Metastatic spinal cord compression (MSCC) is an oncological emergency that requires efficient and effective diagnosis, treatment and rehabilitation (NICE 2008).
The current MSCC quality standards for adults highlight the need for:
- Early detection of MSCC through appropriate assessment by MSCC Co-ordinator, spinal surgeon and clinical oncologist, and imaging within 24 hours.
- Treatment (dexamethasone, radiotherapy, surgery) commencement within 24 hours of confirmed diagnosis
- Timely rehabilitation and discharge planning with patient and family input
The aim of this audit is to:
- Determine whether the multidisciplinary team (MDT) management of MSCC patients meets national (NICE 2008) and local (KHP, 2016) guidelines at Guys and St Thomas Foundation Trust (GSTT)
- To identify if and where improvements need to be made against both national and local guidance.
- To assess components of the care pathway for timeliness, clinical decisions and processes – namely referrals to clinical oncologists, neuro/spinal surgeon, access to timely imaging, prescribing a suitable dexamethasone dose, timely treatment decisions, confirming spinal stability status and referral to rehabilitation services with provision of timely rehabilitation.
A retrospective clinical audit of current practice was conducted by comparing key indicators with best practice standards (NICE guidelines (2008) and the updated local KHP’s (2016)) using proportions of compliance. Expected compliance was 100% for all standards and was assessed using an audit tool developed by a panel of expert Physiotherapists and Doctors.
Best practice standards were divided into three categories:
1) Actions required without delay.
2) Actions required within 24 hours.
3) Actions required of MDT including therapy professional and functional outcomes.
Evidence of current practice was determined in all suspected cases of MSCC admitted to inpatient oncology wards at Guys hospital site between April 2017-March 2018 retrospectively using relevant NHS trust database records. Electronic medical records (from local proprietary software applications) were subsequently reviewed individually with respect to the audit tool by a doctor and three physiotherapists. Demographic data, including the age and gender of the patient, tumour site and site of cord compression were collated. In addition, physiotherapy rehabilitation activity was captured to describe the dose of therapy delivered and the functional outcome.
A total of 80 suspected MSCC cases were included between April 2017-April 2018, 54 (68%) male, 26 (33%) female, with an age of 67 (±14) years. No patients were excluded. The most common tumour sites associated with suspected MSCC were prostate, myeloma, lung and breast. MSCC was confirmed in 40 (50%) cases, impending MSCC in 24 (30%) and no MSCC in 16 (20%) cases.
Most cases (70) were commenced on dexamethasone (88%) and 76 (95%) on venous thromboembolism (VTE) prophylaxis immediately on suspicion of MSCC. Diagnostic imaging and medical treatment (radiotherapy, surgery or chemotherapy) was commenced within 24-hours in 56 (70%) and 28 (47%) of cases retrospectively. Spinal stability was documented in 47 (73%) of cases and 69 (86%) of all individuals were reviewed by a specialist registrar or consultant from their parent oncology team within 24 hours of admission. A formal ASIA assessment was completed in 34.4% of cases on admission and 3% of cases on discharge.
Examination of the rehabilitation pathway for individuals with confirmed or impending MSCC demonstrated that 98% of individuals had rehab commenced within 24hours of referral. The mean (range) length of stay for all cases was 21 (1-117) days. Active rehabilitation was provided for a mean of 17.2 (±25) hours per patient during their admission. On average, 50 (±20) minutes of active rehabilitation was delivered per session
There is a need for the local streamlining of the MSCC pathway to improve timelines of standards and to ensure high quality of care for patients with suspected and or confirmed MSCC is delivered. Additionally, the rehabilitation needs of those with confirmed or impending MSCC are not shy of requiring dedicated time and resource reflecting the complexity of the physical rehabilitation needs these patients have.
Cost and savings
There were no costs associated with this project.
Early detection and timely management is vital for individuals with MSCC. Our findings provide some early guidance on the multidisciplinary team role in managing patients with MSCC. Collaborative working between the Rehabilitation, Oncology and Surgical services is vital to implement changes to improve MSCC pathways and ensure quality care for patients with MSCC. It is recommended progress should be audited through routine repeat annual audit.
Top three learning points
This work was unfunded.
This work was presented at Physiotherapy UK 2019
Please see the attached Innovations poster below.
For further information about this work please contact Nicola Peat.
Kings Health Partnership (2016) South East London and Kent Standard Operating Procedure for the Management of Metastatic Spinal Cord Compression (MSCC) 1-27
National Institute for Health and Care Excellence (2008), Metastatic Spinal Cord Compression in adults: Risk assessment, diagnosis and management