The advent of easier access to CT thorax and the desire of clinicians in UK Assessment Units and Emergency Departments to request a CTPA for most patients with chest pain and an abnormal D dimer has resulted in the rise of what could be called VOMIT (Victim Of Modern Imaging Technology) syndrome.
We are left with managing a cohort of patients with incidental findings on their imaging, the nature and implication of which is often unclear to the managing clinician and thus the patient and their family. For many patients (and clinicians) this involves trying to manage pulmonary nodules. The publication of the BTS Pulmonary Nodule guidelines has made the clinical strategy for managing pulmonary nodule(s) much easier than previously and, locally, we are very grateful for the work that went into producing such helpful guidelines. However, each respiratory service has to develop and implement a strategy to manage these patients in as clinically and cost effective manner as possible.
Given these tasks we have been running a “Nodule Virtual Clinic” (NVC) at Glenfield Hospital in Leicester for at least 5 years. The aim of this clinic is to “review” patients under follow up for surveillance of their pulmonary nodule(s) and plan ongoing management without having the patient having to endure the inconvenience of a face to face outpatient clinic attendance.
Triaging
We have a system of an initial face to face meeting to discuss what nodules “are” to the patient and their relatives and what possible pathologies may be underlying it/them. We make an assessment of their clinical performance status, their lung function (spirometry), co-morbidities and their wishes regarding potential outcomes.
For some patients with poor performance status and/or significant life limiting co-morbidities, ongoing imaging and/or clinical follow up of their incidental nodule(s) is inappropriate. In these cases we explain this to the patient and their relatives and discharge them. For those with better performance status and functionality who would be suitable for potential intervention e.g. surgery or radical radiotherapy should the nodule turn out to be malignant we follow the BTS guidelines.
Most patients prefer the convenience of the NVC but some still prefer face to face consultations for discussion of their CT results.
Process
Our NVC is formally registered on the hospital HISS system and patients are booked into the next clinic following their follow up CT scan. The NVC runs on the last Wednesday of each month, at the same time with the same administrative support re access to notes, ensuring the imaging has been delivered and formally reported as a standard face to face clinic. The NVC comprises one Respiratory Physician and one Chest Radiologist. All appropriate images are reviewed and nodule measurements are confirmed during the NVC. The images from sequential CT scans, in the context of the previous clinical history, are discussed and a clinical management strategy is agreed. An outcome letter is generated by the respiratory physician from the review, appropriate imaging is requested by the respiratory physician and is verified at the time by the Chest radiologist.
A follow up outcome is generated on the HISS system. The outcome letter is sent to the GP and copied to the patient and other relevant healthcare professional.
The NVC has an average of 8-12 patients booked in per month and usually takes no more than one hour to complete. A local tariff was agreed with commissioners to support this innovative outpatient strategy.
The feedback has been positive and it works well with the respiratory clinician and chest radiologist. We have established a systematic approach to the care of patients with Pulmonary Nodule(s) which fulfils our requirements of being consistent and clinically and cost effective.