Compliance with NICE Metastatic Spinal Cord Compression Guidelines

Purpose

1) To identify variations from NICE MSCC guidelines in the MSK pathway for patients regarding timelines from early detection and time to MRI 2) To use this clinical audit data to inform clinical commissioning groups (CCGs) and local hospital providers about access of referral

Approach

For this service improvement project, I utilised several methods and approaches.

The project began when clinicians raised concerns regarding in the service pathway for patients with suspected spinal metastases. However, we lacked visibility around the depth and impact of this. From there, a retrospective clinical audit was constructed to evaluate the pathway as initial survey. This helped focus the scoping the potential resources required and prioritise this service improvement project against our other quality audit programmes.

From this data, the problem could be quantified in the pathway clearly and factually. I utilised Root Cause Analysis (RCA) methodology including ‘Cause & Effect’ methods (fishbone) to identify areas for focus for the project.

The next phase included analysing the data to benchmark our pathways against NICE MSCC guideline criteria and also utilise national cancer waiting times (62 day target) terminology. The aim of this was to utilise national measures and established targets to articulate the problem and compare when presenting this to our audience to help influence change in the pathway included Commissioners, Trust MSCC leads, and Diagnostic Imaging department; we needed greater collaboration around this pathway and unlock barriers together. This methodology allowed me to prioritise where the effort could be invested for greatest impact by influencing decision making.

After the audit, with a strategy for service improvement started to take shape, I presented this back to my internal clinical team. The aim was to acknowledge the excellent contributions of the clinicians in the team, to present the initial findings of the data with case studies and discuss a draft strategy for service improvement.  

Outcomes

Our first major finding was that no patients met criteria for same day escalation of care (NICE guidelines), which was reassuring and factual. There were however some areas of moderate-low clinical risk of MSCC where we were not compliance with NICE guidelines; which became the focus of the service improvement project.

After implementing the project, re-audit determined that NICE compliance was achieved and this remained an ongoing audit for monitoring of clinical pathway quality within our services. 

Cost and savings

We did not quantify the cost of the project, as resource was derived from existing apportioned service improvement time. Savings to the individual services were not measured, however the pathway achieved by this service improvement project was more efficient so there may have seen system wide efficiencies.

Implications

Overall, this clinical audit demonstrated gaps in local service provision including GP awareness of local MSCC pathways, identification of risk factors of MSCC, lack of access to MSCC services by AHP lead service pathways. Improving GP awareness of MSCC was helpful to reduce the percentage of patients referred into CATS services by 50% in a one year period. In 2015, access was gained for all 4 hospitals for AHPs to access MSCC coordinators and further audit will be completed to evaluate the impact of this more integrated, pan-provider MSCC by regional area.

    Achieving direct access to urgent clinical pathways for AHPs has been achieved within the region for MSCC.

    Top three learning points

    Several lessons I have concluded from this include:

    • Quantify concerns about clinical care quality with data
    • Use standard benchmarks (NICE, NHSE) to measure and assess service quality, measure progress and prioritise service improvement projects
    • Use data and benchmarks to influence discussions with commissioners
    • “Medic only” access to urgent pathways prevents the system from meeting NICE guidelines in the modern commissioned clinical service design (ie- self-referral to physiotherapy) and should be challenged with data and narrative

    Fund acknowledgements

    This work was funded by Connect Health

    Additional notes

    To contact the author of this project please email: aimee10065@yahoo.com

    This work was presented at Physiotherapy UK 2017.