Rethinking Emergency Care for Low Back Pain: Lessons from a Same Day Emergency Care Model

Posted by ma403

8 July 2026

Eleanor Dunstan and Lianne Wood on behalf of the author team.

This is a summary blog of the paper accepted in the EMJ: Dunstan et al., Same day emergency care for low back pain: quality improvement to support emergency flow and reduce unnecessary acute admissions https://tinyurl.com/35e2367s .

Low back pain (LBP) is one of the most common reasons for emergency department (ED) attendance, yet most patients do not require hospital admission. Despite this, admission rates remain high, placing pressure on already stretched services and exposing patients to low-value care.

In our recent quality improvement project at Nottingham University Hospitals, we set out to address this challenge by redesigning how LBP is managed at the ED–spinal interface. The result was the development and embedding of a same day emergency care (SDEC) pathway, delivered by a specialist multidisciplinary team and led by advanced practice physiotherapists (APPs).

What did we do?

We repurposed a 12‑bedded unit adjacent to the spinal wards, creating a dedicated SDEC unit for patients with non-traumatic spinal pain. The service was co-designed with ED clinicians, spinal surgeons, radiology and patients, ensuring it met both clinical and operational needs.

Key features included:

Senior decision-making by APPs or spinal fellows, enabling rapid assessment and treatment
Direct referral pathways from ED (and later primary care)
Access to same-day MRI when clinically indicated
A focus on assessment, reassurance, and conservative management, aligned with guideline-based care

The pathway was developed iteratively over four plan–do–study–act (PDSA) cycles, allowing ongoing refinement based on real-world feedback and data.

What were the outcomes?

Over three years, we saw more than 3,900 referrals to the SDEC pathway. As the service matured, several key improvements emerged:

Hospital admissions fell substantially, from around 31% in early phases to just 8% once the model was embedded
Length of stay remained short, typically around 2–3 hours
Same-day MRI utilisation remained low and appropriate (around 6–15%)
Patient satisfaction was high, with over 96% recommending the service

Importantly, these improvements were progressive and sustained, reflecting both increased system engagement and optimisation of the pathway over time.

Why did it work?

Several factors were critical to success:

Senior clinical decision-making

APPs, with their expertise in musculoskeletal care and biopsychosocial management, were well positioned to provide supportive reassurance, holistic care and discharge decisions with support from the spinal on call team to avoid unnecessary admission.

Whole-system collaboration

The pathway was not an ED initiative alone—it relied on strong partnerships between ED, spinal services, radiology and primary care. An ED–spinal interface group was key to maintaining alignment.

Iterative improvement

Using PDSA cycles allowed us to identify barriers early (e.g. low referrals, inconsistent handovers) and adapt rapidly—whether through education, process redesign or workforce changes.

Focus on flow, not just care delivery

By creating a dedicated pathway outside the ED, we improved both patient experience and departmental flow, aligning with broader SDEC principles of delivering “right care, right place, right time”.

What should other services consider?

For clinicians and healthcare leaders looking to implement a similar model, a few key lessons stand out:

Engage stakeholders early and often – co-design builds ownership and sustainability
Invest in workforce capability – senior decision-makers are essential
Make referral pathways simple and visible to drive uptake
Measure what matters, including admissions, flow and patient experience
Expect iteration – successful models evolve over time

Final thoughts

Our findings suggest that a spinal SDEC pathway is a feasible and effective alternative to traditional ED pathways for patients with non-traumatic LBP. While further work is needed to evaluate cost-effectiveness and long-term outcomes, this model offers a practical way to reduce unnecessary admissions and improve system efficiency.

At a time of increasing demand on ED services, rethinking pathways for common conditions like LBP presents a real opportunity for meaningful transformation.