Prospective Evaluation of the Neurology Same Day Emergency Care (NeuroSDEC) Model in Secondary Care: data from 931 patients over the first 12 months.

Prospective Evaluation of the Neurology Same Day Emergency Care (NeuroSDEC) Model in Secondary Care: data from 931 patients over the first 12 months - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Neurol Open . 2026 Apr 9;8(1):e001400. doi: 10.1136/bmjno-2025-001400 Search in PMC Search in PubMed View in NLM Catalog Add to search Prospective Evaluation of the Neurology Same Day Emergency Care (NeuroSDEC) Model in Secondary Care: data from 931 patients over the first 12 months Ali Alim-Marvasti Ali Alim-Marvasti 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK 2 Hillingdon Hospitals NHS Foundation Trust, Uxbridge, England, UK 3 National Hospital for Neurology and Neurosurgery, London, England, UK Find articles by Ali Alim-Marvasti 1, 2, 3, ✉, 0, 1 , Michelle Balaratnam Michelle Balaratnam 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK 3 National Hospital for Neurology and Neurosurgery, London, England, UK Find articles by Michelle Balaratnam 1, 3, 0, 1 , Benjamin Sacks Benjamin Sacks 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Benjamin Sacks 1 , William Bierrum William Bierrum 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by William Bierrum 1 , Maria Francisca Rocha Maria Francisca Rocha 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Maria Francisca Rocha 1 , Isaiah See Isaiah See 4 University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Isaiah See 4 , Roberto Macarimban Roberto Macarimban 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Roberto Macarimban 1 , Charlie Lane Charlie Lane 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Charlie Lane 1 , Nehzat Koohi Nehzat Koohi 5 Neuro-otology, University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Nehzat Koohi 5 , Anne Schlattl Anne Schlattl 6 Ambulatory Care and Medical SDEC, University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Anne Schlattl 6 , Christine Gregson Christine Gregson 6 Ambulatory Care and Medical SDEC, University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Christine Gregson 6 , Ben Killingley Ben Killingley 6 Ambulatory Care and Medical SDEC, University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Ben Killingley 6 , Alun Marc Henry Alun Marc Henry 7 Emergency Department, University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Alun Marc Henry 7 , Timothy Baruah Timothy Baruah 7 Emergency Department, University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Timothy Baruah 7 , Chris Turner Chris Turner 8 Neurology, University College London Hospitals NHS Foundation Trust, London, England, UK 9 MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, England, UK Find articles by Chris Turner 8, 9 , Diego Kaski Diego Kaski 5 Neuro-otology, University College London Hospitals NHS Foundation Trust, London, England, UK Find articles by Diego Kaski 5 , Arvind Chandratheva Arvind Chandratheva 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK 10 Stroke Service, National Hospital for Neurology and Neurosurgery, London, England, UK Find articles by Arvind Chandratheva 1, 10 , Robert Simister Robert Simister 4 University College London Hospitals NHS Foundation Trust, London, England, UK 10 Stroke Service, National Hospital for Neurology and Neurosurgery, London, England, UK Find articles by Robert Simister 4, 10, 2 , Salman Haider Salman Haider 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK 3 National Hospital for Neurology and Neurosurgery, London, England, UK 10 Stroke Service, National Hospital for Neurology and Neurosurgery, London, England, UK Find articles by Salman Haider 1, 3, 10, 2 Author information Article notes Copyright and License information 1 Neurology Same Day Emergency Care (NeuroSDEC), University College London Hospitals NHS Foundation Trust, London, England, UK 2 Hillingdon Hospitals NHS Foundation Trust, Uxbridge, England, UK 3 National Hospital for Neurology and Neurosurgery, London, England, UK 4 University College London Hospitals NHS Foundation Trust, London, England, UK 5 Neuro-otology, University College London Hospitals NHS Foundation Trust, London, England, UK 6 Ambulatory Care and Medical SDEC, University College London Hospitals NHS Foundation Trust, London, England, UK 7 Emergency Department, University College London Hospitals NHS Foundation Trust, London, England, UK 8 Neurology, University College London Hospitals NHS Foundation Trust, London, England, UK 9 MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, England, UK 10 Stroke Service, National Hospital for Neurology and Neurosurgery, London, England, UK Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. Additional supplemental material is published online only. To view, please visit the journal online ( https://doi.org/10.1136/bmjno-2025-001400 ). No, there are no competing interests. ✉ Dr Ali Alim-Marvasti; Alijesus.alim-marvasti@nhs.net 0 AA-M and MB contributed equally. 1 AA-M and MB are joint first authors. 