Impact of strategies to improve flow and lower hospital admissions for low back pain in the emergency department: an interrupted time-series analysis

Background Low back pain (LBP) is a common, disabling condition that often results in presentation to the emergency department (ED). There is currently a paucity of research examining how to optimise care for this patient group and concurrently improve service efficiency. We assessed the impact of a suite of co-designed strategies to improve the flow and reduce admission rate of people with LBP presenting to the ED. Methods A quasi-experimental implementation science study in a 30-bed ED at an Australian tertiary referral hospital. We implemented four improvement strategies: (1) co-design and development of a local ED guideline, (2) patient handout, (3) clinician education programme and (4) rapid-access physiotherapy follow-up clinic. We included all ED presentations from patients ≥16 years old, with a final diagnosis of LBP. Using an interrupted time series analysis, we compared a pre-implementation phase (July 2014–December 2019), a transition phase (July 2020–February 2021) and a post implementation phase (March 2021–November 2021). Our primary outcome was the proportion of patients admitted to hospital, in each phase. Secondary outcomes included ED length of stay (LOS), ED presentation cost, re-presentations within five days, admission LOS and outcome measures for those patients who attended the rapid-access physiotherapy clinic. Results There were 5301 LBP presentations pre-implementation, 752 during transition and 732 post implementation. The mean age of patients was 50.3 (20.1) years, 53% were female and 6.5% identified as Aboriginal and/or Torres Strait Islander. We observed a small reduction (2%) in the proportion of admissions per month (post implementation vs pre-implementation slope difference 0.98 ((95% CI 0.928 to 1.035), p=0.467) and a monthly decrease of 1.5 min in the average ED LOS for these patients (post implementation vs pre-implementation slope difference −1.5 ((95% CI −8.1 to 5.1), p=0.653) which was not statistically significant. 121 patients were referred to the follow-up physiotherapy clinic, and 41% attended an appointment. Conclusion The improvement strategies did not significantly reduce admissions or LOS for people with LBP presenting to the ED, and based on the CIs, we cannot exclude that these increased. times, admission into hospital may be appropriate, for example, if urgent imaging or intervention that is not available in the ED is required or if the person would be unsafe at home. However, there appears to be substantial variation in admissions between hospitals.¹⁰ Reducing the number of potentially inappropriate admissions for LBP that could be managed in primary care has the benefit of avoiding risks related to low-value care and hospital-acquired complications (eg, falls), while also producing considerable cost savings due to the high costs of hospital admissions for LBP.^{11 12} The clinical care provided by ED clinicians is patient-centred, but at the same time, EDs need to meet key performance indicators related to the flow of patients (eg, time to treatment, ED length of stay (LOS), admissions from ED).¹³