Our clinical audit was initially designed as a quality assurance method to measure compliance against NICE Metastatic Spinal Cord Compression (MSCC) guidance (CG75). Due to our service design, the section of NICE MSCC guidelines applicable was the “early detection” recommendations. From this clinical audit, we were able to identify variation from the NICE guideline.
This information was presented to Acute Trusts MSCC Clinical Leads to discuss community services to gain access to existing MSCC pathways (without needing a GP referral). The output from this was improved service integration between community services and tertiary services, whilst sparing general practice time and improving effective and efficient signposting of patients with suspected MSCC.
Aims and objectives
1) To evaluate appropriateness of the referrals into the service based on presence or absence of recommendations from NICE guidelines for early detection (of those with confirmed spinal malignancy) (Right choice of clinical care).
2) To evaluate the effectiveness of the service pathway of those with confirmed spinal malignancy in the overall duration of their care (number of days) (Right process of clinical care).
3) To monitor the impact of service quality improvement initiatives over time on the appropriateness and effectiveness of the service pathway of these patients over time.
Reasons for implementing your project
Within the North east of England, 7 Clinical Assessment and Treatment Services (CATS) were commissioned to Connect in the community setting. We are responsible for delivering these services and work alongside 4 Acute Trusts in the region. Each acute trust had separate Metastatic spinal cord compression (MSCC) pathways based on NICE guidelines for MSCC.
These pathways were only accessible by medical staff and not by allied health professionals (AHPs) and were poorly understood by primary and community care providers in the region. In addition, this was causing delay in patient care when measured against NICE MSCC guidelines.
How did you implement the project
Through our clinical audit of serious diagnoses within community MSK services in 2012, we identified that there were some patients who possibly should have been signposted to tertiary services with retrospective review of their episode of clinical care (based on NICE guideline CG75).
From speaking to the clinical leads from the clinical commissioning group (CCG) it was clear that at that point there was no service provision for MSCC known to access/integrate with in 2012. I then spoke with acute trust clinical leaders in sarcoma team who identified the development of a MSCC team. However, this pathway was developed with medical referral access and admission only. This meant that the service was being developed but for us would require redirecting back to the GP to then make a referral to MSCC.
The feedback from the acute trusts was that they didn’t feel we would see these patients. I then planned clinical audit to have the evidence to have a data based discussion regarding this and the lack of compliance of our services with NICE MSCC early detection and imaging timelines standards. It was with this data, evidence and identification of variance from NICE recommendations that allowed the healthy debate regarding service pathway integration (primary care awareness of this service, community services referral access without need for GP referral and tertiary services accepting patients from multiple sources, based on clinical need).
It was then recognised that for community MSK services (particularly those that were single point of access or had self-referral of patients), our clinicians were able to identify risk factors (early detection) of MSCC, but then lacked ability to direct care.
The outcome from this was that we gained access to the MSCC pathway, without need to redirect to GP to then refer to MSCC tertiary service. We then planned education directives for our clinicians in community care from the colleagues in acute tertiary services to align with their policies and processes and patient information leaflets. We continued to audit this area of practice to evaluate the impact that this had and ensure that we maintained continued compliance against NICE MSCC early detection standards.
Initially in 2012-13, we noted that 9 patients should have been seen in MSCC coordinator rather than managed in community. These patients had a variance of 40 days from the recommendations outlined by NICE Guidelines (recognition of symptoms to imaging time).
From this data evidenced, we gained referral privileges.
- In 2014-15 we noted 4 patients should have been seen in MSCC coordinator and therefore invested heavier in training programmes with clinical staff on identifying & recognising symptoms and local guideline, tools and processes for their appropriate signposting.
- In 2016 we noted no patients with MSCC and therefore 100% compliance with early detection MSCC guidelines.
- We are planning now the 2017 continued audit to ensure compliance is maintained
- The outcome from this was that we gained access to the MSCC pathway, without need to redirect to GP to then refer to MSCC tertiary service.
- We then planned education directives for our clinicians in community care from the colleagues in acute tertiary services to align with their policies and processes and patient information leaflets.
We continued to audit this area of practice to evaluate the impact that this had and ensure that we maintained continued compliance against NICE MSCC early detection standards
Key learning points
We learned a lot as a service provider about our quality and improve the patient pathway and outcomes for patients as a result of this.
- To gather data on performance and do this consistently is important. But to gather the correct data, against areas of clinical quality risk is important.
- It was valuable to analyse our clinical quality performance against a standard benchmark of NICE guidelines and outline variance from NICE guidelines. Initially it was perceived that this wasn’t an issue, as I portrayed the information about the lack of service integration as anecdotal. Having evidence changed and transformed this, and using the NICE guidance added depth of meaning to this.
- This helped us to plan our service improvement plans, identify training needs of clinicians and improved our communication between primary care, commissioners and acute trust clinical leaders.
- We saw better outcomes for the patients we see in our services - right place, right time.
- Clinicians feel happier knowing that they are equipped with skills to identify these patients better and have the tools to know where to locally signpost these patients as a result.