2 RS and SH contributed equally. Received 2025 Oct 15; Accepted 2026 Mar 5; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084849  PMID: 42007401 Abstract Background Acute neurological presentations are common in emergency settings. These are managed with a high rate of misdiagnosis in about one-third of cases. This is the first description of a consultant-led model within an existing same day emergency care service. Methods As part of service evaluations, we prospectively collected data from 931 acute neurological presentations, over the first year since establishing the neurology same day emergency care (NeuroSDEC) embedded within the emergency department (ED) at University College London Hospital. The service was evaluated in terms of diagnostic accuracy, cost-saving and efficiency. Results 60.8% were female, mostly between 25 years and 40 years old. Most referrals were from ED, with the most common presenting symptom of headaches (343 cases, 36.8%). NeuroSDEC reduced lack of diagnosis in over 27% of cases, prevented admissions in over one-third of cases seen, saw same-day cases on average within 1 hour, reduced intended outpatient neurology referrals from 36.4% to 4.8%, cut stroke and transient ischaemic attack clinic referrals in half, completed the care of more than a third of cases (36.1%) exclusively in NeuroSDEC, aborted unnecessary acute brain imaging in 9.7% and cut intended lumbar punctures by 40% (49 reduced to 29). Conclusion Acute neurology presentations challenge acute physicians in distinguishing benign from serious neurological conditions in real time. Our NeuroSDEC model provides a successful example of a transformative healthcare model, safely reducing unnecessary investigations, outpatient referrals, admissions and misdiagnosis rates. A conservative estimate for potential cost savings was £660 000 in admission prevention alone, more than the excess staff cost of £363 000. Keywords: CLINICAL NEUROLOGY, HEALTH ECONOMICS, EVIDENCE-BASED NEUROLOGY, HEALTH POLICY & PRACTICE WHAT IS ALREADY KNOWN ON THIS TOPIC Emergency departments frequently face delays and diagnostic uncertainty in patients presenting with acute neurological symptoms. Same day emergency care (SDEC) models have transformed other specialties, but neurology has lacked a systematically evaluated, consultant-led front-door service. The impact of such a model on admission rates, diagnostic accuracy and service efficiency had not been prospectively studied. WHAT THIS STUDY ADDS This study provides the first prospective, large-scale evaluation of a consultant-delivered neurology SDEC service, demonstrating rapid specialist access, improved diagnostic clarity, reduced unnecessary admissions, investigations and substantial cost savings. It shows that embedding acute neurology within SDEC pathways is feasible and clinically effective. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY The neurology SDEC model offers a scalable template for acute neurology services, supporting national goals to reduce avoidable admissions and streamline emergency care. Future research can build on these findings to optimise multidisciplinary integration, evaluate long-term patient outcomes and inform commissioning policy for acute neurological care across the National Health Service and beyond. Introduction Neurological disorders account for up to 20% of emergency hospital attendances in the National Health Service (NHS), with a high misdiagnosis rate of approximately one in three. 1 , 7 In 2016–2017, there was a 21% increase in emergency neurological admissions with prolonged inpatient stays. 8 In non-stroke acute presentations, this may in part be due to lack of streamlined ambulatory and outpatient pathways and inadequate engagement of neurologists during acute admissions. In contrast, there has been considerable national investment in defining acute stroke pathways. 9 Indeed, only 1.4% (3230 of 1.4 million) of emergency admissions in the UK associated with a neurological diagnostic code were under the care of a neurologist or neurosurgeon in the large-scale analysis of 2019/2020. 5 A joint report by the Association of British Neurologists and Royal College of Physicians, in 2011, emphasised the need for organised acute neurology liaison in-reach to acute medical units and rapid access neurology clinics, with the aim of improving patient care and reducing length of stay (LOS). 6 10 11 The London Neuroscience Strategic Clinical Network (2013–2017) proposed modernising the delivery of neurology services, outlining the case for neurology to move from the traditional outpatient setting to acute and community settings, to improve quality and reduce avoidable general practitioner (GP), outpatient appointments and unplanned emergency admissions. 12 The Getting It Right First Time report identified 136 hospital trusts that provide acute neurology services in England. 13 Acute neurology services have taken various forms across the UK, from overbooking patients into neurology clinics to acute neurologists of the week. 14 There is considerable variation in the organisation of acute neurology services, which the NHS England Neurology Transformation Programme aims to standardise nationally, through the forthcoming outcomes-based acute neurology service commissioning guidelines for integrated care boards. Acute neurology services have been associated with reductions in LOS, admissions and re-admissions. 