Implementation of a pediatric trauma cervical spine clearance pathway

Pediatric cervical spine (c-spine) injuries are rare events, with an incidence of approximately 1 to 2 percent and potentially devastating consequences.^1-3 Although the incidence, characteristics, and severity of c-spine injuries differ between adult and pediatric populations, pediatric patients are generally subjected to the same traumatic workup of their c-spine as adult trauma patients.⁴ Until recently, the c-spine workup at many institutions involved obtaining multiple c-spine films and often a complete c-spine computed tomography (CT) scan. Aggressive imaging in the pediatric patient population can be costly and may expose children to large amounts of radiation and, therefore, potential future malignancies.⁵ Injuries cannot be missed, but patients at low risk for injury should not be subject to unnecessary radiation exposure early in their lives. An established algorithm for c-spine evaluation can help balance these conflicting ideals in clinical decision making. Separate pathways for clearance of the pediatric c-spine have been found to be effective and reduce radiation exposure.^6-8

The problem

Beaumont Children’s Hospital/Beaumont Health, Royal Oak, MI, lacked any guidelines on c-spine clearance. As a result, patients experienced variations in care. The decision for imaging often depended on the practices of the physician(s) seeing the patient rather than predefined clinical criteria and risk stratification. Pediatric patients were generally evaluated with the same workup used in adult patients and, quite often, a CT scan was obtained.

Beaumont Children’s is a Level 2 pediatric trauma center and is housed on the campus of Beaumont Hospital Royal Oak, a 1,100-bed tertiary care and Level 1 adult trauma center. Pediatric specialty services offered include pediatric surgery, pediatric emergency medicine, pediatric orthopaedic surgery, pediatric neurosurgery, and pediatric radiology, among others. Pediatric patients ages 12 and younger are managed by the pediatric surgery trauma team, and approximately 200 pediatric trauma admissions occur yearly.

The plan

A multidisciplinary group of pediatric trauma surgeons, emergency medicine physicians, orthopaedic spine surgeons, neurosurgeons, and radiologists developed the c-spine clearance pathway through discussion and a thorough review of the literature and other available guidelines.^6-7 As a first step, we convened multidisciplinary journal clubs to review the characteristics of pediatric c-spine injuries, including mechanisms of injury, imaging findings, and types of injuries.^9-11 These activities and reviews led the pediatric trauma surgeons to develop algorithms for low-risk patients and high-risk patients. These guidelines were then presented to the entire group for review and approval. Once all the specialty groups reached consensus, we presented the pathway to our hospital’s medical executive board for final approval (see Figures 1A and 1B).

Figure 1A. Pediatric trauma c-spine Clearance guidelines

Figure 1B. Pediatric c-spine clearance guidelines for low-risk patients

The four pediatric trauma surgeons educated the surgical and emergency medicine groups—including 36 general surgery residents, eight pediatric emergency physicians, and six pediatric emergency medicine fellows—about the pathway before its implementation, because these specialists are present during the initial trauma evaluation. This training was provided during educational conferences, and digital copies of the pathway were widely distributed. It was also posted in the trauma bay for quick reference during trauma activations. Furthermore, the algorithm was strategically placed into our electronic health records by inserting the guidelines into our history and physical templates. This process ensured that the evaluating trauma team’s use of the pathway was documented.

The pathway was implemented in August 2016 with institutional review board approval, and we began collecting data in September 2016.

The results

To evaluate the efficacy of Beaumont Children’s c-spine clearance pathway (CSCP), we initially reviewed patient charts six months before and after implementation, and then again at 15 months before and after implementation. Statistical analysis was performed using χ2 test, Fischer’s exact test, and Mann-Whitney U test. A p-value less than 0.05 was considered statistically significant.

At six months, 53 patients were included in our preimplementation group and 30 patients in our postimplementation group. Patients treated using the CSCP received fewer c-spine radiographs (39.6 percent versus 6.7 percent, p <0.05) despite higher injury severity scores (ISS) (average ISS 4.0 versus 9.5, p <0.05). Additionally, in the CSCP group we saw a trend toward fewer CT scans, and more patients were cleared clinically (20.8 percent versus 53.5 percent, p <0.05). Overall, length of stay (LOS) also decreased (p <0.05). Although LOS changes may have been statistically significant, multiple factors may have been at work, so the changes in LOS are not clinically or cost significant. Neither group missed any injuries (see Figure 2).

Figure 2. Impact of c-spine clearance pathway: 6 months

We then looked at 15 months before and after pathway implementation. Our preimplementation (n = 119) and postimplementation (109) groups were similar in terms of age, gender, mechanism of injury, and ISS. Patients treated using the CSCP received fewer plain c-spine radiographs (34 percent versus 16 percent, p <0.05). In the CSCP group, we noticed a trend toward fewer CT scans (28 percent versus 23 percent, p <0.05), more patients were cleared clinically (44 percent versus 62 percent, p <0.05), and fewer spine specialty consults were placed (28 percent versus 13 percent, p <0.05). No missed injuries were detected in either group (see Figure 3).

