Although the advent of rapid access secondary care services has shortened the wait to timely diagnosis in lung cancer, significant delays and congestion can still occur through patients needing to attend clinic before appropriate investigations are organised.To circumvent this, with primary care colleagues we designed a “straight to CT” system where if a general practitioner is concerned about a patient, or a chest X-ray in the community or emergency department shows suspicious changes, the radiology department automatically offers the patient a CT scan to be performed within 72 h with a same day report. This allows the primary care clinician to reassure patients with normal scans, or where necessary direct appropriately patients with scans showing non-malignant abnormalities. Patients with scans showing possible malignancy are intercepted by the lung cancer team who then organise appropriate further management.We replaced our one stop rapid access lung cancer clinic with this new service in January 2014 and have now reviewed its use one year on.468 patients from the local community were eligible for the “straight to CT” service. Of the 246 with a coded X-ray, 222 underwent a 72-hour CT scan (18 of the reminder declined or were not contactable), and of these 127 (57%) showed suspicious abnormalities and were intercepted by the lung cancer team. Of the 222 referred by a concerned clinician, 177 underwent a 72-hour scan (of the remainder 19 were not contactable or declined and the rest were deemed inappropriate) and 60 of these (34%) showed suspicious changes and were intercepted by the lung cancer team. Overall, 401 72-hour scans were performed in 2014: this is similar to the number of scans performed (402) in 2013 using the traditional rapid access clinic model.As well as empowering primary care, by preventing unnecessary clinic attendance this innovative service has significantly reduced costs and by bringing forward investigations has reduced the lead time to diagnosis (to a mean of 19 days) in our patients. Furthermore, fears that such a service might increase unnecessarily the number of CT scans performed have proved groundless.We recommend the use of such a service to colleagues to aid timely and economical investigation of patients with a suspected diagnosis of lung cancer.

In order to speed up the diagnostic pathway, in January 2014 we set up a “straight to CT” service for patients with suspected lung cancer from primary care, where positive scans undergo immediate chest physician review to decide the next diagnostic test and a lung cancer nurse specialist (CNS) offers the patient a telephone assessment to plan this. We have looked at the utility of this “virtual clinic” in the management of our patients with lung cancer over the first 2 years, in particular paying attention to patient uptake and satisfaction, and outcomes.Of about 300 patients annually who have been triaged in this way, 82% have chosen the virtual clinic, 13% preferred or the CNS advised a outpatient appointment, 4% required immediate inpatient referral, and the remaining and 1% were referred back to the GP as outpatient intervention not felt appropriate (too unwell). Overall, 75% subsequently were diagnosed with lung cancer.For those patients who chose the virtual clinic consultation, feedback has been overwhelmingly positive. This has been captured qualitatively at the time and at subsequent events e.g. patients report feeling well informed and supported, and quantitatively by an ongoing survey: 98% prefer the telephone clinic versus clinic appointment, 97% felt prepared for next test.This study has shown that performing a number of diagnostic investigations using a telephone support is not only feasible but preferred by patients with suspected lung cancer. By avoiding unnecessary clinic attendances it improves patient convenience, speeds up the diagnostic pathway and reduces unnecessary costs. This early CNS assessment and interventions reduces the level/scope of patient concerns prior to the time of diagnosis, this has further significance to the team formalising the Holistic Needs Assessment process.CNSs are best placed to do the consultations as they have the specialist skills and knowledge of the local clinical pathways, tests, disease symptomology and ultimately provide the continuity throughout the diagnostic pathway through to treatment and we recommend this to other cancer units.

Introduction Lumbar puncture (LP) is part of the neonatal septic screen. A cerebro-spinal fluid (CSF) red blood cell (RBC) count of <500 is required to accurately interpret the CSF white cell count.1 Up to 50% of neonatal CSF samples are blood-stained, with increasing incidence in pre-term infants.2 Mid spinal canal depth (MSCD) varies significantly between neonates of different weights.3 In adults ultrasonically determining the MSCD increases success rates.4 A recent study described a formula to estimate MSCD in neonates.3 Aim To determine if calculated MSCD improves LP success rates. Methods A prospective audit. LPs were performed without and with prior calculation of MSCD. In our primary analysis, a successful tap was defined as CSF obtained with <500 RBCs on cell count. Secondary analysis defined success as obtaining a sample suitable for culture. A multiple regression logistic model was used. We report OR (95% CI). Independent variables were gestational age, weight, operator seniority and whether MSCD was estimated. A 5% level of significance was used. Results Results summarized in table 1; OR compare chance of success with new technique to chance of success without. Abstract PF.20 Table 1Details of results by technique and outcome measure MSCD Total LPs Successful LPs Primary outcome OR (95% CI) Samples for culture Secondary outcome OR (95% CI) No 25 13 0.25 (0.06 to 1.05; p=0.06) 22 0.34 (0.07 to 1.61; p=0.17) Yes 19 5 14 MSCD, mid spinal canal depth; LP, lumbar puncture. Discussion Although neither primary nor secondary results were significant, both showed a trend to decreasing success rates. We show no evidence that estimating MSCD improves success rates, but suggest it may be detrimental. The reason for this is unclear. A randomized trial is required.

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