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

Introduction: Cauda equina syndrome (CES) is a neurosurgical emergency. Early diagnosis with MRI and subsequent surgical decompression surgery can prevent permanent neurological dysfunction. Charing Cross Hospital (CXH) is a tertiary neurosurgical referral centre where in the emergency department (ED), current practice mandated a neurosurgery review prior to requesting MRI. Hypothesis: It was hypothesised that a new clinical pathway, with better coordination from the ED, radiology and neurosurgical teams could reduce the time of presentation to diagnosis or exclusion of CES. Method: Retrospective case-note analysis of patients presenting with back pain to CXH ED over a 3-month period was performed. The primary outcome was the time interval between the patient's arrival to the ED and the MRI preliminary report. Results: The baseline primary outcome was recorded at 8 hours and 16 min (n=30). A new clinical pathway was designed empowering ED senior decision makers to order MRIs prior to neurosurgical review. Two Plan-Do-Study-Act (PDSA) cycles were performed, each measured over a 2-month period. The first PDSA cycle was performed after the pathway was initially launched (n=17), while the second PDSA cycle measured the effect of staff education and active promotion of the pathway (n=17). MRI was requested earlier, waiting and reporting time for MRI were reduced. The exclusion or diagnosis of CES was reduced to 5 hours and 54 min in PDSA 1 and 5 hours 17 min in PDSA 2, a 29% and 36% reduction (p=0.048 and p=0.012, respectively). Conclusion: The clinical protocol was a cost-neutral and sustainable intervention that effectively reduced the time taken to diagnose or exclude CES and ED waiting times.

Inpatient- versus Outpatient-Onset Acute Coronary Syndrome: Comparison of Clinical Features and Outcomes.

The clinical characteristics and outcomes among patients with inpatient-onset non-ST-segment-elevation acute coronary syndrome have not been fully investigated. Therefore, we conducted a retrospective single-center analysis of patients who were ≥18 years old and diagnosed with acute coronary syndrome at our hospital during 2014. We performed logistic regression analysis to evaluate outcomes and made adjustments for age, race, family history of premature coronary artery disease, and comorbidities. Our search through 31,274 hospital discharge records identified 683 cases of acute coronary syndrome: 32 were inpatient-onset and 651 were outpatient-onset. The inpatient-onset group was older (74.6 ± 9.6 vs 64 ± 12.8 yr; P <0.001), and patients were more likely to be black (28.1% vs 12.9%). Diagnoses at admission in the inpatient-onset group varied widely, including 4 cases of pneumonia and 3 of intestinal obstruction. The inpatient-onset group was less likely than the outpatient-onset group to undergo cardiac catheterization (34.4% vs 90.2%; adjusted odds ratio [AOR], 0.11; 95% CI, 0.05-0.28; P <0.001) or percutaneous coronary intervention (12.5% vs 61.6%; AOR, 0.16; 95% CI, 0.05-0.48; P=0.001), or to be discharged from the hospital (53.1% vs 88.9%; AOR, 0.26; 95% CI, 0.11-0.6; P=0.002). The inpatient-onset ACS group had longer hospital stays than did the outpatient-onset group (9.9 ± 8.9 vs 6.4 ± 5.2 d; P=0.03). We found that inpatient-onset acute coronary syndrome was associated with less interventional management, a longer hospital stay, and a lower likelihood of discharge to home.