Emergency medicine physicians develop novel approach that reduces unnecessary imaging by half
Emergency medicine physicians and other specialists have developed a novel approach that reduces the need for certain unnecessary imaging by half.
Cervical spine injuries in children are rare but can lead to serious injuries and potential paralysis. Typically, providers assess such injuries via X-ray or CT, but this can expose patients to harmful radiation, researchers detailed in Lancet Child & Adolescent Health [1].
To fine-tune triage, scientists have created a clinical prediction rule, incorporating it into an algorithm to help guide ED providers considering imaging. Testing the tool in a prospective, observational study, the approach proved powerful.
Had the algorithm been applied to all participants to guide imaging use, the number of kids undergoing CT would have dropped from 17% (3,856) to less than 7% (1,549).
“Quickly and accurately identifying children with potentially severe injuries is crucial for emergency medical providers,” Julie Leonard, MD, who led the study team and is a pediatric EM physician at Nationwide Children’s Hospital, said in a statement. “Our extensive, multicenter study demonstrates that using this rule, which relies solely on self-reported symptoms and physical examination, can prevent unnecessary radiation in children.”
For the study, Leonard and colleagues screened individuals 17 and under who presented with known or suspected blunt trauma across 18 specialized U.S. children’s EDs. Hospitals participating in the project are affiliated with the Pediatric Emergency Care Applied Research Network, a federally funded research effort dedicated to improving outcomes. Injured children were eligible for enrollment if they were transported to the ED, evaluated by a trauma team and underwent neck imaging for suspected spine injury. Before reviewing scan results, an attending ED provider completed a clinical exam and documented the findings via an electronic questionnaire.
The decision model incorporated nine risk factors, all identifiable via this physical exam. These included predisposing conditions, injury mechanism, neck and neurological complaints and regionalized physical exam findings (of the head, torso and spine). Nine of the participating EDs utilized the algorithm while nine others did not. A total of more than 22,000 children presenting with blunt trauma were enrolled in the study. About 2% of the total population (or 433 kids) had a confirmed cervical spine injury.
Leonard and colleagues found that the injury-prediction rule logged sensitivity of 94.3%, specificity of 60.4% and negative predictive value of 99.9%.
“The rule is clinically sensible, relying solely on the child's symptoms and results of a physical examination upon arrival in the emergency department,” the authors noted. “When incorporated into a clinical care algorithm, the cervical spine injury prediction rule showed promising potential for reducing unnecessary use of CT without increasing use of plain X-ray.”
Further work is still needed to validate the rule in other non-research settings such as community EDs, along with pinpointing the best implementation methods. Read much more about the results, including potential limitations, at the link below.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.