Figure 3. Impact of c-spine clearance pathway: 15 months

Setbacks

One of the biggest challenges in this study was ensuring compliance with the CSCP. Several education sessions occurred with the surgical and emergency medicine residents and attending physicians, and the algorithm was widely distributed. However, initially, we had no accurate way to determine whether health care professionals were complying with the pathway. Documentation of the markers for low-risk criteria that led to being able to clear the patient’s c-spines clinically was lacking in the reviewed charts. Documentation of timing of clinical clearance also was lacking.

To address these barriers, we inserted the pathway into our trauma history and physical templates, which acted as documentation of c-spine evaluation and clearance. It also served as a reminder to use the clearance pathway, as specific questions required physician input to complete the documentation. We posted the pathway on the wall of our trauma bay as a reminder to physicians to use the pathway when evaluating patients.

Furthermore, some patients were transferred from outside hospitals that do not use or have access to our pathway. Many of these patients already came with imaging studies that may or may not have been performed had our pathway been used. Thus, patients who were transferred with cervical imaging already completed were excluded from our data analysis.

Cost savings

A decrease in the number of imaging studies performed on these patients led to a decrease in cost associated with evaluation of our patients at both intervals. Using cost data obtained from our imaging department, we were able to roughly calculate these cost savings. At six months, the number of c-spine X rays decreased from 30 to two, and the number of c-spine CT scans decreased from 24 to 13. Total costs for combined modalities dropped from $2,325 before pathway implementation to $865 after pathway implementation, which represents a 63 percent reduction in imaging cost.

At 15 months, 65 c-spine X rays and 33 c-spine CT scans were performed prior to implementation, and 28 c-spine X rays and 25 cervical CT scans after implementation. The total combined costs for X rays and CT scans was $3,853 before implementation and $2,332 after implementation, which represents an approximately 40 percent reduction in imaging cost.

Tips for others

Following are tips for dealing with pediatric c-spine injuries.

Getting started

Existing literature supports the use of pathways driven by clinical criteria when evaluating pediatric c-spines.^4,6-7 Funding is not necessary, but multidisciplinary support is critical for the development of a usable and accepted pathway. We recommend meetings of the various services involved in pediatric trauma care to review the existing literature and develop a pathway that works best for the institution. No universally used and validated set of guidelines for c-spine evaluation exists for children; thus, a pathway like the one implemented at Beaumont Children’s can be developed, or modifications of adult NEXUS (National Emergency X-Radiography Utilization Study) criteria can be used. By including all groups in the development of the pathway, buy-in and adherence are more likely.

Sustaining the activity

Continued use of the activity is best achieved by making the pathway a consistent part of the initial trauma evaluation. By including it in our electronic medical record documentation, we were able to clearly document utilization for each patient. We also were able to document reasons for deviation from the pathway, such as transfers from other medical centers. Regular monitoring through institutional review board-approved reviews of charts and data collection also can show effectiveness and benefit, which should help maintain adherence and improvement moving forward. Finally, feedback during monthly trauma task force and quality improvement meetings can help address any concerns or issues with the pathway.

References

1. Reynolds R. Pediatric spinal injury. Curr Opin Pediatr. 2000;12(1):67-71.
2. Avellino AM, Mann FA, Grady MS, et al. The misdiagnosis of acute cervical spine injuries and fractures in infants and children: The 12-year experience of a Level I pediatric and adult trauma center. Childs Nerv Syst. 2005;21(2):122-127.
3. Ruge JR, Sinson GP, McLone DG, Cerullo LJ. Pediatric spinal injury: The very young. J Neurosurg. 1988;68(1):25-30.
4. Rosati SF, Maarouf R, Wolfe L, et al. Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact. J Trauma Acute Care Surg. 2015;78(6):1117-1121.
5. Chen JX, Kachniarz B, Gilani S, Shin JJ. Risk of malignancy associated with head and neck CT in children: A systematic review. Otolaryngol Head Neck Surg. 2014;151(4):554-566.
6. Sun R, Skeete D, Wetjen K, et al. A pediatric cervical spine clearance protocol to reduce radiation exposure in children. J Surg Res. 2013;183(1):341-346.
7. Lee SL, Sena M, Greenholz SK, Fledderman M. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatr Surg. 2003;38(3):358-362.
8. Anderson RC, Kan P, Vanaman M, et al. Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. J Neurosurg Pediatr. 2010;5(3):292-296.
9. Easter JS, Barkin R, Rosen CL, Ban K. Cervical spine injuries in children, part I: Mechanism of injury, clinical presentation, and imaging. J Emerg Med. 2011;41(2):142-150.
10. Easter JS, Barkin R, Rosen CL, Ban K. Cervical spine injuries in children, part II: Management and special considerations. J Emerg Med. 2011;41(3):252-256.
11. Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical spine injuries. J Pediatr Surg. 2001;36(1):100-105.