Development of the Network Cord Compression Pathway

1. Development of the Network Cord Compression Pathway Dr Peter Robson (Oncology) and Mr Martin Wilby (Neurosurgery) Joint MSSC Leads for MCCN

2. History of the Network •MCCN formed in 2000 • Linking organisations that use, provide or commission cancer care • Allows an understanding of population needs across the network • Allows development of services to meet these needs • Only a Network focus can deliver wide ranging changes

3. Metastatic spinal cord compression services • Services fragmented – pockets of excellence but significant inequalities (worse in many areas of the country) • NICE CG75 November 2008 – set out an approach to delivering effective MSCC services to avoid delay and disability • Early detection • Imaging • Treatment • Rehabilitation

4. Key priority • ‘Every cancer network should ensure that appropriate services are commissioned and in place for the efficient and effective diagnosis, treatment, rehabilitation and ongoing care of patients with MSCC. These services should be monitored regularly through prospective audit of the care pathway’ NICE CG75 introduction • A significant task for the network

5. Service needs for MSCC • Rapid diagnosis • Patient information for those at risk • • Awareness in health professionals • • Access to admission and imaging • <24 hrs if neurology • <1 week if pain and cancer • • Rapid surgical/oncological decision • • Transfer and treat within 24 hrs • • Discharge planning and rehabilitation

6. Developing of Network group •Initially meetings supported by Network Medical Director • Bring together stakeholders • Neurosurgery/Spinal surgeons • Oncologists • Palliative Care • Radiology • Patient Transport • Commissioners • Acute Trusts • Primary Care • Patient groups

7. Network MSSC group • Clinical leads appointed in Oncology and Surgery • Work with Associate Director of MCCN to deliver a clear and accountable treatment pathway for the Network • Discussion with CNGs affected by the changes • Network guidance produced September 2010 and circulated to all Trusts/PCTs/Cancer Leads/CNGs

8. Development of the process • 6 monthly meetings to discuss the pathway and difficult cases • Development of robust data capture • • Audit of time to scan, time to treat, outcomes • • Peer review of MSCC under Acute Oncology • • Development of primary care guidance • • Development of patient information leaflet • • Pathway review 2012 • Protocols at treatment centers

9. Problems encountered – working on solutions • Getting the information to the coal face • 240 cases a year in 2.4 million population • Education • Teaching sessions • Time • • MSCC coordinator • Based at Walton (quick surgical opinion) • Continuity of care/handovers

10. Problems continued • • Joint Surgical/Oncology decision • Day cover Consultant Oncologists • Surgeon of the week • Image transfers • Prompt transfer of patients • Prioritisation with ambulance service • • Patients unfit for surgical intervention • Who should have MRI • Who should go directly for radiotherapy • Minimal invasive procedures/kyphoplasty

11. More problems • • Development of a service at RLH • Different setup – pre MRI spinal surgery involvement • Equitable • Clear and transparent • All audit data collected centrally • • Data collection • Alteration in electronic data collection record for radiotherapy • Collecting patient data via MSCC coordinator • Cross referencing • • Developing protocols for treatment centers

12. Thoughts at this stage • As you improve one problem in the process the next area will be highlighted • All cases are individual – very difficult to apply a generalised process to varying cases • Everyone always tells you about the cases where it goes wrong – however it remain better than it was • Our service has vastly improved using this process

13. Future developments • Audit needs strengthening • Surgical techniques advancing • “Keyhole surgery” (1/3 surgeries) • Prior radiotherapy not a major contraindication to Surgery anymore