Suspected Cauda Equina Syndrome, who you gonna call?: Evaluating the Impact of education and on-call support on referrals to A&E.

Purpose

Cauda Equina Syndrome (CES) is an emergency diagnosis presenting with a myriad of different red flag symptoms of bladder and bowel dysfunction, saddle anaesthesia, bilateral radiculopathy, and/or sexual dysfunction. Diagnosis is clinically challenging and is only established with confirmatory radiological compression of the cauda equina nerves. Despite a level of disagreement in what constitutes CES, timely management of this condition in order to preserve the function of affected systems appear key. The aim of this project was to identify the volume and outcomes of A&E referrals prior to and following the provision of an education and on-call rota package. The educational material, face to face teaching, and clinical reasoning sessions, aimed to create a more uniform understanding of CES including nuanced questioning, answer interpretation, chronology and local pathway access. The on-call rota provided national support for clinicians who could not directly access local support to utilise to aid their clinical decision making. This On-call rota consisted of Advanced Practice Physiotherapists, Consultant Physiotherapists and a Sports and Exercise Medicine consultant.

28% reduction in referrals to A&E (n=39).
following the introduction of a CES education and On-Call pathway.

Approach

A retrospective audit of referrals with suspected CES sent to A&E over 6 months was completed. Referral numbers and subsequent outcomes were utilised as standards for the audit. Data were captured utilising inbuilt electronic records functions and exported to Microsoft Excel for analysis. The time periods were Jan-Mar 2019 (prior to the education / rota package) and Apr-Jun 2019 (following introduction of the package).

Outcomes

Results: 143 records were audited utilising the categories: Referrals to A&E (Pre n=141, Post n=102), scanned in A&E (Pre n=34, Post n=44), positive diagnosis of CES (Pre n=1, Post n=1), scanned in the community post A&E discharge (Pre n=33, Post n=22). The introduction of the education and On-Call package correlated with a 28% reduction in referrals to A&E (n=39). A 29% increase was observed in scanning rates of those attending A&E (n=10), with a 33% reduction in community scanning rates (n=11). In both periods, one positive diagnosis was made (1.4% incidence).

Conclusion(s): Although causal relationships cannot be inferred, the combined education and on-call package correlated with a reduction in referrals to A&E, a higher rate of conversion to MRI in A&E and a reduce rate of community scanning following A&E discharge. This suggests higher quality and more appropriate referrals from community MSK to A&E in cases of suspected CES.

Cost and savings

See implications 

Implications

Impact:

1. Alleviated A&E pressure through more appropriate referrals.

2. Potential reduced cost burden. At the time of audit, the reported cost of an A&E visit without treatment was £124, and an MRI with report was £108. Based on the above numbers, the net cost burden reduction could be estimated at £3756. Calculates as £4836 (£124 x 39 fewer referrals), minus increased cost from higher scan rates in A&E (10 x £108 = £1080).

Top three learning points

No further data 

Funding acknowledgements

Work was not funded