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Integrated Care Pathway for Metastatic Spinal Cord Compression: A Quality Improvement Project to Strive for Better Patient Care

October 10, 2022 2:11 PM | Anonymous

Author: LING Wai Man (MScN, RN, FHKAN), Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong

Metastatic spinal cord compression (MSCC) is an oncological emergency which can cause severe debilitation and adverse impacts on patient’s quality of life. A preliminary review conducted between January 2018 and June 2019 in our oncology wards on 6 MSCC patients revealed that there were delayed initiation of multidisciplinary supportive care and a paucity of routine psychosocial assessment. The lack of a systematic and timely multidisciplinary MSCC care plan was evident. Therefore, we decided to initiate a quality improvement project to enhance the MSCC care by establishing and implementing a systematic multidisciplinary care pathway.

Based on the gaps identified from the aforesaid review and current international guidelines like the Christie NHS Guideline and NICE Pathway, a departmental integrated care pathway (ICP) for MSCC was developed. Emphasis was placed on the multidisciplinary input for timely therapeutic interventions, pain management, psychosocial care and supportive measures so as to maximize rehabilitation, prevent complications and aid discharge planning. To facilitate the systematic care delivery, a clinical practice checklist was designed and used since September 2019. A clinical audit was then conducted in late 2020 to evaluate the effectiveness of the project, including the (i) compliance to the ICP, (ii) effectiveness in multidisciplinary communication and service coordination, and (iii) effectiveness of the enhancement in clinical care.

A retrospective approach with the pre and post historical comparison design was adopted. Twenty-one MSCC patients from September 2018 to August 2019 (pre cohort) and 40 from September 2019 to August 2020 (post cohort) were recruited. Their median age was 71 with the range of 41 to 100. Thirty-eight (62.3%) of them were male. The top 5 cancer diseases were lung, prostate, colorectal, breast and lymphoma. The most common site of MSCC was thoracic spine (86.7%), followed by cervical (18.3%) and lumbar (15%). Ratio of single to multiple levels of MSCC was half to half. Radiotherapy (85.2%) was the most common primary treatment for the MSCC, whereas surgery (4.9%) and supportive management (9.8%) were the minority. Their median survival time was 3.2 months only.

The overall compliance to ICP was good. All the post cohort patients were under its care with 85% initiated within 1 day. All had a clear documentation of the spinal stability. Use of anti-embolism stockings rose from 19% to 75% (p<0.001). There was a statistically significant increase in the referral to physiotherapist (81% vs 100%; p<0.5), occupational therapist (72.6% vs 95%; P<0.5) and social worker (42.9% vs 75%; P<0.5). Although it was not statistically significant yet, there was a trend of improvement in pain control, prevention of constipation and discharge planning. The median length of stay was shortened from 13 to 10 days with over three-fourths back to home or elderly home.

Our audit results support the use of ICP, which can promote systematic, timely and holistic MSCC care, and is worthwhile to adopt in routine practice. Improvement actions (like a stepwise remobilization protocol and a more convenient multidisciplinary referral system) have been identified afterwards to strive for a continuous quality enhancement in our MSCC care.

Christie Hospital NHS Foundation Trust. (2020a). Overview of the Management of Metastatic Spinal Cord Compression due to Cancer (Version: V6). Retrieved from https://www.christie.nhs.uk/media/9329/overview-of-the-management-of-mscc-due-to-cancer-sept-2020-final.pdf
Christie Hospital NHS Foundation Trust. (2020b). Protocol for Mobilisation and Rehabilitation (Version: V6). Retrieved from https://www.christie.nhs.uk/media/9321/guidelines-on-mobilisation-and-rehabilitation-sept-2020-final.pdf
Laufer, I., Bilsky, M., Schiff, D., & Brown, P. (2021). Treatment and prognosis of neoplastic epidural spinal cord compression (Topic 2820 Version 42.0). Retrieved from https://www.uptodate.com/contents/treatment-and-prognosis-of-neoplastic-epidural-spinal-cord-compression?search=malignant%20spinal%20cord%20compression&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
National Institute for Health and Clinical Excellence. (2008). Metastatic spinal cord compression in adults: risk assessment, diagnosis and management (CG75). Retrieved from https://www.nice.org.uk/guidance/cg75
Vogel, W. (2020). Structural Emergencies. In J. M. Brant, D. G. Cope, & M. G. Saria. (Eds.), Core Curriculum for Oncology Nursing (6th ed.) (pp. 470-486). St. Louis, Missouri: Elsevier.

Oncology nurses are practicing the essential skills in MSCC care: the application of orthotics and log rolling.

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