312 15 , 17 The neurology same day emergency care (NeuroSDEC) service at University College London Hospital (UCLH) was established in 2021, combining acute neurology, liaison and rapid access models into a single physical location delivered at the critical preadmission phase of the patient pathway. In this paper, we describe and evaluate the prospective data obtained from the first year of activity while NeuroSDEC was being established. Methods Clinical setting: UCLH NeuroSDEC setup NeuroSDEC was set up at UCLH embedded in the emergency department in May 2021. The service grew from May 2021 to February 2022, from only a single consultant covering partial weekday afternoons, to three consultants covering a full-time working weekday model running Monday to Friday, 9:00 to 17:00, complete with an advanced nurse practitioner (ANP), two residents (internal medicine trainee (IMT)), doctors and a daily afternoon symptoms-review and test-results follow-up telephone clinic. The NeuroSDEC service provides immediate same-day consultant-led review for patients referred from all departments within the ED, urgent treatment centre (UTC), ambulatory care and the medical take. Acute out-of-hours referrals are discussed with the on-call resident at the National Hospital for Neurology and Neurosurgery (NHNN) and/or referred via a dedicated email address for triage and face-to-face booking. The current cost of the service, which is considerably more than when the service was established, is estimated at £363 k and includes 12.75 Programmed Activities (PA) for consultant cover including Supporting Professional Activities (SPAs), one Whole Time Equivalent (WTE) IMT resident doctor and one WTE ANP. This service was audited prospectively from commencement with predefined categories of data. We used the Standards for Quality Improvement Reporting Excellence guidelines. 18 UCLH serves north central London with a population of 1.8 million people. It is ethnically diverse with 50% of the population Caucasian, 20% Asian and 20% Afro-Caribbean. It is the second most deprived in London, with one in five people living in areas in 20% of the most deprived neighbourhoods nationally. The population is relatively young, with 87% of people below the age of 65 years. 19 Inclusion criteria All patients reviewed by the NeuroSDEC service from 5 May 2021 to 26 May 2022 were included. There was no upper age limit, and the lower age limit was 16 years. Patients were seen based on referral to the service and clinical need. Towards the end of the 12-month period, a new stream of patients within the local catchment area on the 2-week-wait cancer pathway was integrated into the service who were referred via community GPs and had been triaged as not likely cancer but would benefit from acute review. Exclusion criteria Already under an outpatient neurology team without new acute neurological concerns. Out of the area of the hospital catchment area and without any potential acute neurological concerns from the referral history (eg, progressive neurological symptoms or signs, incomplete or insufficient investigations to exclude a potentially evolving neurological condition). Patients whose referrals suggested that they would be best managed under an alternative pathway, for example, those with severe traumatic brain injuries or primarily neurosurgical presentations. Referrals directly from GP through electronic advice and guidance (A&G) to neurology seen in the NeuroSDEC quickly became an exclusion criterion for the service, as the number of 2-week-wait referrals from GP could easily overwhelm the service, which was primarily intended to support pathways to the ED. Therefore, a limited number of patients were seen in the service through GP electronic A&G, before this exclusion criterion was initiated. Patient and public involvement statement Patients were aware that the NeuroSDEC service was newly established both when referred and when seen in the service and were asked for feedback at various points in their service. There was no direct patient and public involvement in this study. Prospective data collection Data for this study were obtained prospectively from consecutive patients attending the NeuroSDEC service from 5 May 2021 to 26 May 2022. These dates were chosen as this period used prospective data capture supervised by the consultant into a pseudonymised spreadsheet held on secure NHS computers for audit purposes. We collected data that could help delineate the value of such a service from the perspectives of diagnostic accuracy, cost-saving and efficiency. Demographics and referral sources Demographics (age, sex). Source of referral (ED majors, ED rapid assessment and triage, ED other encompassing ED resus and minors, GP, out of hours email to neuro SDEC inbox triage, medical take, other neurologist, other specialty). Time from referral to NeuroSDEC review (Efficiency) Time from referral to review. Range of conditions seen and diagnostic impact of NeuroSDEC (accuracy) Initial presenting symptoms were collected prospectively as reported by the patients in their notes to the referring clinician. Retrospectively, patients’ symptoms were also grouped together based on similarity. For example, floaters and positive visual symptoms were classed as visual disturbance, whereas hemianopias were classified as visual loss. Referrer’s working diagnosis. NeuroSDEC working diagnosis. All symptoms