Introduction Cauda equina syndrome (CES) is a very rare but devastating surgical emergency that can lead to permanent bowel, bladder or sexual dysfunction and lower limb paralysis. Although it is a clinical syndrome, an MRI scan is a critical diagnostic investigation for these patients and should be done as soon as possible. Our hospital is a district general hospital with no spinal services on site. There is a protocol in place for the management of these patients locally with MRI scanning during daytime hours. However, if the patient presents after 8 pm, they are discussed with the tertiary spinal centre, which then advises if the patient requires transfer overnight for urgent scanning. Considering an MRI scan is a critical diagnostic step for these patients, we introduced a role for an orthopaedic doctor in the Emergency Department (ED) to assess all of these patients before collecting data for the second cycle. The aim of this audit was to see the effect of having an orthopaedic doctor in the ED for the assessment of these patients and its impact on waiting times and admission rates. Methods A closed-loop audit cycle was done looking into all referrals to trauma and orthopaedics with acute back pain and suspected CES in a district general hospital with no spinal services on site. The first cycle was between September 30, 2020, and May 31, 2021, and included 93 patients in total. Following this, a role for an orthopaedic doctor in ED was introduced from December 1, 2021, to January 31, 2022, for assessment of these patients. Data was then collected retrospectively for all patients referred during this period (n=36). Data was extracted from all relevant clinical systems including electronic patient record (EPR), Patient Pass (Patient Pass Ltd, Greater Manchester, England), which is the system used to digitally communicate with regional spinal services, and PACS (picture archiving and communication systems). The data was collated on a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, Washinton, United States) and analysed. Results Data were collected for a total of 36 patients in the second cycle following the introduction of an orthopaedic doctor in the ED. The age of patients referred was 30-89 years with a mean age of 51; 44.4% were male (n=16) and 55.5% female (n=20). All the patients who were referred received their MRI scan and report within 24 hours of presentation to the ED. In the first cycle of the audit, the mean waiting time for an MRI scan had been 12.5 hours, which was reduced to eight hours following the introduction of an orthopaedic doctor in the ED during daytime hours. This was stratified further according to the time patients presented to the hospital. From 8 am to 4 pm, the mean waiting time for an MRI scan was 9.5 hours pre-intervention and 5.5 hours after. From 4 pm to 12 am, the mean waiting time was 18 hours before and 13 hours after, and from 12 am to 8 am, the waiting time for scans improved from 8.5 hours to 6.5 hours. The number of patients discharged on the same day greatly improved from 29% (n=27) in the initial study to 58% (n=21). This decreased unnecessary inpatient stays from 71% (n=66) to 42% (n=15). Conclusion This study showed that an orthopaedic doctor in the ED for the acute assessment of patients referred with possible CES is an effective way of improving their management. This decreases waiting times for MRI scans and therefore allows the patient to be managed more efficiently.
Keywords: cauda equina syndrome; decrease waiting times; mri scan; orthopaedic emergency; spinal services.
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