Reducing Computed Tomography in Pediatric Cervical Spine Clearance: A Quality Improvement Study

Evaluation for cervical spine injury (CSI) in children is complex, and provider concern for missed injury often leads to advanced imaging. Computed tomography (CT) exposes children to high radiation doses, increasing the risk of malignancy and higher health care costs. Pediatric guidelines reserve cervical spine CT for patients with a Glasgow Coma Scale (GCS) less than 14 to decrease ionizing radiation exposure. We aimed to reduce cervical spine CT in children with GCS at least 14 by 15% in 8 months.

This quality improvement initiative was conducted at a level 1 pediatric trauma center emergency department (ED) between January 2022 and February 2024. Interventions included development of a cervical spine clearance pathway, clinical decision support, education, and provider audit and feedback. The primary outcome was cervical spine CT rate in pediatric patients with GCS of at least 14. Balancing measures included ED length of stay (LOS) and return to ED or hospitalization within 72 hours for missed CSI. Statistical process control charts were used to evaluate cervical spine CT rates and detect process changes.

Cervical spine CT rate in trauma activations with GCS of at least 14 decreased by 20% over the study period. Guideline publication and provider education led to the most substantial decrease in cervical spine CT imaging. No significant difference was noted in ED LOS. Spine consultations decreased during our intervention period. No CSIs were missed.

We demonstrate sustained reduction of CT imaging in pediatric trauma. Decreased cervical spine CT use led to annual cost savings of $33 600 and reduced radiation exposure.