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.