Implementation of Pediatric Trauma Cervical Spine Clearance Pathway

General Information

Institution Name: Beaumont Children's/Beaumont Health

Primary Author and Title: Jennifer Cirino, MD

Name of Case Study: Implementation of Pediatric Trauma Cervical Spine Clearance Pathway

What Was Done?

Global Problem Addressed

Pediatric cervical spine (c-spine) injuries are rare events with an incidence of about 1 to 2 percent and potentially devastating consequences.^1-3 Differences exist in the incidence, characteristics, and severity of cervical spine injuries between adult and pediatric populations; however, pediatric patients are generally subjected to the same traumatic workup of their cervical spine as adult trauma patients.⁴ Until recently, the cervical spine workup at many institutions, including ours, involved obtaining multiple cervical spine films and, often, a complete cervical spine computed tomography (CT) scan. Aggressive imaging in the pediatric patient population can be costly and can expose children to large amounts of radiation, exposing them to 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 cervical spine have been found to be effective and reduce radiation exposure.^6-8

Identification of Local Problem

At our institution, no guideline was in place, and c-spine clearance was non-uniform. The decision for imaging often depended on the practice of the physician(s) seeing the patient rather than predefined clinical criteria and risk stratification. Pediatric patients were generally evaluated by using the same workup used in adult patients and, quite often, imaging, including a CT scan was obtained.

How Was the Quality Improvement (QI) Activity Put in Place?

Context of the QI Activity

Beaumont Hospital Royal Oak is a 1,100-bed tertiary care and Level 1 adult trauma center in Royal Oak, Ml. Beaumont Children's is a Level 2 pediatric trauma center within Beaumont Hospital's Royal Oak Campus. There are pediatric specialists on staff in the areas of pediatric surgery, pediatric emergency medicine, pediatric orthopaedic surgery, pediatric neurosurgery, and pediatric radiology among multiple other subspecialties. Pediatric patients 12 and younger are managed by the pediatric surgery trauma team, and there are about 200 pediatric trauma admissions yearly.

Description of the Quality Improvement Activity

Prior to implementation, the pediatric trauma surgeons provided detailed education of the pathway to the surgical and emergency medicine groups, as they are present during the initial trauma evaluation. This step included providing education to all trauma surgeons, general surgery residents, and pediatric emergency physicians and fellows. The information 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 medical records by inserting it into our history and physical templates, which allowed for documentation of the pathway's utilization by the evaluating trauma team.

Date when the QI activity was first implemented: We implemented the pathway in August 2016 and began collecting data in September 2016.

Resources Used and Skills Needed

Staff

The project required four pediatric trauma surgeons, eight pediatric emergency medicine physicians, approximately 36 general surgery residents, and six pediatric emergency medicine fellows.

Costs

There were no additional costs beyond the normal hospital operations to implement and maintain the project. There was no additional funding for this project.

What Were the Results?

To evaluate the efficacy of our Cervical 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 x2 test, Fischer's exact test, and the Mann-Whitney U test. A p-value less than 0.05 was considered statistically significant.

At six months, there were 53 patients in our pre-implementation group and 30 patients in our post-implementation group. Patients treated using the CSCP received fewer c-spine radiographs (39.6% versus 6.7%, p-value < 0.05) despite higher injury severity scores (average ISS 4.0 versus 9.5, p-value < 0.05). Additionally, in the CSCP group there was a trend towards fewer CT scans and more patients were cleared clinically (20.8% versus 53.5%, p-value < 0.05). Overall, length of stay (LOS) also decreased (p-value < 0.05). Although LOS changes may have been statistically significant, we feel these are likely multifactorial and not clinically or cost significant. There were no missed injuries in either group.

We then looked at 15 months before and after pathway implementation. Our pre-implementation (n=119) and post-implementation (109) groups were similar when comparing age, sex, mechanism of injury, and injury severity score. Patients treated using the CSCP received fewer plain c-spine radiographs (34% versus 16%, p<0.05). In the CSCP group there was a trend towards fewer CT scans (28% versus 23%, p>0.05), more patients were cleared clinically (44% versus 62%, p<0.05), and fewer spine specialty consults were placed (28% versus 13%, p<0.05). There were again no missed injuries in either group.

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, there was no way to tell for sure whether or not there was compliance with our pathway. Documentation of the markers for low­ risk criteria that lead to being able to clear the patient's cervical spines clinically was lacking in the reviewed charts. Documentation of timing of clinical clearance was also lacking.

To address these barriers, we inserted the pathway into our trauma history and physical templates. This template acted as documentation of cervical spine evaluation and clearance. It also served as a reminder to use the clearance pathway, as there were specific questions that required input by the physician to complete the documentation. We also posted the pathway on the wall of our trauma bay in an attempt to remind physicians evaluating the patients to use the pathway.

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 not included in our data analysis.

Cost Savings

By decreasing the number of imaging studies obtained in these patients, there was a decrease in cost associated with evaluation of our patients at both intervals. When 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. When combining both imaging modalities, this represented a cost of $2,325 before pathway implementation and $865 after pathway implementation, which represents a 63 percent reduction in imaging cost.

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

Tips for Others

Getting Started

Text BoxExisting literature does support the use of pathways driven by clinical criteria when evaluating pediatric cervical spines.^{4 6 7} Funding is not necessary, but multidisciplinary support is critical for 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 their institution. No universally used and validated set of guidelines for cervical spine evaluation exist for children, thus a pathway like ours can be developed or modifications of adult NEXUS criteria can be used. By including all groups in the development of the pathway, buy-in and adherence is more likely.

How to Sustain the Activity

Sustaining the activity is best done by making the pathway a consistent part of the initial trauma evaluation. By including it in our EMR documentation, we were able to clearly document utilization on every patient. We were also able to document reasons for deviation from the pathway (in other words, trauma transfers). Regular monitoring through IRB-approved reviews of charts and data collection can also show effectiveness and benefit, which should help maintain adherence and improvement moving forward. Finally, feedback during monthly trauma task force and QI meetings can help address any concerns or issues with the pathway.

References

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11. Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical spine injuries. J Pediatr Surg. 2001;36100-105. 
12. IRB Approval August 15, 2016. Ref No 2016-258.