Expediting the management of cauda equina syndrome in the emergency department through clinical pathway design

[摘要] Introduction Cauda equina syndrome (CES) is aneurosurgical emergency. Early diagnosis with MRI andsubsequent surgical decompression surgery can preventpermanent neurological dysfunction. Charing CrossHospital (CXH) is a tertiary neurosurgical referral centrewhere in the emergency department (ED), current practicemandated a neurosurgery review prior to requesting MRI.Hypothesis It was hypothesised that a new clinicalpathway, with better coordination from the ED, radiologyand neurosurgical teams could reduce the time ofpresentation to diagnosis or exclusion of CES.Method Retrospective case-note analysis of patientspresenting with back pain to CXH ED over a 3-monthperiod was performed. The primary outcome was the timeinterval between the patient’s arrival to the ED and the MRIpreliminary report.Results The baseline primary outcome was recorded at8 hours and 16min (n=30). A new clinical pathway wasdesigned empowering ED senior decision makers to orderMRIs prior to neurosurgical review. Two Plan-Do-StudyAct (PDSA) cycles were performed, each measured overa 2-month period. The first PDSA cycle was performedafter the pathway was initially launched (n=17), while thesecond PDSA cycle measured the effect of staff educationand active promotion of the pathway (n=17). MRI wasrequested earlier, waiting and reporting time for MRI werereduced. The exclusion or diagnosis of CES was reducedto 5 hours and 54 min in PDSA 1 and 5 hours 17 min inPDSA 2, a 29% and 36% reduction (p=0.048 and p=0.012,respectively).Conclusion The clinical protocol was a cost-neutral andsustainable intervention that effectively reduced the timetaken to diagnose or exclude CES and ED waiting times.

[学科分类] 药学