Developing spinal cord Developing spinal cord compression care guidelines at compression care guidelines at

WPHWPH

Spinal cord compression team: Spinal cord compression team: Sue Banks, Jean Buchanan, Dr Bernie Foran, Sue Banks, Jean Buchanan, Dr Bernie Foran,

Suzanne Hodson, Liz Kirkham, Suzanne Hodson, Liz Kirkham, Rebecca Mills, Jan Siddall, Rebecca Mills, Jan Siddall,

Rebecca Walsh, Clare WarnockRebecca Walsh, Clare Warnock

With assistance from Christine Cafferty With assistance from Christine Cafferty

Aim of the projectAim of the project

Review the current care of patients with spinal Review the current care of patients with spinal cord compressioncord compression

Identify areas for improvementIdentify areas for improvement Develop guidelines and practice for improving Develop guidelines and practice for improving

carecare Implement guidelinesImplement guidelines Review implementation Review implementation

This presentation focuses on the process for reviewing care This presentation focuses on the process for reviewing care and some of the findings that have lead to us developing and some of the findings that have lead to us developing improvements in practice improvements in practice

Project outlineProject outline Spinal cord compression group established in 2006Spinal cord compression group established in 2006 Multi-professional groupMulti-professional group

nursing, physiotherapy, pharmacy, DN liaison, social work, nursing, physiotherapy, pharmacy, DN liaison, social work, palliative care, dietetics, doctors, therapy radiography, palliative care, dietetics, doctors, therapy radiography, occupational therapyoccupational therapy

Key topics for review were identified reflecting the Key topics for review were identified reflecting the perspectives of the group membersperspectives of the group members positioning and mobility, positioning and mobility, medication (steroids and DVT prophylaxis), medication (steroids and DVT prophylaxis), bowel and bladder management, bowel and bladder management, psychological support, psychological support, discharge planningdischarge planning

Project outlineProject outline 3 stage project3 stage project Questionnaire Questionnaire

to nursing and medical staff to evaluate current to nursing and medical staff to evaluate current practice, gain their perspectives practice, gain their perspectives

Retrospective audit to identify problems and Retrospective audit to identify problems and provide a benchmark to evaluate care provide a benchmark to evaluate care

Prospective audit to evaluate implementation of Prospective audit to evaluate implementation of care care

Interest groups were established to develop Interest groups were established to develop guidelines for specific aspects of careguidelines for specific aspects of care Most aspects crossed multidisciplinary boundaries but Most aspects crossed multidisciplinary boundaries but

special interests were identifiedspecial interests were identified

Methods Methods Two questionnaires designed by the groupTwo questionnaires designed by the group

covered the same topics but with subtle covered the same topics but with subtle differences reflecting the interests of doctors differences reflecting the interests of doctors and nursesand nurses

Replies were received fromReplies were received from 66% of consultants66% of consultants 71% of SpR’s71% of SpR’s 25% of nurses25% of nurses

Retrospective audit of case notesRetrospective audit of case notes 50 patients who had received radiotherapy for 50 patients who had received radiotherapy for

SCC between SCC between July 2005 and June 2006July 2005 and June 2006 Prospective auditProspective audit

30 patients who had received radiotherapy for 30 patients who had received radiotherapy for SCC between January 2009 and July 2010SCC between January 2009 and July 2010

Contextual data from the auditContextual data from the audit

Brief overview to give a flavour of patients and Brief overview to give a flavour of patients and their care needs…..their care needs…..

DiagnosisDiagnosis

0

10

20

30

40

50

60

Prostate Breast unknown primary Lung Colorectal Other

Audit 1 Audit 2

Age at diagnosisAge at diagnosis

0

5

10

15

20

25

30

35

40

45

50

41-49 50-59 60-69 70-79 80-89 90+

Audit 1 Audit 2

80% aged over 60, mean age 68Male 59, Female 21

Contextual dataContextual dataReferred fromReferred from Audit 1Audit 1 Audit 2Audit 2

Chesterfield Chesterfield 88 77

BassetlawBassetlaw 55 44

DoncasterDoncaster 77 55

RotherhamRotherham 44 22

Barnsley Barnsley 55 44

SheffieldSheffield 1414 66

Other Other 77 00

TotalTotal 5050 3030

Discharge dataDischarge data Duration of admission Duration of admission

Audit 1, range 6 to 48 days, mean 13.1Audit 1, range 6 to 48 days, mean 13.1 Audit 2, range 5 to 58 days, mean 17Audit 2, range 5 to 58 days, mean 17

