Improving the care of patients diagnosed with cerebral metastases
Cerebral metastases are often associated with poor prognosis and the management of these patients was based on the experience of the individual clinician with ad hoc care planned following discharge, not only to dose reduce the steroids but also to manage the side effects these could cause.
Concerns about the variance in practice were raised to a chest physician colleague. A quality improvement project to assess the current dexamethasone prescribing practice for cerebral metastases was undertaken. Following this, a 6 month retrospective audit identified 21 patients, their dexamethasone prescription and reduction plan. Seven patients had full written dose reduction plans documented, 5 had their reducing dose part planned and 9 patients and no plan in place to reduce their steroids. The audit also identified side effects the patients experienced and also if they had PPI cover. The performance statuses were recorded and also if any follow up care was planned.
There is limited research into the use of steroids, including dosage and duration of treatment, in the management of cerebral metastases.
The audit, carried out by two junior doctors, showed that the admitting Hospital teams were excellent at prescribing steroids however there were inconsistencies when documenting a weaning programme, prescribing PPI cover or planning follow up care. There was also concern over the management of blood sugars when two patients were admitted with steroid induced diabetes mellitus.
It was recognised that a more standardised dosing regimen for dexamethasone needed be implemented. The Edinburgh Cancer Centre policy for steroid use in patients with symptomatic cerebral metastases was considered as an excellent tool for clinicians to use. To ensure that trust medical and nursing staff were made aware of the new guidance the original concern regarding the management of cerebral metastases raised by the Macmillan lung CNS and the subsequent audit has been presented at the Trust lead nurse/sisters meeting by the Macmillan lung CNS therefore promoting this practice throughout the nursing workforce. The junior doctors presented their audit to the medical directorate and the chest physician has had the guidance implemented on the Trust intranet site.
The management of patients who now present with cerebral metastases should follow the Edinburgh Cancer Centre Guidance with the subsequent recommendations:
- A careful assessment of the severity of any midline shift and/or oedema on the CT/MRI
- Any symptom the patient is experiencing is recorded before the first dose of
dexamethasone is prescribed.
- A PPI is prescribed as standard alongside the dexamethasone.
- A weaning regime for the dexamethasone is documented within the medical notes
- Documentation of side effects of the dexamethasone.
- The patient is referred to the acute oncology nurses or lung cancer specialist nurses
promptly, (if primary cancer is of lung origin).
- This in turn reduces variance across admitting teams and also hopefully a reduction
in bed stays.
- Blood sugars are monitored as standard from commencement of the steroids.
A plan of care following discharge is formulated which includes a referral to the community
Macmillan specialist palliative care nurse to manage the dose reduction of the steroids based
on assessment of the symptoms (occasionally steroids may need to be reduced more slowly
or even be increased again).
Each patient is also referred to the district nursing team to monitor the blood sugars and referred to the diabetic team if needing treatment to manage hyperglycaemia.
This is a change in practice so there are no further funding, resources or cost implications. If anything this will hopefully lead to a reduced number of bed stays for patients. A more proactive management of cases with the lung CNSs' or acute oncology nurses involvement will streamline further investigations and the diagnosis pathway.
Edinburgh Cancer Centre policy for the management of cerebral metastases Audit carried out by Dr Christopher Taylor and Dr Samantha Foreman - date of report 20.3.2017 Consultant Physician overseeing this project - Dr Benjamin Prudon.