The Impact of a Complex Consulting Process with Physiatry on Emergency Department Management of Back Pain

Objectives and Design: Prospective interventional trial. Setting: An university hospital emergency department. Patients: Two hundred consecutive persons admitted for back pain before, during, and 6 months after the process was begun. Interventions: Institution of a coordinated process of Emergency physician and patient education, standardized intake and order protocols, and rapid access to Physiatry and physical therapy. Patient characteristics, ED evaluation, ED orders, and 1-month rate of return were measured. Main Outcome Measures: Change in medication, imaging, referral to Physiatry and therapy, and 30-day readmission. Results: Most patients had red flags for danger and yellow flags for disability risk, 19-25% had objective radicular signs, and 14-24% had a second non-spinal complaint. There were no important demographic or pain characteristic changes. Compliance with study paperwork was low (20% patients, 6% physicians). There were significant increases in Physiatry and therapy referrals and a decrease in work restrictions. Medication prescriptions decreased overall, notably NSAID and diazepam prescriptions. Imaging orders did not change significantly. Return visits to the ED for back pain decreased from 16% to 4%, P = 0.02. Physician belief that patients had sciatica decreases (10% to 3%, P = 0.02), and detection of actual dangerous disease increased (3.5% to 6.5%). Conclusions: Even without full compliance with the protocol, this complex consultation process changed emergency management of back pain, most significantly by detecting more dangerous diseases, altering medication prescription habits, and decreasing return visits.