The effect of introducing guidelines for cervical spine radiographs in the accident and emergency department

Effectiveness of Implementing Evidence-based Interventions to Reduce C-spine Image Ordering in the Emergency Department: A Systematic Review

OBJECTIVES

Appropriate use of imaging for adult patients with cervical spine (C-spine) injuries in the emergency department (ED) is a longstanding issue. Guidance for C-spine ordering exists; however, the effectiveness of the decision support implementation in the ED is not well studied. This systematic review examines the implementation and effectiveness of evidence-based interventions aimed at reducing C-spine imaging in adults presenting to the ED with neck trauma.

METHODS

Six electronic databases and the gray literature were searched. Comparative intervention studies were eligible for inclusion. Two independent reviewers screened for study eligibility, study quality, and extracted data. The change in imaging was reported using individual odds ratios (ORs) with 95% confidence intervals (CIs) using random effects.

RESULTS

A total of 990 unique citations were screened for relevance of which six before-after studies and one randomized controlled trial were included. None of the studies were assessed as high quality. Interventions consisted primarily of locally developed guidelines or established clinical decision rules such as the NEXUS or the Canadian C-spine rule. Overall, implementation of interventions aimed at reducing C-spine image ordering resulted in a statistically significant reduction in imaging (OR = 0.69, 95% CI = 0.51-0.93); however, heterogeneity was high (I²  = 82%). Subgroup analysis revealed no differences between studies that specified enrolling alert and stable patients compared to unspecified trauma (p = 0.81) or between studies employing multifaceted versus nonmultifaceted interventions (p = 0.66). While studies generally provided details on implementation strategies (e.g., teaching sessions, pocket cards, posters, computerized decision support) the effectiveness of these implementation strategies were frequently not reported.

CONCLUSION

There is moderate evidence regarding the effectiveness of interventions to reduce C-spine image ordering in adult patients seen in the ED with neck trauma. Given the national and international focus on improving appropriateness and reducing unnecessary C-spine imaging through campaigns such as Choosing Wisely, additional interventional research in this field is warranted.

Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening

Cervical spine injury occurs in 5-10% of cases of blunt polytrauma. A missed or delayed diagnosis of cervical spine injury may be associated with permanent neurological sequelae. However, there is no consensus about the ideal evaluation and management of the potentially injured cervical spine and, despite the publication of numerous clinical guidelines, this issue remains controversial. In addition, many studies are limited in their application to the obtunded or unconscious trauma victim. This review will provide the clinician managing unconscious trauma victims with an assessment of the actual performance of clinical examination and imaging modalities in detecting cervical spine and isolated ligamentous injury, a review of existing guidelines in light of the available evidence, relative risk estimates and a proposed management scheme.

1998 ARRS Executive Council Award. Radiology in the emergency department: technique for quantitative description of use and results. American Roentgen Ray Society

OBJECTIVE

We sought to develop quantitative methods to describe the use and results of imaging studies in emergency department patients.

MATERIALS AND METHODS

A computerized nonrelational database containing records of 3.5 million diagnostic reports generated by our radiology department from 1988 to 1997 was queried using Boolean and natural language search tools. Each record contained data fields for patient demographics, examination description and billing code, names of interpreting radiologists and referring physicians, patient history, report body, and report impression.

RESULTS

Emergency department admissions and imaging studies were stable from 1991 to 1997, averaging 60,000 and 52,000 per year, respectively. Bone radiographs comprised 45.1% of examinations; chest radiographs, 44.6%; and abdominal radiographs, 10.4%. The percentages of radiographs interpreted as normal were 75.9% in 1992 and 75.3% in 1996, with cervical spine (88.7%), thoracic spine (86.3%), and knee (86.3%) yielding the highest proportion of studies with normal findings. The number of CT studies of the body increased from 1840 in 1993 to 3101 in 1997. Studies of the abdomen accounted for most of this increase (52.3% in 1993 to 66.0% in 1997). During evaluations for cervical spine injury, a mean of 6.5% of radiographic studies were followed by CT studies, and the findings of 89.0% of those CT studies were interpreted as normal.

CONCLUSION

Radiology report databases represent a resource from which broad descriptions of the use and results of imaging studies can be obtained. Such descriptions may be useful in departmental and hospital administration, technology assessment, cost-effectiveness studies, and health policy formulation.