Discharge locationDischarge location Hospice Hospice

26% audit 1, 33% audit 226% audit 1, 33% audit 2 Other hospital Other hospital

34% audit 1, 30% audit 234% audit 1, 30% audit 2 Own homeOwn home

24% audit 1, 17% audit 224% audit 1, 17% audit 2 Died before dischargeDied before discharge

14% audit 1, 10% audit 214% audit 1, 10% audit 2

Survival post SCC diagnosisSurvival post SCC diagnosis Audit 1 - 45 patients had a date of death Audit 1 - 45 patients had a date of death

documented documented Number of days from admission with spinal cord Number of days from admission with spinal cord

compression to deathcompression to death Range = 2 days to 319 days Range = 2 days to 319 days Mean = 58.6 daysMean = 58.6 days

Audit 2 - 22 had a date of death documented Audit 2 - 22 had a date of death documented Number of days from admission with spinal cord Number of days from admission with spinal cord

compression to deathcompression to death Range = 10 days to 448 daysRange = 10 days to 448 days Mean 115 days Mean 115 days

SymptomSymptom On admissionOn admissionAudit 1/Audit 2Audit 1/Audit 2

(%overall)(%overall)

At dischargeAt dischargeAudit 1/Audit2Audit 1/Audit2

(%overall)(%overall)

Unable (wheelchair)Unable (wheelchair) 20/1820/18(47%)(47%)

25/1825/18(54%)(54%)

Assistance/Assistance/supervisionsupervision

17/617/6(29%)(29%)

5/25/2(9%)(9%)

IndependentIndependent 13/613/6(24%)(24%)

10/710/7(21%)(21%)

Died before time Died before time pointpoint

-- 7/37/3(13%)(13%)

Missing dataMissing data -- 3/03/0

Mobility symptoms of spinal cord compression

Bladder symptoms on admissionBladder symptoms on admission

CatheterisedCatheterised 24/1424/14

IncontinenceIncontinence 7/47/4

No problemsNo problems 18/1218/12

Bowel problems and SCCBowel problems and SCC

Incidence on Incidence on admissionadmission

Incidence at Incidence at dischargedischarge

ConstipationConstipation 26/1426/14

(50%)(50%)18/518/5

(29%)(29%)

IncontinenceIncontinence 6/66/6

(15%)(15%)7/47/4

(14%)(14%)

No problemsNo problems 16/1016/10

(33%)(33%)17/1617/16

(42%)(42%)

Died before dischargeDied before discharge -- 7/37/3

(13%)(13%)

Incidence of complications across both Incidence of complications across both

auditsaudits Pressure area concerns – 21 Pressure area concerns – 21 Chest infection – 16Chest infection – 16 UTI/catheter malfunction – 15 UTI/catheter malfunction – 15 Oral problems e.g. thrush, sore mouth – 10Oral problems e.g. thrush, sore mouth – 10 Confusion – 9 Confusion – 9 Pain – 11 Pain – 11 Dehydration – 3 Dehydration – 3 Fall – 2Fall – 2

Number of complications per patientNumber of complications per patient0 = 150 = 15 1 = 25 1 = 25 2 = 11 3 = 13 4 = 5 2 = 11 3 = 13 4 = 5

Findings from the audit and Findings from the audit and questionnairesquestionnaires

Steroids and PPI’s Steroids and PPI’s High dose steroids cornerstone of initial treatmentHigh dose steroids cornerstone of initial treatment

Doses need to be reduced over time Doses need to be reduced over time

The audit found that The audit found that all all patients were commenced patients were commenced on dexamethasone O/A on dexamethasone O/A Most common starting dose 8 mg BDMost common starting dose 8 mg BD There were differences in reducing schedulesThere were differences in reducing schedules

Need to develop steroid reducing protocol was Need to develop steroid reducing protocol was identifiedidentified

All patients in both audits were prescribed gastric protection (PPI’s) Lansoprazole most widely usedLansoprazole most widely used

TThrombo-prophylaxishrombo-prophylaxis Audit 1 Audit 1

4% were prescribed thrombo-4% were prescribed thrombo-prophylaxis as a consequence of SCCprophylaxis as a consequence of SCC

Few patients were given anti-embolic Few patients were given anti-embolic stockings stockings

Audit 2Audit 2 83% were prescribed thrombo-83% were prescribed thrombo-

prophylaxis prophylaxis Not much better on stockings but OK as Not much better on stockings but OK as

not required! not required!

