Expediting the Management of Suspected Cauda Equina Syndrome (CES) in the Emergency Department Through Clinical Pathway Design at a District General Hospital: A Quality Improvement Project

Background: Cauda equina syndrome (CES) is an uncommon condition that occurs due to compression of the terminal portion of the spinal cord. Early recognition and intervention in CES are crucial for an improved prognosis. Delayed diagnosis and action may lead to irreversible adverse effects, i.e., permanent disability, and in some circumstances can lead to litigation.

Aim: The aim of this quality improvement project (QIP) was to identify areas for improvement and expedite the management of suspected CES patients presenting to the hospital.

Material and methods: This was a retrospective study in which patients admitted to the Poole district hospital were analyzed in three groups with more than 50 patients in each subset group. The first group was audited from 1^st October 2020 to 27^th November 2020; a re-audit on the second group of patients was done from 1^st June 2021 to 16^th July 2021; the third group was re-audited from 1^st of January 2022 to 31^st of March 2022.

Results: There were a total of 168 patients in all audit groups, of whom 71% were female. The mean time from getting triaged to having an MRI improved from 13hrs 54mins to 10hrs 39mins. The total inpatient length of stay (LOS) of less than 24 hours was 28% in the first cycle and improved to 54.4% by the third cycle of the audit. Eight patients exhibited a diagnosis of cauda equina syndrome (CES) and were sent to the tertiary care center.

Conclusions: This quality improvement project identified delays in requesting the MRI for the diagnosis of CES and was addressed by ED booking the scans directly. This, in turn, reduced the length of stay in the hospital for patients who did not have cauda equina syndrome.