and diagnoses were classified into separate groups. If there were multiple symptoms or diagnoses, we analysed only the most pertinent presenting symptoms and primary diagnoses. For example, a presenting symptom of ‘stabbing head pain’ was grouped under headache presentations, while co-occurrence of ‘vertigo and dyspnoea’ was classified under vertigo. Prevention metrics and outcomes (cost savings, accuracy) During the referral process, the referring team and neurologist often prospectively decided on what hypothetical pathway the patient would have been referred to in the absence of NeuroSDEC and if any scans would have been performed by the referring team. If this was not available prospectively, it was determined retrospectively (see below). If, after review in NeuroSDEC, patients did not require an investigation or referral to another service, then this was documented as a prevention. We considered the following preventions: Admission prevention, that is, admission under medical take team would have been the default pathway without NeuroSDEC. Prevented referral to outpatient general neurology clinic, that is, no longer required after reviewed in NeuroSDEC. Stroke or transient ischaemic attack (TIA) clinic referrals prevented—that is, would have been referred to stroke or TIA clinic in the absence of NeuroSDEC. Unnecessary imaging aborted: CT or CT angiography, MRI; if after review in NeuroSDEC no imaging was required. Unnecessary lumbar puncture (LP) aborted, for example, working diagnosis from referrer, but not NeuroSDEC, warranted LP. The following outcomes were recorded prospectively: Discharged either as ‘care completed’ or further GP input required for a non-neurological complaint. Care completed was defined as no further hospital or GP outpatient input was required for the presenting complaint. NeuroSDEC telephone clinic follow-up, which was booked from 1 week to 6 weeks after NeuroSDEC review to check on symptoms, any treatment effects and pending test results. Referral to general neurology outpatients as long-term follow-up for a chronic condition. Direct referral to subspecialty neurology clinic (stroke, neuro-otology, neuro-ophthalmology, diagnostic demyelination clinic for first presentations, neurosurgery, first seizure). Admitted to hospital (UCLH/NHNN). To help identify which patients could be appropriately categorised as an avoided admission, discussions were held with experienced co-authors. The following criteria were used as admission prevention, as previous. 20 Persisting headache with or without focal neurology requiring specialist intervention (eg, needing urgent LP, Greater Occipital Nerve (GON) block, intravenous magnesium). Referred from medical take to NeuroSDEC. Would have otherwise been referred to medical take by ED team. Presentation needing urgent further investigations, for example, next day/urgent MRI. Urgent neurology review is recommended by specialties such as stroke or neurosurgery. Prospective and supplemented retrospective data collection Data that could not be collected prospectively were collected retrospectively from the electronic health record, where available. Dates of referral and dates seen were clear in the notes. Time of referral was also obtained through EPIC notes or via filtering the triage email inbox. Time seen was obtained retrospectively by looking at the timestamp of the first NeuroSDEC notes. Comparator data UCLH ambulatory care/ED referrals to outpatient neurology Internal outcomes: the difference between ED and NeuroSDEC working diagnoses. National data (eg, https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2021-22/ ). Statistical analyses Data were analysed in Python (V.3.9.15) available from the Python Software Foundation online ( http://www.python.org ). Continuous data were assessed for normality using both histogram plots and Shapiro-Wilk tests. Normally distributed variables were compared using Student’s t-test and non-normally distributed variables using the Mann-Whitney U (MWU) test. Comparisons of proportions between groups were performed using the χ² test. Fisher’s exact test was used if expected cell counts were <5. Type I alpha level of significance was set at 0.05. Where we quote prevention metrics with missing data in the results, in order not to over-estimate the effectiveness of the service, we quote the proportion with the denominator as the total number of cases (931) to give a conservative lower limit. Ethical approval This study was approved by the Queen Square Quality and Safety Team at the NHNN, as a quality improvement project and audit in the department of stroke and acute neurology using pseudonymised data (registration number 65–2 02 526 SE). Results Data pertaining to 931 patients were obtained prospectively over 227 half-day sessions. Demographics and referral sources 60.8% of patients were female (p<0.0001), the majority were between 25 years and 40 years old (median 40 years, range 18–91 years, table 1 and figure 1 ). Females seen in the service were on average 4 years younger, with a median of 38.0 years compared with 42.0 years in men (MWU 99270, p=0.002). Table 1. Demographics of sex and age of patients seen in NeuroSDEC (n=931). Demographics n (%) Female 566 (60.8%) Male 334 (35.9%) Non-binary 1 (0.1%) Missing sex 30 (3.2%) Age (years) (mean±SD) Median (IQR) Mode Minimum–maximum 43.1±16.2 40 (30–54) 37 18–91 Missing age 48 (5.2%) Open in a new tab NeuroSDEC, neurology same day emergency care. Figure 1. Demographics. Open in a new tab Patients’ ages were skewed towards 25–40 years (Shapiro-Wilk male: p<0.0001 and female: p<0.0001) ( figure 1 ). Overall, most referrals were from the ED department (31.4% of all cases), of which 250 (26.9%) were from ED majors (41 from ED rapid access and triage or minors, 87 referred out-of-hours, and two from ED minors, figure 2 ). 