Audit into the Appropriateness of CT Cervical Spine Scan Requesting in the Emergency Department

Marc Adam Jacobson; Damien Ryan

doi:10.2218/resmedica.v22i1.812

Marc Adam Jacobson Graduate Entry Medical School, University of Limerick, Limerick, Ireland
Damien Ryan Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland

Keywords: Medical Audit, Accident and Emergency Department, Computed X Ray Tomography, Neck Injuries, Spinal Injuries

Abstract

Introduction: The use of computed tomography (CT) imaging of the cervical spine (CS) is now the recommended primary screening modality for suspected CS injuries following trauma. The aim of this audit is to review the appropriate use of CS CT imaging in the emergency department (ED) and assess compliance with the National Institute for Health and Care Excellence (NICE) head injury clinical guidelines.

Methods: Charts were reviewed for the last 50 trauma patients to receive a CS CT scan following a request from the ED at University Hospital Limerick between 10 July 2013 and 19 December 2013. The NICE clinical guideline 176 on head injury was used as the standard of care. These data were used to perform a retrospective audit to assess patients who satisfied NICE criteria to qualify for a CS CT scan.

Results: 45 patients who had undergone a CS CT scan were identified, this group had a mean age of 42 years and 71% of them were male. At least one of the NICE guideline criteria was fulfilled in 100% of patients who had a CS CT, with 2.64 of the criteria fulfilled on average. Plain-film X-ray radiography (PF) was inadequate for diagnosis in 20 (44.4%) patients.

Discussion: ED consultants appropriately refer patients for CS CT scans following CS trauma and adhere to NICE head injury clinical guidelines.

Conclusion: Having guidelines in place in the ED and adopting CS CT imaging as an initial screening modality following CS injury may reduce time to definitive care and improve resource implications.

Author Biographies

Marc Adam Jacobson, Graduate Entry Medical School, University of Limerick, Limerick, Ireland

3rd year Graduate Medical Student (BSc, MSc)

Damien Ryan, Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland

Consultant in Emergency Medicine (MRCSI, MRCSEd(A&E), DIMC, FCEM)

References

1. Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma. 2009 Sep;67(3):651-9. DOI: 10.1097/TA.0b013e3181ae583b.

2. Ball C, Watson D. A 12 month clinical audit of cervical spine imaging in multiply injured and intubated patients. Br J Radiol. 2010 Mar;83(987):257-60. DOI: 10.1259/bjr/53146076.

3. Gale S, Gracias V, Reilly P, Schwab CW. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma. 2005 Nov;59(5):1121-5.

4. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma. 2005 May;58(5):902-5.

5. National Institute for Health and Care Excellence. Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Children, Young People and Adults (CG176). London, UK: National Institute for Health and Care Excellence; January 2014.

6. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974 Jul 13;2(7872):81-4. DOI: 10.1016/S0140-6736(74)91639-0.

7. Mathen R, Inaba K, Munera F, Teixeira PGR, Rivas L, McKenney M, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma. 2007 Jun;62(6):1427-31. DOI: 10.1097/01.ta.0000239813.78603.15.

8. Cain G, Shepardson J, Elliott V, Svensson J, Brennan P. Imaging suspected cervical spine injury: plain radiography or computed tomography? Systematic review. Radiography. 2010;16:68-77. DOI: http://dx.doi.org/10.1016/j.radi.2009.09.001.

9. Kanji HD, Neitzel A, Sekhon M, McCallum J, Griesdale DE. Sixty-four–slice computed tomographic scanner to clear traumatic cervical spine injury: systematic review of the literature. J Crit Care. 2014 Apr;29(2):314.e9-13. DOI: 10.1016/j.jcrc.2013.10.022.

10. Antevil JL, Sise MJ, Sack DI, Kidder B, Hopper A, Brown CVR. Spiral computed tomography for the initial evaluation of spine trauma: a new standard of care? J Trauma. 2006 Aug;61(2):382-7. DOI: 10.1097/01.ta.0000226154.38852.e6.

11. Brenner DJ, Hall EJ. Computed tomography — an increasing source of radiation exposure. N Engl J Med. 2007 Nov 29;357(22):2277-84. DOI: 10.1056/NEJMra072149.

12. Grogan EL, Morris JA, Dittus RS, Moore DE, Poulose BK, Diaz JJ, et al. Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan. J Am Coll Surg. 2005 Feb;200(2):160-5. DOI: 10.1016/j.jamcollsurg.2004.10.019.

13. Daffner RH. Cervical radiography for trauma patients: a time effective technique? AJR Am J Roentgenol. 2000 Nov;175(5):1309-11.

14. Kokabi M, Raper DMS, Xing M, Giuffre BM. Application of imaging guidelines in patients with suspected cervical spine trauma: retrospective analysis and literature review. Emerg Radiol. 2011 Jan;18(1):31-8. DOI: 10.1007/s10140-010-0901-z.

15. Blackmore CC, Ramsey SD, Mann FA, Deyo RA. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology. 1999 Jul;212(1):117-25. DOI: 10.1148/radiology.212.1.r99jl08117.

DOI: https://doi.org/10.2218/resmedica.v22i1.812