Same day emergency care for low back pain: quality improvement to support emergency flow and reduce unnecessary acute admissions

Abstract

Globally, patients with low back pain (LBP) account for 4.4% of all emergency department (ED) attendances, in the UK, 50 000 visits have been reported each month. LBP is reportedly challenging to manage in this setting. Consequently, hospital admission is common despite low numbers of serious pathology. This quality improvement (QI) project aimed to reduce avoidable hospital admissions by implementing and embedding a same day emergency care (SDEC) pathway for LBP over a 2-year period.A 12-bedded area was repurposed as an SDEC unit, staffed by specialist spinal nurses and a senior decision maker (advanced practice physiotherapist or spinal surgical fellow). The service was co-designed with key stakeholders, including spinal leadership, ED representatives, radiology and patients to form an ED-spinal interface group. The pathway was developed and refined over four plan-do-study-act (PDSA) cycles (2018–2021), supported by regular interface meetings and iterative feedback. Prospective data collection included referral activity, clinical timings, MRI utilisation and patient satisfaction. The project was registered as a QI initiative and did not require formal ethical approval.Between November 2018 and December 2021, the spinal SDEC recorded 3921 referrals. PDSA cycle 1 (pilot) recorded 267 referrals with 82 (31%) admitted and 19 (7%) requiring same day MRI. PDSA cycle 2 (referral expansion) recorded 569 referrals with 177 (31%) admitted and 39 (7%) requiring same day MRI. PDSA cycle 3 (system engagement) recorded 1043 referrals with 119 (11%) admitted and 154 (15%) requiring same day MRI. PDSA cycle 4 (embedding SDEC) recorded 2042 patient referrals with only 8% (n=172) admitted and 224 (11%) requiring same day MRI. Across four improvement cycles, the spinal SDEC demonstrated progressive and sustained reductions in hospital admission without an apparent increase in demand for same day MRI.