14.4% of cases seen were referred via GPs (n=134), the majority of which came from the UTC embedded within UCH ED (n=83), referred from GP via ambulatory care and seen directly by NeuroSDEC (n=26), or through electronic A&G direct to general neurology (n=25) (see the Exclusion criteria section). 87 cases (9.3%) were referred out of hours. There were 63 missing data points (6.7%) on referral source. 60 (6.4%) cases were seen immediately following medical take for early consultant-led neurology input prior. 47 cases had been referred from a neurologist (on-call registrar from NHNN, acute attending neurologist for admission prevention or early discharge). 18 patients were seen in NeuroSDEC who had been referred by other medical specialties, and 18 directly from Moorfields Eye Hospital. Eight cases that were either en route to the hyperacute stroke unit or diverted to NeuroSDEC ( figure 2 ). Figure 2. Sources of referral to NeuroSDEC. ED, emergency department; GP, general practitioner; NeuroSDEC, neurology same day emergency care; RAT, rapid access and triage. Open in a new tab Time from referral to review 876 cases had data for both date of referral and date seen in NeuroSDEC. The median time from referral to review was 0 days (IQR 0–1) (range 0–10 days, figure 3 ). 627 were seen on the same day. Figure 3. Time from referral to review in NeuroSDEC during the first year of establishing the service. NeuroSDEC, neurology same day emergency care. Open in a new tab 680 of 876 cases also had the time of referral and the time seen in NeuroSDEC, of which 488 were seen on the same day (IQR 0–1 hour). Range of conditions seen and diagnostic impact of NeuroSDEC Initial presenting symptom We had prospective data on initial presenting symptom or most prominent symptom in 713, referrers’ working diagnoses in 794 and neurologists’ diagnoses in 827 cases. The most common presenting complaints were headaches (48.8%), sensory disturbances including paraesthesia and numbness (10.4%), limb or facial weakness (9.8%), acute vertigo or dizziness with or without vomiting (7.9%). Visual symptoms cumulatively made up 4.1% of all cases, involving reported diplopia, visual disturbance (floaters, blurred vision, positive auras) and visual loss (reported hemianopia, quadrantanopia and visual loss) ( table 2 ). Table 2. Distribution of symptoms seen in NeuroSDEC. Most prominent or initial presenting symptom (categorised) Number of cases (n=931, %) Headaches 343 (36.8%) Somatosensory 76 (8.2%) Weakness 63 (6.8%) Dizziness/vertigo 57 (6.1%) Pain 29 (3.1%) Reported seizure 26 (2.8%) Confusion/consciousness 16 (1.7%) Syncope/collapse 15 (1.6%) Diplopia 11 (1.2%) Visual disturbance 11 (1.2%) Shaking or twitching 10 (1.1%) Dysphasia/aphasia 9 (1.0%) Generally unwell (systemic or polysymptomatic) 9 (1.0%) Foot drop 7 (0.8%) Visual loss 6 (0.6%) Unsteady 6 (0.6%) Head injury 4 (0.4%) Hyperkinetic 3 (0.3%) Hearing loss 2 (0.2%) Dysarthria 2 (0.2%) Ptosis 2 (0.2%) Other 6 (0.6%) Not stated or missing 218 (23.4%) Open in a new tab NeuroSDEC, neurology same day emergency care. The rare cases categorised as other (n=6, table 2 ) included one case each of Multiple Sclerosis (MS) relapse (out of area and not under an MS team hence exception was made against exclusion criteria for NeuroSDEC), leg swelling, hemifacial spasm, dyspnoea, dysphagia and incontinence. Under a quarter of presenting complaints were missing (23.4%, table 2 ). Referrers’ working diagnoses Overall, 35.2%–34.6% of all referrals to NeuroSDEC had no specific documented working diagnosis (and a further 6.8% had missing data). This was made up of 17.7% who had the presenting symptom as the working diagnosis (eg, ‘right upper limb weakness’ or ‘vertigo’), a further 16.9% had ‘headache’ not otherwise specified and 0.6% unclear central versus peripheral working diagnosis ( table 3 ). Table 3. Referrer’s working diagnosis. Referrer’s working diagnosis (categorised) Number of cases (n=931) Percentage (%) None (symptom-based ) 165 17.7 Headache NOS 157 16.9 Migraine 129 13.9 Ischaemic stroke 50 5.4 Seizure/epilepsy 48 5.2 Demyelination 29 3.1 IIH 21 2.3 SAH 18 1.9 Radiculopathy 16 1.7 TIA 15 1.6 Bell’s palsy 12 1.3 CNS differentials 12 1.3 Vestibular 11 1.2 FND 10 1.1 Cranial neuropathy 10 1.1 Cluster headache 10 1.1 Headache (thunderclap) 9 1 TBI 9 1 BPPV 8 0.9 Neuromuscular/MG 8 0.9 Trigeminal neuralgia 8 0.9 Cord syndrome 8 0.9 GBS 7 0.8 Foot drop 7 0.8 Central versus peripheral 6 0.6 CVST 6 0.6 Headache (coital) 5 0.5 CTS 4 0.4 Headache (red flag) 4 0.4 Brachial plexopathy 3 0.3 Tension headache 3 0.3 Meningo/encephalitis 3 0.3 Peripheral neuropathy 3 0.3 Other 54 6 Missing 63 6.8 Open in a new tab Diagnoses which lacked a specific working diagnosis are shown in italics. BPPV, benign paroxysmal positional vertigo; CNS, Central Nervous System; CTS, carpal tunnel syndrome; CVST, cerebral venous sinus thrombosis; FND, functional neurological disorder; GBS, Guillain-Barré syndrome; IIH, idiopathic intracranial hypertension; MG, myasthenia gravis; NOS, not otherwise specified; SAH, subarachnoid haemorrhage; TBI, traumatic brain injury; TIA, transient ischaemic attack. The most common working diagnosis was migraines, with 129 cases (n=13.9%). The next most common working diagnoses were ischaemic strokes, seizures, CNS demyelination and idiopathic intracranial hypertension ( table 3 ). 