Implementation of an Emergency Department Back Pain Clinical Management Tool on the Early Diagnosis and Testing of Spinal Epidural Abscess.

Abstract

Spinal epidural abscess (SEA) is a rare, catastrophic condition for which diagnostic delays are common. Our national group develops evidence-based guidelines, known as Clinical Management Tools (CMT), to reduce high risk misdiagnoses. We study whether implementation of our back pain CMT improved SEA diagnostic timeliness and testing rates in the emergency department (ED). We conducted a retrospective observational study before and after implementation of a non-traumatic back pain CMT for SEA in a national group. Outcomes included diagnostic timeliness and test utilization. We used regression analysis to compare differences before (01/2016-06/2017) and after (01/2018-12/2019) with 95% confidence intervals (CI) clustered by facility. We graphed monthly testing rates. In 59 EDs, pre vs. post periods included 141,273 (4.8%) vs. 192,244 (4.5%) back pain visits and 188 vs. 369 SEA visits, respectively. After implementation, SEA visits with prior related visits were unchanged (12.2% vs. 13.3%, difference = +1.0%, 95% CI -4.5 to 6.5). Mean days to diagnosis decreased but not significantly (15.2 vs. 11.9 days, difference = -3.3 days, 95% CI -7.1 to 0.6). Back pain visits receiving CT (13.7% vs. 21.1%, difference = +7.3%, 95% CI 6.1 to 8.6) and MRI (2.9% vs. 4.4%, difference = +1.4%, 95% CI 1.0 to 1.9) increased. Spine x-rays decreased (22.6% vs. 20.5%, difference = 2.1%, 95% CI -4.3 to 0.1). Back pain visits receiving erythrocyte sedimentation rate or C-reactive protein increased (1.9% vs. 3.5%, difference = +1.6, 95% CI 1.3 to 1.9). Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related, prior visit or time to SEA diagnosis.