Clinical clearance of cervical spinal injuries by emergency nurses

To determine the interrater reliability between emergency nurses and emergency physicians on defined criteria for clinically clearing the cervical spine in blunt trauma patients.

Blunt trauma patients, 12 years or older, arriving with cervical spinal precautions were prospectively enrolled as a convenience sample. Each member of the emergency physician-nurse pair completed a questionnaire with regard to five criteria for clinically clearing the cervical spine for each patient. Interrater reliability was determined by calculating the kappa statistics for the individual and combined criteria.

Physicians and nurses agreed on the presence or absence of the combined criteria in 175 of 211 patients (82.9%; kappa, 0.65). Agreements on individual criteria were as follows: 1) intoxication--203 patients (96.2%; kappa, 0.82); 2) altered consciousness--197 patients (93.4%; kappa, 0.60); 3) neck pain--185 patients (87.7%; kappa, 0.75); 4) distracting injury--160 patients (75.8%; kappa, 0.36); and 5) neurologic deficit--198 patients (93.8%; kappa, 0.45). If disagreements in which the physician would clinically clear the patient but the nurse would not were considered as agreements, then overall agreement would be 198 of 211 patients (93.8%; kappa, 0.88). On the assumption that nurses would assess patients prior to physicians, they would have cleared 35% of the patients before the physicians. However, they would have ordered 12% more radiographs and unsafely clinically cleared 5% of the patients.

The interrater reliability for the combined cervical spinal injury criteria between emergency nurses and physicians was good to excellent. However, with the training given in this study, nurses would order more radiographs than physicians and would unsafely clinically clear cervical spines in some patients.