6.8% of the data were missing ( table 3 ). The comparison between the presenting symptom and referrer’s diagnosis can be seen in the Sankey diagram ( online supplemental figure 1 ). Patients presenting with headaches or pain most frequently had no working diagnosis, and a considerable proportion of weakness and dizziness/vertigo presentations also had no working diagnosis. Neurologists’ working diagnoses Migraines were the most diagnosed condition in NeuroSDEC ( table 4 ). Lack of a specific working diagnosis ( italics ) reduced to 4.3% and 10.4% missing data for NeuroSDEC ( table 4 ). Table 4. Neurologist’s working diagnosis on referral to NeuroSDEC. Neurologist’s working diagnosis (categorised) Number of cases (n=931) Percentage (%) Migraine without aura 277 29.8 Status migrainosus 72 7.7 Seizure 35 3.8 FND 30 3.2 Ischaemic stroke 26 2.8 None (symptom-based ) 24 2.6 Radiculopathy 23 2.5 Multiple sclerosis 22 2.4 Non-neurological 17 1.8 Idiopathic intracranial hypertension 15 1.6 Bell’s palsy 14 1.5 Syncope or presyncope 12 1.3 Transient ischaemic attack 11 1.2 Differentials 11 1.2 CNS differentials 11 1.2 Cluster headache 11 1.2 Vestibular neuritis 10 1.1 Common peroneal nerve palsy 10 1.1 Headache NOS 10 1.1 Cranial neuropathy 9 1 BPPV 9 1 Headache (low pressure) 7 0.8 Demyelination 7 0.8 Myelopathy 7 0.8 Headache (coital) 7 0.8 Peripheral neuropathy 7 0.8 Neuroinflammatory 6 0.6 Systemic/toxic/metabolic 6 0.6 Cervicogenic headache 6 0.6 Mild TBI 6 0.6 Central vs peripheral 6 0.6 Optic neuritis 5 0.5 Epilepsy 5 0.5 Neoplastic 5 0.5 Trigeminal neuralgia 5 0.5 Primary exertional headache 5 0.5 Ulnar neuropathy 5 0.5 Dissection 5 0.5 Myasthenia gravis 5 0.5 Vasculitis 4 0.4 Brachial neuritis 4 0.4 Headache (thunderclap) 4 0.4 Hemicrania continua 3 0.3 Transient global amnesia 3 0.3 Parkinsonism 3 0.3 Guillain-Barré syndrome 3 0.3 B12 deficiency 3 0.3 SUNA/SUNCT 3 0.3 Holmes-Adie 3 0.3 Neurodegenerative 3 0.3 Other 34 3.7 Not stated or missing 97 10.4 Open in a new tab Diagnoses which lacked a specific working diagnosis are shown in italics. BPPV, benign paroxysmal positional vertigo; CNS, Central Nervous System; FND, functional neurological disorder; NOS, not otherwise specified; SUNA, Short-lasting Unilateral Neuralgiform headache attacks with cranial Autonomic symptoms; SUNCT, Short-lasting Unilateral Neuralgiform headache with Conjunctival Injection and Tearing; TBI, traumatic brain injury. Prevention metrics and outcomes Prospective data on admissions prevented were available from 673, from which 320 potential admissions were prevented (47.5% of 673 or 34.4% of all 931 individuals). 87/931 were referred out of hours and seen in NeuroSDEC to facilitate early discharge from the ED (9.3% of all cases). 740/931 cases had data on outpatient referrals prevented. 339 (45.8% or 36.4% of all cases) total potential outpatient neurology referrals were reduced to 45/931 (4.8%) ( figure 4 ). Figure 4. Outcomes from NeuroSDEC review. ‘SDEC results clinic’: care completed at follow-up appointment. ‘Care completed’: care completed at first appointment. ESU, early stroke unitEarly Stroke Unit; FND, functional neurological disorderFunctional Neurological Disorder; GP, gGeneral pPractitioner; MHLT, mental health liaison teamMental Health Liaison Team; NeuroSDEC, neurology same day emergency care; NHNN, National Hospital for Neurology and Neurosurgery; OPD, outpatients department; TBI, traumatic brain injury; TIA, transient ischaemic attackTransient Ischaemic Attack. Open in a new tab Stroke and TIA referrals were avoided in 286/931 of all cases (30.7%), and there was a considerable overlap with prevented admissions (overlap in 217 cases). There were 271 missing datapoints on stroke/TIA referrals prevented (therefore referrals avoided from available data 286/660=43%). On the other hand, 145 (15.6%) cases were referred to TIA/stroke clinic after initial investigation and treatment in NeuroSDEC ( figure 4 ). Overall, more than a third of cases (36.1%) were exclusively treated in NeuroSDEC (336/931), of which 208 (25%) required symptoms review and results follow-up in telephone clinic. A further 62 (7%) had their neurology care completed but required further input from the GP ( figure 4 ). A total of 82/931 patients (8.8%) were admitted from NeuroSDEC, the majority (60) via the medical take, 19 directly to NHNN and three to the hyperacute stroke unit ( figure 4 ). Planned acute brain imaging was aborted in 90/931 patients (9.7%). 49 possible or planned lumbar punctures were also aborted (compared with 29 LPs performed). 