctors. So for the next slides, I will be referencing materials when I trained in Singapore. As we move further in our practice, I think that as doctors we should be humble enough to admit our limitations and be brave enough to pursue what we are good at. We should know when to refer and ask for help from other people who ARE SMARTER / MORE EXPERIENCED than us IN A PARTICULAR FIELD.
- If you are not the right doctor to do a particular task, you might lose patients because of inexperience, not being up to date, and lack of foresight. That’s why we need to train and help from other experts.
- Let us always keep in mind that our patients have families waiting for them outside the operating rooms and outside the ICU. So it will be a great DISSERVICE to our patients if we do not give them the best care and the BEST PEOPLE. This is the logo of Singhealth where I trained. And I have always put this to mind. PATIENTS. AT THE HEART OF ALL DO. And that we should all be partners in the practice of ACADEMIC MEDICINE, meaning evidence based. Always up to date.
- The best way to start a peritoneal malignancy program is to have a MULTDISCIPLINARY TEAM composed of doctors, who are EXPERTS in their OWN fields, who will be DEDICATED enough to give their time and effort to the advancement of the program. You need people who you can trust, who will HAVE YOUR BACK and who you expect to do their own tasks excellently, and who you know will do ROUNDS DAILY. Because sometimes, if you miss something on post-op day 1, that can spell all the difference already.
- Why do we need teamwork? According to WHO, he importance of effective teams in health care is increasing due to some factors such as: (i) the increasing complexity and specialization of care; (ii) increasing co-morbidities; (iii) increasing chronic disease;
- The better the members of a healthcare team are able to work together, the better they are able to provide the best quality patient care possible. Here are just a few ways that teamwork works in healthcare: Seeks the same goal: If you’re on a healthcare team, you and everyone you work with wants what’s best for the patient. Fosters communication: The team members are in constant communication. The teams that succeed the most are those when everyone knows where they’re supposed to be and what they’re supposed to be doing. Prevents medical errors: When you’re part of a team, you help your team members perform their jobs the best they can. You add your knowledge about a patient to any treatment decisions. You make certain no task is left undone and always double check your own work and the work of your colleagues. Creates a better work environment:
- When you feel like you’re a valued team member, you’re more likely to do the best work you can.
- So what is our dream? Our dream is that someday, doctors in Mindanao will also be able to offer great quality cytoreductive surgeries and HIPEC that will EXTEND LIVES OF OUR PATIENTS.
- And again, we will need a TEAM with diverse abilities to work though that goal.
- I think the key here is that you refer to the same people because the learning curve is steep.
- This is the clinical pathway I made for Asian Hospital and Ill share it with you.
- This takes time and effort. You have to vacate clinic hours and schedule later operations so that you can sit with the team and discuss cases. For me, never operate on a patient without presenting the patient first in an MDT because 2 or more eyes will ALWAYS be better than one. You might miss something, and because of that something might go wrong.