MobilityMobility Traditional practice of flat bed rest Traditional practice of flat bed rest

However, is it only indicated in spinal instability and poor However, is it only indicated in spinal instability and poor pain controlpain control

75% of doctors said they did not recommend that 75% of doctors said they did not recommend that patients were routinely on bed rest patients were routinely on bed rest

69% of nurses said patients were routinely 69% of nurses said patients were routinely commenced on flat bed rest for the duration of commenced on flat bed rest for the duration of their treatment their treatment

Audit 1 found that 88% of patients were on flat Audit 1 found that 88% of patients were on flat bed rest for all of their treatment bed rest for all of their treatment 16% had a reason for bed rest documented in the notes 16% had a reason for bed rest documented in the notes 10% had spinal stability assessment documented10% had spinal stability assessment documented

Mobility audit 2Mobility audit 2 Audit 2 found improved evidence of individualised

care 67.5% of patients received care according the

mobility guidelines. 37% had a mobility plan of care and were not on bed

rest within 2 days of being admitted 23% were assessed but were unable to mobilise due to

other symptoms such as pain, chest infection, general deterioration

7.5% had spinal instability and were waiting for a corset 32.5% of patients did not receive care that

followed the guidelines. Most common reason was organisational factors

e.g. communication lapses between the MDT or waiting for physiotherapy assessment

Bowel managementBowel management 81% of nurses felt bowel 81% of nurses felt bowel

management was not effectivemanagement was not effective Shortfalls in documentation and Shortfalls in documentation and

practice were found in both audits practice were found in both audits Assessment within 48 hoursAssessment within 48 hours

68% audit 1, 70% audit 268% audit 1, 70% audit 2 Daily documentation of bowel actionsDaily documentation of bowel actions

56% audit 1, 58% audit 256% audit 1, 58% audit 2 Evidence of bowel management regimenEvidence of bowel management regimen

26% audit 1, 63% audit 2 26% audit 1, 63% audit 2

Bowel management and Bowel management and SCCSCC

Potential bowel problems include:Potential bowel problems include: changes in sensation, changes in sensation, urgency, urgency, constipation constipation faecal incontinencefaecal incontinence

In many cases the type of bowel problem In many cases the type of bowel problem is related to the site and the extent of the is related to the site and the extent of the compression compression

There are three main types of bowel There are three main types of bowel problem that can arise from SCCproblem that can arise from SCC

Reflex neurogenic dysfunctionReflex neurogenic dysfunction

More likely when the SCC occurs in C1 to C7, More likely when the SCC occurs in C1 to C7, T1 to T12T1 to T12

reflex functions of the rectum are preserved reflex functions of the rectum are preserved but sensation and voluntary control are but sensation and voluntary control are absent absent little or no awareness of bowel fullness little or no awareness of bowel fullness unable to initiate or inhibit defecation unable to initiate or inhibit defecation incontinence and constipation are common incontinence and constipation are common

The intact reflexes can be used in bowel The intact reflexes can be used in bowel management through mechanical (digital) management through mechanical (digital) and/or chemical (suppositories/enemas) and/or chemical (suppositories/enemas) stimulation stimulation

Flaccid neurogenic dysfunction

More likely when SCC occurs in L1 to S5More likely when SCC occurs in L1 to S5 reflex pathways have also been disrupted so the reflex pathways have also been disrupted so the

bowel will not respond to mechanical or chemical bowel will not respond to mechanical or chemical stimulation stimulation

Flaccid bowel can be diagnosed by digital rectal Flaccid bowel can be diagnosed by digital rectal examination examination if there is no tone or tightening when a finger if there is no tone or tightening when a finger

is inserted and sphincter control is absent this is inserted and sphincter control is absent this is suggestive of flaccid dysfunctionis suggestive of flaccid dysfunction

Digital rectal evacuation of faeces may be Digital rectal evacuation of faeces may be required for bowel management in flaccid required for bowel management in flaccid neurogenic dysfunction neurogenic dysfunction

Mixed neurogenic bowel Mixed neurogenic bowel dysfunctiondysfunction

More common for patients with SCCMore common for patients with SCC Many patients with SCC do not have Many patients with SCC do not have

complete compression and are likely to complete compression and are likely to have varying degrees of sensation and/or have varying degrees of sensation and/or control control

The impact of SCC on bowel function The impact of SCC on bowel function needs to be assessed for each patient as it needs to be assessed for each patient as it can vary greatly depending on the site and can vary greatly depending on the site and extent of the compressionextent of the compression

