Improving the suspected cauda equina syndrome pathway at a district general hospital: a quality improvement project

Cauda equina syndrome (CES) is a surgical emergency caused by acute compression of the lumbosacral nerve roots, requiring urgent surgical decompression. Delays in management can lead to permanent bowel and bladder incontinence, sexual dysfunction, lower limb paralysis and chronic pain.The Getting it Right First Time (GIRFT) National CES Pathway 2023 mandates that patients with red flag symptoms require an 'emergency MRI as soon as possible, certainly within 4 hours of request'. However, an audit at Medway Hospital (MH) showed that despite achieving this target, patients still experience delays from emergency department (ED) attendance (time of arrival) to MRI scan (median 5.9 hours).In response, MH launched a CES working group of orthopaedic surgeons, radiologists, emergency doctors and managers. Having identified time to MRI request as a major driver of delays, the team altered the GIRFT target to a SMART primary aim of 4 hours from ED presentation to MRI. Two key interventions were planned: (1) the translation of the GIRFT guidelines into a standard operating procedure (SOP), cotargeting a secondary outcome improvement of more accurately identifying those at risk of CES, thus reducing unnecessary MRIs for those that did not meet those guidelines and (2) the extension of MRI operational hours.The new SOP was implemented across three plan-do-study-act cycles, but MRI operational hours were not extended. The primary outcome of reduction in time from ED presentation to MRI was not achieved (5.9 to 5.7 hours). Secondary aim improvements include a reduction of unnecessary MRIs (38% to 18%), CES MRI scans/day (0.5/day to 0.4/day), time to analgesia (5.3 to 4.2 hours) and incorrect referrals to the General Practitioner-led Medway on Call Care service (9% to 0%).Suggestions for further improvements within district general hospitals include a 24-hour emergency MRI service and a standardised CES MRI request form.