Transcript YCN MSCC Pathway Implementation of NICE CG75

YCN MSCC Pathway
Implementation of NICE CG75
Level 1: Early warning
Dr Rob Turner
Chair YCN MSCC Group
Units to localise slides to clarify responsibilities of the MSCC
Coordinator and specify points of referral from the initial triage to the
MSCC Coordinator and then on to the AOL / AOT
YCN MSCC Competency for Initial
Identification
The Local Cancer Unit Acute Oncology Team (AOT) take responsibility for the
diagnosis and transfer of appropriate patients
Competency has been defined for the staff groups involved in the diagnosis,
management and treatment of MSCC patients
Staff involved in the initial identification of potential MSCC
including A&E and Acute medical Unit staff
Competency
a) Knowledge and understanding of which patient groups are at a higher risk of
developing MSCC
b) Knowledge and Understanding of the signs and symptoms of MSCC
c) Understanding of the appropriate aspects of the MSCC pathway
d) Escalation process to the Local MSCC Coordinator
Education
E - Learning level 1- Early Warning
What is MSCC?
Malignant (metastatic)
Spinal
Cord
Compression
Basically a complicated bony metastasis as
a consequence of advancing malignancy
Mechanism
Predictable symptomatic course
– Three phases of patho-physiology
Vertebral infiltration/expansion
Axonal compression
Vascular compromise (esp. mid thoracic)
– Arterial
– Venous
– Influenced by
Vertebral anatomy (local & spinal)
Biomechanical compromise
MSCC: Anatomical heterogeneity
MSCC
MSCC: Symptomatic course
Bone pain
Radicular pain
– Band-like/belt-like
– Sciatica
Motor weakness
– With preserved gait function
– With paraplegia
– With paralysis
Sensory loss
Autonomic dysfunction (loss of sphincters)
MSCC: Motor symptom evolution
Invariably presents late
MSCC: Time-course
(from first symptom)
Symptom
Rate of change
Motor weakness
40% presentation
50% within 7 days
80% within 80 days
Loss of gait function
50% within 38 days
Paralysis
50% within 12 days
Outcome by ambulation
Ambulant state pre-RT
Ambulant post-RT
Walking
90%
Walking with help
60%
Unable to walk
40%
Paraplegic
10%
Goals of YCN MSCC Pathway
1.
2.
3.
4.
Patient education for early presentation
Diagnosis at an early phase of process
Treatment with greater success
Improved function and QoL
E – Learning Training Packs on the YCN website
Level 1- Early Warning
Level 2 – Diagnostic
Level 3 – Specialist Intervention
Patient Education
Predictable clinical course
Suitable for screening
– Symptomatic patients
– MRI imaging for those who need
– Rapid access to diagnosis and treatment
Patient Education
Concerns
– Bony metastases present in 30% cancer patients
– Non-malignant back pain common in population
– Generalised weakness common in advanced cancer
Solution
– Identify high risk groups and target them
Improved specificity of screening
Reduced anxiety in patient population as a whole
High Risk Patient Groups
Any patient who has had prior MSCC
Any patient with known bony metastases at any
site from any primary site
Known cancer awaiting investigation for
suspicious spinal pain
Tumour site-specific recommendations
–
–
–
–
–
Prostate:
Renal:
Lung:
Breast:
Myeloma:
Hormone resistant prostate cancer
Metastatic renal cell cancer
Any metastatic lung cancer
Any metastatic breast cancer
Any myeloma
High-risk patient groups
High-risk patients identified clinically
Face-to-face discussion
Provided with MSCC Early Warning
Leaflet Features of MSCC
– What to do if they are worried
– How to access help
Via 24-hour SINGLE POINT CONTACT NUMBER
Insert local contact point
LTHT MSCC Early Warning Booklet –
Substitute Local Version & Title
Overall goals
Earlier diagnosis and treatment
– Outcomes linked to pre-treatment status
Faster access to diagnostic MRI
– Suspected
MSCC within 24 hours
VBM within 7 days
Rapid escalation to definitive therapy
– Proven
MSCC within 24 hours
VBM within 7 days
Definitive therapy case-appropriate
Co-ordinated case-appropriate rehabilitation
MSCC Pathway Components
1.
2.
3.
4.
Education and early warning
Triage
Diagnosis & generic care
Specialist intervention
 Spinal surgery
 Radiotherapy
5. Rehabilitation
MSCC symptoms & signs
Triage: Mechanism (Insert Local
Process Below)
Nursing staff will take basic details
Escalate to on-call clinical oncology team
– In hours to be handled immediately
Contact - Insert Local Information
– Overnight (Local Number)
Escalate to resident/duty ward medical staff
– Insert Local Procedure
– Priority
Immediate or deferred?
– Ward or clinic for clinical assessment
Is MRI required and how quickly?
Nursing Triage (Insert Local
process)
Question & Answer data recording form
– Patient & referrer details
– LOCATION & CONTACT DETAILS
– Patient symptoms/features
– Advice/instruction as to what will happen next
Complete for ALL MSCC related calls
Hand-over to medical staff / MSCC
Coordinator
Local Process for Escalation to Local MSCC
Co-ordinator
Triage: Need for MRI
Probability MRI shows neural compression
(after Lu, J Sup Care 2005;3:305-312)
Neurological deficit
Present
Absent
High-risk & suspicious pain
81%
69%
Suspicious pain only
44%
33%
Triage: Endpoints
MSCC possible – Refer to Local MSCC
Co-ordinator
– Urgent clinical assessment
– Urgent in-patient MRI (within 24 hours)
Admission may be required
MSCC less likely but VBM possible
– Prompt outpatient assessment
– Prompt outpatient MRI (within 7 days)
Further information
YCN Website
EQMS
YCN MSCC Lead
([email protected])