36 of the 49 aborted LPs (73.5%) were directly because the neurologist’s diagnosis differed from that of the referrer’s (whereas 13 LPs were avoided because of altered clinical management plans). Discussion Acute neurological presentations constitute a large and ever-growing proportion of ED attendances in the UK. The NeuroSDEC model counters the pressures on the emergency services and acute medical beds within the NHS by addressing the significant misdiagnosis rate in the ED and lack of engagement by neurologists. 1 2 4 5 By bringing the neurologists to the front door, our service addresses the requirements by the NHS England transformation programme; it is proactive, responsive and enables patients to be reviewed at the acute presentation. Our study is unique in that it curated prospective NeuroSDEC data and evaluated the service from several perspectives, with results that highlight a reduced misdiagnosis/lack of diagnosis from 35.2% (and 6.8% missing data) to 4.3% (and 10.4% missing data) representing a neurological working diagnosis contribution to over 27% of cases, prevented admissions in over one-third of cases seen, same-day cases seen on average within 1 hour, reduced intended outpatient neurology referrals from 36.4% to 4.8%, cut stroke and TIA clinic referrals in half, completed the care of more than one-third of cases (36.1%) exclusively in NeuroSDEC, aborted unnecessary acute brain imaging in 9.7%, and cut intended LPs by 40% (49 reduced to 29). The impact of neurology liaison services has been highlighted in several early UK-based hospital studies showing that involvement of specialist neurology input leads to a change in diagnosis as well as reduced length of inpatient stay. Data from these historical control studies show that management of neurological presentations by non-specialist teams can take on average 6 days of inpatient bed, which after liaison neurology reduced to three nights’ stay. 11 21 It can be inferred from these previous studies that earlier neurology involvement at the front door of the hospital would significantly help prevent admissions and LOS further, and this is quantified in our study. Our data suggest that constructing a working diagnosis in ED can be difficult, especially for patients referred to neurology with headaches, pain, dizziness and vertigo, with up to 34.6% lacking a specific working diagnosis or differential. Even early studies had shown that a new neurological diagnosis is contributed or an incorrect neurological diagnosis is changed in over 50% of patients seen by liaison neurology. 21 Further studies are required to ascertain whether physician and ED education on developing focused differential diagnoses on these limited symptoms and presentations might dent the approximately one in three misdiagnosis rates. 22 The presence of acute neurology consultants in ED is central to this NeuroSDEC model, with rapid access to neuroimaging and acute diagnostics, allowing for senior same-day decision-making in over 70% of cases, enabling significant admission prevention 16 ; this is not possible with rapid access clinics and in-reach liaison models. NeuroSDEC is therefore the preferred model consistent with the 2024 NHS SDEC 23 and SAMEDAY NHS strategy. 24 Rapid reviews within 1 hour in our study are similar to some other non-neurology SDEC studies 25 but are faster than long ED waiting times, other SDEC studies 23 and faster than the outpatient neurology data for the same trust during the same 12 months, when only 84% of patients were treated within 18 weeks of referral (referral to treatment, RTT) based on provider-reported RTT data (median waiting time per month, range: 6.5–9.6 weeks). 26 Patients are also seen in NeuroSDEC on average five times faster and reach a diagnosis 1 month sooner than those seen on the 2-week-wait NHS cancer-referral pathway to neurology outpatients at NHNN. 27 Based on a lower bound estimate for the average standard bed cost of £345 per day 28 and an average duration of stay between 3 days and 6 days (4.5 days in 2019/2020, 29 and the first year of the NeuroSDEC service resulting in at least 320 prevented admissions), we estimate a cost saving of between £330 000 and £660,000 annually (£345 × range(3–6) × 320). It should be noted that this is a conservative figure for a part-time newly set-up service. A full-time NeuroSDEC service without missing data, and adding cost-savings from aborted outpatient referrals, scans and LPs, would significantly raise this figure. Therefore, the annual cost savings presented here are a lower bound estimate on the potential annual cost savings of the NeuroSDEC service. On the other hand, as our service was implemented in an existing ambulatory care department and used existing infrastructure, additional costs of our service are therefore limited to staffing which for the duration of this study was £363 000. This NeuroSDEC service model does not require acute stroke or tertiary neurological subspecialties and can therefore be replicated across the NHS. However, our service is uniquely integrated with a tertiary regional neuroscience centre, and since the collection of this prospective data, subspecialised care pathways have been developed: a dedicated hyperacute neuro-otology and vestibular service (the fourth most common presenting symptom to the service, table 2 ) and an acute functional neurological disorder pathway (the fourth most common neurological diagnosis, table 4 ). 