DOI: 10.1093/bjs/znad258.539 ISSN:

1080 A Quality Improvement Project Developing a 'Return to Scan' Failsafe Protocol for Barnsley Hospital Emergency Department Patients with Suspected Cauda Equina and Renal Colic

A Luesley, C Ginnis, J Emberey, I Soar, S Pitt
  • Surgery



A staff survey noted patients returning for scans for suspected cauda equina and renal colic were on occasion not returning or returning late. Overall, staff and patient experience were poor and posed risk to patients. To improve this, aims were to develop a standard process for recording ED patients due to return for scan and formalised information about this process to be provided to the patient.


Three cycles were completed. Staff surveys identified areas of concern, supported by a fishbone diagram and process map. A proforma and patient information sheet were developed. Further staff surveys assessed satisfaction and effectiveness of the changes, leading to replacement of the proforma with a patient notes sticker. A booking system was created identifying patients to reception staff. Further cycles identified 64 patients in a 3-month period by suspected diagnosis using SNOMED codes. Records were accessed electronically using Mediviewer to review documentation and time returned for scan.


98% of patients returned for scan. Process followed: 36% of patients returned late, with an average of 22 minutes and maximum of 40 minutes late. Process not followed: 36% of patients returned late, with an average of 58 minutes and maximum of 219 minutes late. The process was followed correctly in 17% of cases.


Patients were late by a shorter on average time when the process was followed - with providing patient information having the greatest positive impact. Staff education may improve process compliance which is poor. Patient experience and barriers to returning on time must be explored.

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