JCUH NICE MSCC Guidelines Compliance audit Ruth Mhlanga Senior Specialist Physiotherapist Oncology and Haematology.

Patient identification Extremely difficult No specific coding for MSCC Screened patients who had received emergency radiotherapy. 92 patients identified. Needed 40 sets of case notes therefore patients screened by memory and screened some case notes by site of radiotherapy. 35 case notes used for audit.

Method Data collection based on NICE audit tool. Rehab outcomes also added to the proforma. Care of patients assessed against 10 quality standards from NICE. Radiotherapy case notes, physiotherapy notes, medical notes and live CAMIS updates also used to get information. All the above sources did not provide all the required information for the audit.

Results Breast, myeloma, lung and prostate were the most frequent cancers associated with MSCC. Lung, breast and prostate cancers constituted 60% of all the diagnoses of MSCC in this audit.

Cancer knowledge at diagnosis

Frequency of primaries

Results.. 9 out 35(25.7%)patients were not known to oncologists on diagnosis, thus MSCC was first diagnosis of cancer. Evidence of liaison between oncologist and surgical team available for only 40% of the patients. None of the patients in this audit proceeded to have surgery.

Site of pain on admission.

Results Length of stay ranged from 5 to 36 days. Five of the patients died during the admission. One patient received radiotherapy as an outpatient (myeloma). Only 80% of the patients had a whole spine MRI. A few of the patients only had part spine MRIs. Not clear why. Not part of this audit. 18.5% of patients with spinal pain had definitive treatment planned in 1 week of admission. Discharge not initiated on admission. Mobility on admission noted but less so on discharge. Most of information from physio notes, not all notes available so a lot of missing data. Most patients maintained mobility on discharge.

Summary of standards and compliance levels QualityStandardAchieved Whole spine MRI100%80% Spinal pain- definitive treatment planning within 1 week 100%18.5% Neurological symptoms- definitive treatment planning with 24hrs 100%51.6 Patients nursed flat where patients have an unstable spine 100%?30.7% Treatment started before neurological deterioration 100%62.9%

Place of discharge FrequencyPercentage Home Community hospital Hospice12.9 Died514.3 Not recorded617.1 Other12.9 Missing12.9 Total35100

Survival at 600 days 33% alive at 60 days, 27% alive at 90 days and 13% alive at the end of the first year post diagnosis.

Survival vs mobility on admission

Survival vs primary 1-bladder 2-breast 3-lung 4-myeloma 5-oesophagus 6-prostate 7-renal 8-unknown

Discussion of results Most of the findings including site of pain on presentation, frequency of MSCC per primary in line with available data. 60% of MSCC from prostate, lung and breast. ?Need to target the at risk patients for awareness purposes. 80%of patients had whole spine MRI. A few had part spine and one had had a private MRI. Most likely due to poor documentation and filing system. 40% of cases discussed with surgical teams with none having surgery. May need to explore if d/t late presentation - unilateral decisions, poor communication between teams or patient choice.

Discussion of results Most of the information that was missing pertained to assessment of patients re: presenting symptoms. Could be improved by standardised documentation. Patients nursed flat – stability of spine never documented. 30.7% not true representation of instability. Ambulant patients routinely nursed flat. LOS - Might reduce length of stay if discharge planning started at admission, where appropriate. Could link place of discharge with PPC including what percentage achieved.

Discussion of results.. Survival remains very poor – 5% alive at 600 days post diagnosis. Survival dependent on primary and mobility status on admission. Early presentation and maintaining mobility may therefore save lives. Full implementation of guidance may improve patient outcomes including survival, length of stay and could also be cost effective.

Future recommendations Prospective audit to ensure all cases captured. Information filed in single place for easy follow up. Standardised documentation may facilitate compliance with NICE guidance as may improve data completeness. Coordinator role - to facilitate implementation of NICE guidance and adoption of network care pathways.