A novel spinal rapid access unit led by advanced spinal physiotherapists to manage urgent spinal presentations.

Purpose

Low back pain(LBP) is the largest cause of disability in the UK (Deyo et al., 2016). A small proportion of those with LBP may present to the Emergency Department: generally, if they have symptoms indicative of cauda equina syndrome (CES), worsening neurology or uncontrollable pain. CES is a spinal surgical emergency that requires time efficient management and MRI to confirm or refute its presence. It can lead to a range of severe permanent disabilities including permanent loss of bladder, bowel and sexual function, and lower limb paralysis (Hatton 2018). Standards of care for the screening of CES (SBNS, BASS -19 in GIRFT) have been developed but the last national audit (ENTICE of 2017 records) found that these standards were not being met. Nottingham University Hospitals NHS Trust is a spinal hub provider, with 24/7 emergency services, and is one of the largest university hospitals in Europe. A new spinal rapid access unit has been piloted, led by an Advanced Spinal Physiotherapist Practitioner (ASPP) and the on-call spinal fellows team.

16% admission rate
for those patients seen by Advanced Spinal Physiotherapist Practitioner compared to those seen by the spinal fellows which was 40%
Of the 280 (38.6%) patients presenting with possible CES
only 18 (6.4%) had a final diagnosis of CES

Approach

After this pilot period (Nov 2018- Nov 2019), a retrospective service review was performed in which the total number of patients presenting to the spinal rapid access unit were counted. These were tracked according to whether they were managed by a spinal fellow or ASPP, and admission rates of patients compared. The number of patients with a suspected CES diagnosis were identified and outcomes were tracked to identify the number of patients with a confirmed diagnosis of CES requiring surgery. Other red flag conditions identified were also recorded including myelopathy, tumours, infections, neurological conditions.

Outcomes

Results: A total of 725 patients were managed by the rapid access unit in its first year. Of the 280 (38.6%) patients presenting with an initial diagnosis of possible CES, only 18 (6.4%) had a final diagnosis of CES, of which only 17 (6%) had surgery for this condition. A further 136 (18.8%) cases were identified with other red flag conditions including tumours (n=5), neurological conditions (n=3), infections or post-operative complications (n=82) and acute myelopathy (n=7). The admission rate for those patients seen by the ASPP was 16% compared to those seen by the spinal fellows which was 40%. In addition, despite the ASPP input only being available for 15 hours out of 55 hours (27%) they saw 38% of the patients. This suggests the pathways to the rapid access unit were also better used when led by an ASPP.

Conclusion(s): The rapid access unit using ASPP and the on-call spinal team appears to be an effective method of managing acute spinal conditions, in particular CES. An ASPP led service has resulted in fewer unnecessary hospital admissions and providing holistic management, reassurance and advice in a timeous manner in comparison to a spinal fellow led team.

Cost and savings

Pilot funding for an 8A PT at 20hours for 1 year. Thereafter secured funding of 2 WTE 8A posts and 1 20hour 8B post to manage the service.

Implications

This abstract demonstrates the successful implementation of ASPPs in a senior decision-making role. This pilot provides evidence that patients presenting with acute distress, and with potentially life-altering conditions can be safely and holistically managed by an ASPP, preventing unnecessary hospital admissions.

Top three learning points

No further information. 

Funding acknowledgements

This pilot study was funded by the Nottingham University Hospitals NHS Trust.