Aims of bowel management in SCCAims of bowel management in SCC

The aims are for the patient to have a regular, The aims are for the patient to have a regular, time managed bowel motion that is convenient time managed bowel motion that is convenient for both the patient and carer for both the patient and carer Bowel management episodes in SCC can be so Bowel management episodes in SCC can be so

prolonged as to have a negative impact on prolonged as to have a negative impact on quality of lifequality of life

Other important considerations include:Other important considerations include: achieving continence achieving continence ensuring that approaches used are appropriate ensuring that approaches used are appropriate

to the patients level of mobilityto the patients level of mobility

Guidelines for bowel managementGuidelines for bowel management

Assess the patient Assess the patient History of previous bowel function and changes History of previous bowel function and changes

since SCCsince SCC If the patient has not had a bowel action in the If the patient has not had a bowel action in the

past 3 days, or has had problems suggestive of past 3 days, or has had problems suggestive of constipation or constipation overflow then constipation or constipation overflow then consider a digital rectal examinationconsider a digital rectal examination

Determine the patients bowel symptoms Determine the patients bowel symptoms flaccid, reflex or mixed neurogenic bowelflaccid, reflex or mixed neurogenic bowel

Determine type of stool against Bristol stool chart Determine type of stool against Bristol stool chart criteriacriteria

Determine type of bowel Determine type of bowel problemproblem

Flaccid bowelFlaccid bowel On digital rectal examination there is no tone, On digital rectal examination there is no tone,

no tightening and sphincter control absentno tightening and sphincter control absent Management may require digital removal of Management may require digital removal of

faecesfaeces Training and competency assessment required Training and competency assessment required

Reflex bowelReflex bowel No awareness of bowel fullness and is not able No awareness of bowel fullness and is not able

to initiate or inhibit defecation but on digital to initiate or inhibit defecation but on digital rectal examination there is an anal reflex rectal examination there is an anal reflex

Management is likely to require management Management is likely to require management with micro enemas and digital rectal stimulation with micro enemas and digital rectal stimulation

Determine type of bowel Determine type of bowel problemproblem

Mixed neurogenic bowelMixed neurogenic bowel The characteristics of mixed neurogenic bowel will The characteristics of mixed neurogenic bowel will

vary between patients in terms of the range of vary between patients in terms of the range of sensation and control over bowel function sensation and control over bowel function

These patients require careful assessment and an These patients require careful assessment and an individualised plan of care.individualised plan of care.

Contraindications to rectal interventions Contraindications to rectal interventions includeinclude neutropaenia, rectal bleeding, recent rectal/anal neutropaenia, rectal bleeding, recent rectal/anal

surgery, active inflammatory bowel disease surgery, active inflammatory bowel disease Use caution in patients on anti-coagulation Use caution in patients on anti-coagulation

medicationmedication

Assess type of stool against Bristol Assess type of stool against Bristol stool chartstool chart

The optimum stool is between 3-4 The optimum stool is between 3-4 If stool is hard consider the following If stool is hard consider the following Review diet and fluidsReview diet and fluids

increase fluid intake and dietary fibre increase fluid intake and dietary fibre Review medications Review medications Consider and treat reversible causes e.g. Consider and treat reversible causes e.g.

hypercalcaemia, dehydration, lack of privacy hypercalcaemia, dehydration, lack of privacy If stool is too hard to pass/remove consider using If stool is too hard to pass/remove consider using

glycerine suppositories as part of rectal bowel glycerine suppositories as part of rectal bowel management management

Assess type of stool against Bristol Assess type of stool against Bristol stool chartstool chart

If stool is too soft (stool 5-7) consider the If stool is too soft (stool 5-7) consider the following following

Assess for constipation. Assess for constipation. Loose watery stool may be constipation Loose watery stool may be constipation

overflow from faecal impaction. overflow from faecal impaction. Exclude the possibility of infective causeExclude the possibility of infective cause Review diet and fluids Review diet and fluids Review medication Review medication If infective cause is ruled out then consider If infective cause is ruled out then consider

anti-diarrhoeal medication e.g. loperamide anti-diarrhoeal medication e.g. loperamide Titrate until Bristol 3-4 is achieved. Titrate until Bristol 3-4 is achieved.

