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Institutional Variation in Cervical Spine Imaging among Children with Blunt Trauma: A Multicenter Prospective
Pradip P Chaudhari1, Alexander Rogers2, Rebecca K Burger3
1Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA.
Insights
Children transferred from general emergency departments (EDs) to pediatric EDs more often received cervical spine imaging, including CT scans, compared to those directly admitted to pediatric EDs. This highlights variations in imaging practices for pediatric blunt trauma patients.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Trauma Care
Background:
- Cervical spine injuries (CSIs) are a concern in children following blunt trauma.
- Variations in imaging practices may exist across different emergency department (ED) types.
- Standardized decision rules aim to guide imaging use.
Purpose of the Study:
- To describe institutional variation in cervical spine radiography (x-ray) and computed tomography (CT) use in children evaluated for blunt trauma.
- To compare imaging utilization between referring general EDs and pediatric EDs.
Main Methods:
- Secondary analysis of a multicenter, observational cohort study of children (0-17 years) evaluated for possible CSI.
- Data collected from 18 EDs between December 2018-October 2021.
- Primary outcome: any cervical spine x-ray or CT; Secondary outcome: CT only. Logistic regression used for analysis, adjusting for injury severity predictors.
Main Results:
- 22,430 children were enrolled; 17.9% were referred from a general ED.
- Overall, 52.9% received cervical spine imaging; 1.9% were diagnosed with CSI.
- Children initially evaluated in referring general EDs underwent significantly more cervical spine imaging (71.3%) and CT as the sole modality (32.3%) compared to those presenting directly to pediatric EDs (48.9% and 7.9%, respectively), even after severity adjustment.
Conclusions:
- Children with potential CSI managed in referring general EDs and transferred to pediatric EDs underwent more frequent cervical spine imaging, including CT, than those presenting directly to pediatric EDs.
- Findings indicate significant institutional variation in imaging practices.
- Data can inform future benchmarking for adherence to the PECARN CSI decision rule.
Objective:
To describe institutional variation in use of cervical spine radiographs (x-ray) and computed tomography (CT) among children evaluated following blunt trauma.
Study Design:
We conducted a planned secondary analysis of a multicenter, observational cohort study of children 0-17 years old evaluated for possible cervical spine injury (CSI) in 18 emergency departments (EDs) from December 2018-October 2021. Our primary outcome was any ED cervical spine x-ray or CT, and our secondary outcome was use of CT only. We performed univariable logistic regression, reporting ED-level unadjusted and injury severity-adjusted proportions of children with any cervical spine imaging and CT only, stratified by presenting ED type (referring general ED vs pediatric ED). Severity adjustment was based on Pediatric Emergency Care Applied Research Network high-risk predictors (Glasgow Coma Scale 3-8, unresponsiveness, abnormal airway/breathing/circulation, and focal neurologic deficits).
Results:
We enrolled 22 430 eligible children, of whom 17.9% (n = 4008) were referred from a general ED. Cervical spine x-ray or CT was performed in 52.9% (n = 11 865) and 1.9% (n = 433) were diagnosed with a CSI. After adjusting for severity, imaging proportions were similar within each ED type (referring general EDs and pediatric EDs). Among children whose initial evaluation occurred in a referring general ED, 71.3% underwent any cervical spine imaging and 32.3% underwent CT as the sole modality. Among children presenting directly to a pediatric ED, the corresponding proportions were 48.9% and 7.9%.
Conclusions:
In this observational study of children with potential CSI, those managed in referring general EDs and transferred to pediatric EDs more frequently underwent cervical spine imaging, including CT as the sole modality, than those presenting directly to pediatric EDs. These data can inform future benchmarking to assess concordance after implementation of the PECARN CSI decision rule.
