Fine Needle Aspiration Cytology (F.N.A.C) administered by Nursing staff in TMHACC Breast Clinic

S Y Wong, W Y Lam, Y L Wong,

C C Woo, C L Ip, K M Ma, W T Wong,

9th May 2006

Prepared by:

屯门医院Tuen Mun Hospital

医院管理局

HOSPITALAUTHORITY

1152 12661347

1533 1608 16511787

1918 1997 2059 2106

0

500

1000

1500

2000

2500

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Female Breast Cancer Figures (1993-2003) New Cases Registered

Hong Kong Cancer Registry, Hospital Authority (Aug 2005 updated)

Background

BackgroundIn year 2004, about a million people lived in NTWC.

7600 cases (included 2100 new cases) attended Breast Clinic.

700 cases were suspicious for breast neoplasm and referred to PI for FNAC.

106 cases was diagnosed malignant in NTWC.

Triple Approach of Diagnosis

HKMJ Vol 2 No1 March 1996

Clinical findingse.g. Physical examination, Family hx, High risk gp.

Imaging resultse.g. Mammography, Ultrasound breast

Cytology e.g. FNAC, biopsy

Preliminary Ix

Useful and important means ofpre-op dx

Role of FNAC

HKMJ Vol 2 No1 March 1996

Advantage of FNAC

SimplicityLess invasive procedureWell-tolerated by patientsHigh diagnostic rate

HKMJ Vol 2 No1 March 1996

To facilitate the breast team for early diagnosis of breast cancers

To shorten the FNAC waiting time

To alleviate patient’s anxiety

To reduce operational cost

To widen horizon of nursing practice

Objectives of Nurse led FNA Project

Set up process

At the end of 2004, meetings were launched by breast surgeon, pathologist and nurses for the planning of FNAC projects. Details are as follows:

Seek legal advise and accreditation

Goal setting Design training course Set up project logisticsPrepare for room supplies and instrumentContact other departments for details of cooperation

Training

20-hours theoretical learning module4-days supervised practical trainingLecture of Dx and Mx in Ca Breast Individual evaluation scheme

Logistics of FNAC procedure performed by nurse

in Breast clinic, ACC, TMH

SettingsI

Logistics

InstrumentsII

Logistics

Interview III

Logistics

Patient’s position

IV

Logistics

Logistics

Breast lesion identification

V

Logistics

FNAC techniqueVI

Plastic breast model

Tissue Smear

Logistics

VII

Specimens

VIII

Logistics

BREAST FNA PROFORMA1. Laterality of lesion

Right breastLeft breast

2. Location of lesion: o’clock3. Size of lesion: mm4. Clinical characteristic of lesion

a. DistinctivenessSolitary & discreteVague lesionLumpiness

b. ConsistencyCysticSolid & softSolid & hard

c. Tumor edgeCircumscribed & sharpInfiltrative & poorly defined border

d. MobilityMobileFixed Skin tethering

5. Characteristic of aspirated materialPinkish tissue Purulent material Bloody aspirate Clear fluid Mucoid aspirate Cloudy fluidMilky Turbid fluidFatty oily tissue

6. Specimen submittedWet fixed smears ( x)Air-dried smears ( x)Cytospin fluidFormalin fixed tissue for cell block

Our breast FNA proforma form

R L

IX

Logistics

X

Logistics

Normal breast

The Internet Pathology laboratorySource from PI

Logistics

Lobular carcinoma in situ (LCIS)

The Internet Pathology laboratory

Intraductal carcinoma

The Internet Pathology laboratory

XI

Sources of the Referred Cases in 423 cases15th Mar 05 ~ 31st Mar 06

*All cases are referred by Breast Clinic

Old cases152(36%)

GP55(17%)

A&E28(9%)

New cases271(64%)

Other medicalinstitution44(14%)

GOPD/DH89(27%)

Results

Percentage of Diagnostic Categories in FNAC Results (15th Mar 05 ~ 31st Mar 06) 423 cases

Benign277(65%)

Unsatisfactory61(15%)

Atypical44(10%)

Malignant41(10%)

Results

20% 15%

0%

5%

10%

15%

20%

25%

Standard unsatisfactory rate Unsatisfactory rate of nurses'performance

Unsatisfactory rate of Nurse Performancecompared with

the Standard Unsatisfactory rate(15th Mar 05 ~ 31th Mar 06)

The NATIOINAL CANCER INSTITUTE (USA) recommended that the standard unsatisfactory rate is <20%.

Results

The Beginning of a Satisfaction Survey1st – 30th April, 2006

Clients , Breast Surgeons, Pathologists

Questionnaire

Environment PreparationProcedureAfter care

Diagnostic timeUseful and important means for dxQuota adequacy

Specimens qualityInformation sufficiencyShorten total FNAC waiting time

Period :

Targets :

Methods :

Clients :

Surgeons :

Pathologists :

Conclusion

Shorten breast FNAC waiting time

Reduced operational cost about 46.8%

Re-deployed FNAC resources

Gained the professional satisfaction

Our data and feedback reveal the following accomplishments:

Nanjing Conference

Future

Current improvement scheme Satisfaction survey Regular review meetingFNAC refresher Explore accreditation Professional nursing development

Other techniques explorationEnhance professional nursing development

Reduced Operational Cost

In Pathology :1 SMO + 1 RN = $3694 / 23 + $ 1350 / 23

$ 220 / case

In TMHACC :2 RN = 2($1350 /23)

$ 117 / case

average $ 117 / case reduced (Total 46.8% reduced)

Senior Medical officer basic salary (Max pay) = $3694/dayRegistered Nures basic salary (Max pay) = $1350/dayAssume 23 FNAC cases are done per day

Workload guideline by HK College of Pathologist