Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess

Angela G Cai; Mark S Zocchi; Jestin N Carlson; John Bedolla; Jesse M Pines

doi:10.1111/acem.14765

Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess

Acad Emerg Med. 2023 Oct;30(10):995-1001. doi: 10.1111/acem.14765. Epub 2023 Jul 5.

Authors

Angela G Cai^{1

2}, Mark S Zocchi³, Jestin N Carlson^{2

4}, John Bedolla^{2

5}, Jesse M Pines^{2

4}

Affiliations

¹ Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
² US Acute Care Solutions, Canton, Ohio, USA.
³ Department of Health Policy, Heller School for Social Policy and Management, Waltham, Massachusetts, USA.
⁴ Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
⁵ Department of Emergency Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA.

PMID: 37326026
DOI: 10.1111/acem.14765

Abstract

Background: 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).

Methods: We conducted a retrospective observational study before and after implementation of a nontraumatic back pain CMT for SEA in a national group. Outcomes included diagnostic timeliness and test utilization. We used regression analysis to compare differences before (January 2016-June 2017) and after (January 2018-December 2019) with 95% confidence intervals (CIs) clustered by facility. We graphed monthly testing rates.

Results: In 59 EDs, pre versus post periods included 141,273 (4.8%) versus 192,244 (4.5%) back pain visits and 188 versus 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 number of days to diagnosis decreased but not significantly (15.2 days vs. 11.9 days, difference -3.3 days, 95% CI -7.1 to 0.6 days). 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%).

Conclusions: 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.

Keywords: back pain; clinical decision rules; imaging utilization; laboratory utilization; quality improvement; spinal epidural abscess.