30 31 Nevertheless, it must be noted that no subspecialist services were available in the NeuroSDEC service. Contemporary unpublished analysis of prospectively collected data in 2025 over 2 weeks shows that the service provided input to 19.3 patients on average per day, including same day interventions such as GON block, intravenous magnesium infusions. The results include 67% admission prevention, 35% stroke/TIA and 47% neurology outpatient referrals avoided, and 81% of patients’ care was completed within 31 days. Out-of-hours referrals grew from 9.3% during the first year to 22% in 2025, and instead of 25%, 80% of patients were being followed up in telephone clinics. The wider applicability of this model, which is not dependent on subspecialty neurological services, should be carefully considered. UCLH does not have neurology inpatient beds and prior to NeuroSDEC had only a traditional liaison neurology outreach model for inpatients. The demographics of our patients, including the common presentation of headache, are consistent with headaches accounting for up to 4% of all ED visits. 32 Bed numbers across the NHS in England have more than halved over the last 35 years 29 , and SDEC models help keep patients in the community. The SDEC model will become increasingly relevant with the shift from hospital to community care as part of the NHS 10-year plan. Finally, with neurology trainees now undertaking internal and acute medical training, the shape of training may develop and drive the specialty of acute neurology into emergency care environments. Limitations Evaluating a new service with prospective data carries many challenges; nearly a quarter of patients’ presenting symptoms were missing. Although we attempted to evaluate the service from multiple perspectives and along with the referrer’s intended management, this process is not unbiased. For example, prevention metrics could be subjective and prone to optimism bias as the referring team and neurologist prospectively decided on what hypothetical pathway the patient would have been referred to had NeuroSDEC not been available. In this prospective data, 52 referral dates (5.6%) and 24 dates on which patients were seen in the service (2.6%) were missing. However, there was substantially more missing data regarding the time of referral (n=217, 23.3%) and time seen (n=215, 23.1%), reflecting the challenge encountered in prospectively recording the time of first review simultaneously while prioritising patient care. Control data are also difficult to obtain due to COVID-19 skew of cases before and after this study. Conclusions Four key motivators: A substantial number of emergency attendances are due to neurological symptoms. The proportion of patients with neurological disease attending ED is increasing. There is a high rate of misdiagnosis in these patients. There is a lack of neurology consultant engagement in acute neurological presentations. All the above four factors lead to many admissions and prolonged stays with high cost and inefficient outcomes. Key components and summary of setup: Consultant-led, embedded acute NeuroSDEC in ED (Mondays–Fridays at peak hours). ANP works with the consultant to coordinate and deliver patient care. Immediate same-day consultant neurologist review and care of patients referred from UTC, GP, ambulatory care, medical take, ED majors, minors and resus. The service was slowly ramped up for 8 months, initially with only one consultant with partial afternoon cover, then three consultants covering weekdays, then with ANP support, then with junior IMT trainees (May 2021–February 2022). Key NeuroSDEC results: Reduced lack of working diagnosis by over 27%. Prevented admissions in over one-third of cases seen. Same-day cases seen on average within 1 hour. Reduced intended outpatient neurology referrals from 36.4% to 4.8%. Cut stroke and TIA clinic referrals in half. Completed the care of more than a third of cases (36.1%) exclusively in NeuroSDEC. Aborted unnecessary acute brain imaging in 9.7%. Cut intended LPs by 40% (49 reduced to 29). Annual savings, just from admission prevention, upwards of £660k while the service was being established, with current staffing costs estimated at £363k. Supplementary material online supplemental figure 1 bmjno-8-1-s001.html (3.6MB, html) DOI: 10.1136/bmjno-2025-001400 Footnotes Funding: All authors were employees of University College London Healthcare NHS Foundation Trust (UCLH). Part funding for the service was received from UCLH Charity (Grant Number N/A). RS is part funded by the UCLH BRC. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Not applicable. Data availability statement Data are available upon reasonable request. References 1. Moeller JJ, Kurniawan J, Gubitz GJ, et al. Diagnostic Accuracy of Neurological Problems in the Emergency Department. Can j neurol sci. 2008;35:335–41. doi: 10.1017/S0317167100008921. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Rizos T, Jüttler E, Sykora M, et al. 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[ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials online supplemental figure 1 bmjno-8-1-s001.html (3.6MB, html) DOI: 10.1136/bmjno-2025-001400 Data Availability Statement Data are available upon reasonable request. 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