An audit of cervical spine imaging in alert and stable trauma patients

1. An audit of cervical spine imaging in alert and stable trauma patients Accident and Emergency Department, Whittington Hospital, London Yenzhi Tang, Marianna Thomas, Mike SpiroFoundation Year 2 Doctors in Emergency Medicine January 2007

2. Aim • To compare assessment and C spine radiography in alert stable patients with head/neck trauma presenting to Whittington Hospital Emergency Department, to Canadian C spine rules for radiography

3. Current Practice • No guidelines on the Whittington intranet • No NICE guidelines • No current proforma/standard for assessing pts at risk of C spine fracture

4. Standard • Target level 100%

5. Canadian C spine rules

6. Background • Canadian C spine rule developed from a prospective cohort of alert, stable patients with head/neck trauma. • Pts from 10 Canadian EDs between 1996-1999. (n=8924) • Developed in response to wide variation in indications for requesting C spine x rays

7. Background • Prospectively validated in a large multicentre trial (n=7017) • 99.3% sensitivity (95% CI 96-100) • Specificity 45.1% • Shown to be superior to NEXUS by prospective study by Stiell

8. Audit • Population • Adults presenting to ED with blunt trauma to head/neck, stable vital signs, GCS 15

9. Audit • Exclusions • Known vertebral disease • Pregnant women • <16 • >48 h after injury • Penetrating trauma • Acute paralysis

10. High risk group • >65 • Paraesthesia in extremities • Dangerous mechanism • Fall from >1 metre or stairs • Axial load to head • MVC at high speed >62mph • Motorized recreational vehicles • Bicycle collisions

11. Low Risk Group • Should have C spine ROM assessed if walking, sitting, nil c spine tenderness, nil paraesthesia • If less than 45 degrees rotation to each side then X ray • If full ROM then no radiography

12. Method • Retrospective audit • Pts selected from a 3 week period • Case note analysis • EDIS used to identify pts triaged with neck pain/head injury/neck strain/ RTA

13. Results • 36 pts over 3 weeks • 5 excluded • 4 not meeting criteria • 1 set of notes not found

14. Results • In the high risk group (total 8) 5 had x rays • No fractures imaged in all 5 x rays • None of the X rays were adequate views, none had C1 –T1. None were repeated or had subsequent CT spine

15. Results • Low Risk group • One pt had x ray • No fractures • Difficult to interpret ED performance b/c of lack of documentation

16. Conclusions • Poor documentation • 9/22 in low risk group did not document ROM • Poor knowledge and application of C spine rules • 3/10 ED doctors have heard of C spine rules • 1/10 have used it • 1/10 know the algorithm

17. Conclusions • Radiographers need to be informed of their inadequate views • -can present findings to radiographers • SHO competent in interpreting c spine x rays • Rules open to interpretation: low risk criteria?

18. PLAN • Present findings to ED doctors, emphasize need for better documentation • Put algorithm in majors and minors desk • Incorporate rules into Whittington ED head proforma • Re audit in 3-6 months

19. References • Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286:1841–1848. • Stiell et al Acad Emerg Med 2002 Volume 9, Number 5 359-360 • Hoffman et al Ann Emerg Med 1992; 21 (12): 1454-60 • Stiell et al NEJM Vol 349: 2510-2518 (2003)