Pediatric Emergency Medicine Fellow Riley Hospital for Children at Indiana University Health Avon, Indiana, United States
Background: Children with normal mental status in the emergency department (ED) are at low risk of cervical spine injury (CSI). Pediatric guidelines recommend that cervical spine computed tomography (CT) be reserved for patients with Glasgow Coma Scale (GCS) less than 14 to decrease exposure to ionizing radiation. Objective: We aimed to reduce cervical spine CT imaging from a baseline rate of 40.6% to a rate of 25.6% (15% reduction) in children with GCS 14-15 presenting as blunt traumatic activations to a level-1 pediatric trauma center ED through improvement science methodology. Design/Methods: This study was approved by the Indiana University Institutional Review Board as exempt. A multi-disciplinary team initiated a quality improvement project using the Model for Improvement in activated trauma patients < 18 years of age who were evaluated for cervical spine injury. We completed a retrospective review from January 1, 2022 – October 31, 2022 to obtain our baseline patient sample. There were 423 trauma activations with GCS 14-15 in the pre-intervention period with a cervical spine CT rate of 40.6% (95% CI 35.9-45.2%). We identified key drivers and aimed to reduce cervical spine CT rate in patients with GCS 14-15 by 15%. We created and implemented a cervical spine clearance pathway. Posters of the pathway were hung in trauma bays to serve as visual reminders. A clinical decision tool was integrated into the electronic medical record to assist providers with cervical spine clearance. We met with radiology, general surgery, neurosurgery, and emergency medicine divisions to provide education and training. We are currently conducting our final PDSA cycle which includes individual provider audit and feedback and will be complete in December 2023. Our primary outcome is cervical spine CT rate as the initial imaging modality in patients at low risk of cervical spine injury. Balancing measures include ED length of stay and return to ED or hospitalization within 72 hours for missed cervical spine injury. CT rates are being evaluated over time using statistical process control methodology.