Faecal incontinenceFaecal incontinence

Some patients with spinal cord compression Some patients with spinal cord compression experience faecal incontinence experience faecal incontinence

Step one: Implement measures aboveStep one: Implement measures above Develop individual bowel care management Develop individual bowel care management

regimenregimen We are in the process of developing We are in the process of developing

guidance for faecal incontinenceguidance for faecal incontinence Based on community guidelines Based on community guidelines

Monitor and document effect of Monitor and document effect of bowel interventionsbowel interventions

Documentation enables Documentation enables the development of an appropriate regime of bowel the development of an appropriate regime of bowel

management for the individual patient management for the individual patient continual assessment of the effectiveness of this regime continual assessment of the effectiveness of this regime the early identification of potential life threatening the early identification of potential life threatening

complications including faecal impaction, bowel complications including faecal impaction, bowel obstruction, bowel perforation and autonomic obstruction, bowel perforation and autonomic dysreflexiadysreflexia

Some patients will require regular intervention Some patients will require regular intervention from a nurse/carer in order to evacuate their from a nurse/carer in order to evacuate their bowel. bowel. develop a programme of bowel management with develop a programme of bowel management with

planned interventions planned interventions

Autonomic dysreflexiaAutonomic dysreflexia An uncontrolled reflex response to a noxious An uncontrolled reflex response to a noxious

stimulus such as an over distended bladder or bowel stimulus such as an over distended bladder or bowel Symptoms include: Symptoms include:

severe headache, nausea, bradycardia, respiratory distress, severe headache, nausea, bradycardia, respiratory distress, elevated BP elevated BP

If untreated increased BP can lead to a cerebro-vascular If untreated increased BP can lead to a cerebro-vascular incident incident

Treatment Treatment Promptly remove the noxious stimuli i.e. emptying the Promptly remove the noxious stimuli i.e. emptying the

bowel or bladder bowel or bladder In bowel distension the cause is often the presence In bowel distension the cause is often the presence

of a large mass of constipated stool of a large mass of constipated stool Autonomic dysreflexia can also occur during bowel Autonomic dysreflexia can also occur during bowel

management interventions such as digital removal management interventions such as digital removal of faeces of faeces nurses carrying out this procedure need to be aware of the nurses carrying out this procedure need to be aware of the

signs and appropriate action.signs and appropriate action.

Documenting care Documenting care

A SCC care pathway has been developed. A SCC care pathway has been developed. This has 2 aims;This has 2 aims;

Facilitate easier documentationFacilitate easier documentation Act as an aid to effective care Act as an aid to effective care

Has three main sectionsHas three main sections AdmissionAdmission Daily careDaily care Discharge planning Discharge planning

AdmissionAdmission

Patient informationPatient information Prompts forPrompts for

Mobility assessment Mobility assessment Pressure relieving equipmentPressure relieving equipment DVT risk assessmentDVT risk assessment TED stockingsTED stockings Referral to physiotherapistReferral to physiotherapist Commence discharge planning Commence discharge planning

Daily CareDaily Care Ordered and systematic daily assessment for key Ordered and systematic daily assessment for key

care issues for patients with SCCcare issues for patients with SCC Includes the following: Includes the following:

Patient positioning mobility Adverse effects of the radiotherapy Pain management Bowel management Bladder/catheter management SHEWS observations Hygiene, dressing and mouthcare Pressure areas Diet and fluids High dose steroids – daily urinalysis for glucose

Discharge and MDT workingDischarge and MDT working

Mobility and rehabilitation guidelines Mobility and rehabilitation guidelines MDT meeting and discharge recordMDT meeting and discharge record Discharge plan recordDischarge plan record

What have the reviews shown?What have the reviews shown? Provided a good foundation for reviewing Provided a good foundation for reviewing

carecare Highlighted the need to standardise care Highlighted the need to standardise care

according to best practice according to best practice Identified discrepancies between presumed Identified discrepancies between presumed

practice and actual carepractice and actual care Discovered patterns in practice that are useful Discovered patterns in practice that are useful

starting places for developing protocols and starting places for developing protocols and guidelinesguidelines

Identified the need for improvements in care Identified the need for improvements in care Provided a process for evaluation Provided a process for evaluation Identified some good practice!Identified some good practice!

Outcomes from the projectOutcomes from the project Guidelines Guidelines

Mobility Mobility Steroids and PPI’sSteroids and PPI’s Thrombo-prophylaxisThrombo-prophylaxis Bowel management Bowel management

SCC care pathwaySCC care pathway Education initiatives Education initiatives

This is one of them!This is one of them! Patient information for early detection Patient information for early detection Research project - patients experiences of SCCResearch project - patients experiences of SCC