Prehospital Emergency Care
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Outcome of Trauma Patients Immobilized by Emergency Department Staff, but Not by Emergency Medical Services Providers: A Quality Assurance Initiative Raquel R. Tello MD, EMT-P, Darren Braude MD, MPH, EMT-P, Lynne Fullerton PhD & Philip Froman MD To cite this article: Raquel R. Tello MD, EMT-P, Darren Braude MD, MPH, EMT-P, Lynne Fullerton PhD & Philip Froman MD (2014) Outcome of Trauma Patients Immobilized by Emergency Department Staff, but Not by Emergency Medical Services Providers: A Quality Assurance Initiative, Prehospital Emergency Care, 18:4, 544-549 To link to this article: http://dx.doi.org/10.3109/10903127.2014.912702
Published online: 30 May 2014.
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Date: 12 November 2015, At: 13:56
OUTCOME OF TRAUMA PATIENTS IMMOBILIZED BY EMERGENCY DEPARTMENT STAFF, BUT NOT BY EMERGENCY MEDICAL SERVICES PROVIDERS: A QUALITY ASSURANCE INITIATIVE Raquel R. Tello, MD, EMT-P, Darren Braude, MD, MPH, EMT-P, Lynne Fullerton, PhD, Philip Froman, MD
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ABSTRACT
on the final imaging report. Results. The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of $1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging. Conclusions. In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings. Key words: spinal injury; immobilization; prehospital emergency care; spine clearance
Background. Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol. Methods. This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist
PREHOSPITAL EMERGENCY CARE 2014;18:544–549
INTRODUCTION Of the one million cases of blunt force trauma occurring each year in the United States, only an estimated 1% of patients evaluated at a trauma center have significant cervical injuries and 0.5% of these patients have a spinal cord injury; presumably the number presenting to community hospitals is much smaller.1,2 Despite the rarity of these injuries, the management of blunt trauma patients has generally involved the liberal use of cervical spinal immobilization (CSI), with the presumed benefit of preventing secondary spinal cord injury, though there is very little evidence supporting its use.3 CSI is not without risks, including pain – which may result in additional radiographs – tissue ischemia, increased intracranial pressure, and respiratory compromise.4–14 As a result, selective use of CSI only for patients at risk for injury has been recommended by national guidelines from the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma.15 These guidelines are based on research that indicates such protocols are highly accurate and easily employed by emergency medical services (EMS) personnel.16–23 Evidence exists that prehospital personnel are as accurate as physicians at determining whether spinal immobilization should be withheld.24 Despite this, patients who have been deemed by EMS to not need immobilization are being placed in spinal precautions
Received June 21, 2013 from the University of New Mexico School of Medicine, Albuquerque, New Mexico (RT), University of New Mexico, Department of Emergency Medicine, Albuquerque, New Mexico (DB, LF), and Albuquerque Ambulance Service, Albuquerque, New Mexico (PF). Revision received March 11, 2014; accepted for publication March 13, 2014. An abstract of this paper was presented by Raquel R. Tello at the American Federation for Medical Research 2013 Western Regional Meeting on January 24, 2013, in Carmel, California under the title “Outcome of patients immobilized by ED staff, but not by EMS providers.” The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Thank you to Albuquerque Ambulance Service for their participation in this study. We would also like to thank UNMH for allowing us to access their data system. Raquel R. Tello is currently a resident physician at the University of Hawaii, Honolulu, Hawaii. Address correspondence to Darren Braude, MD, MSC 11 6025, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA. E-mail: [email protected] doi: 10.3109/10903127.2014.912702
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in the emergency department (ED) after their arrival – secondary CSI – as much as 45–67% of the time.24–26 This practice of secondary CSI suggests that either the prehospital assessment is not trusted or the patient has developed new important symptoms over time. We conducted a retrospective quality assurance initiative to investigate whether blunt force trauma patients brought to the ED in our EMS system without CSI, who then underwent secondary CSI, had cervical spine injuries that were initially missed by our prehospital selective CSI protocol. We hypothesized that secondary CSI would not identify any missed acute injuries, but would add substantial additional costs and radiation exposure.
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METHODS Location Albuquerque, New Mexico, is located within Bernalillo County, which are the state’s most populous city and county, respectively.27 Albuquerque has a population of just over 550,000, while Bernalillo county’s total population is approximately 670,000.27 Bernalillo County accounts for one-third of New Mexico’s population.27 Albuquerque Ambulance Service (AAS) provides transport of the majority of 9-1-1 patients within Albuquerque, as well as Bernalillo County. AAS works in conjunction with the Albuquerque Fire Department (AFD) and the Bernalillo County Fire Department (BCFD). The emergency response system in Albuquerque is a two-tier system, whereby AFD or BCFD is the first responder and AAS is the second responder and transporting unit. Depending on the nature of the 9-1-1 call, AFD and/or BCFD send basic life support (BLS) units or advanced life support (ALS) units. All AAS 9-1-1 response units are ALS. On average, AAS responds to approximately 100,000 calls annually and they transport to several large hospitals in the area, including University of New Mexico Hospital (UNMH). UNMH has the state’s only level I trauma center, and is located in Albuquerque.
Study Design We performed a retrospective data analysis of all blunt trauma patients transported by AAS to the UNMH from March 2009 until February 2012, without CSI, who subsequently had cervical spinal imaging done in the ED. This study was approved by the Human Research Review Committee at the University of New Mexico Health Sciences Center. All EMS agencies within Bernalillo County, including AAS, adhere to the same protocol for selective CSI, which has been approved by the local EMS Medical Control Board. This protocol is similar to the National
Association of EMS Physicians and American College of Surgeons Committee on Trauma practice guidelines and is included in Figure 1.15 A computerized data query was performed on UNMH ED patient records to identify all category 1–3 trauma patients – a trauma classification scheme used in Bernalillo County to rank the severity of trauma, with category 1 being the most severe and category 3 the least severe – who were transported by AAS to the ED from March 2009 to February 2012, and who also received cervical spinal imaging. Cervical spinal imaging included plain cervical spinal radiographs, computed tomography (CT), and magnetic resonance imaging as confirmed by an attending radiologist. A positive finding was defined as any acute abnormality found on the cervical spinal imaging studies. AAS uses the Zoll electronic charting system, which can provide patient demographic information, diagnoses, chief complaints, and procedures performed. A separate data search was done with the assistance of the AAS computer analyst who queried their database for patients in the study period who met the following inclusion criteria: blunt trauma, age 18 years and older, and transported by AAS without CSI. Patients were excluded if they were pediatric, interfacility transports, or prisoners, only had penetrating trauma, or refused CSI. The UNMH and AAS databases were linked using exact matching of first and last names, date of birth, and date of service within one day. Data were then hand reviewed by one of the primary investigators (LF) to identify and remove false matches. The lead author (RT) then manually reviewed the prehospital care reports and the hospital trauma/nursing report for all patients identified by this linkage, looking for whether CSI was placed prior to arrival at the ED. Patients who were found to have CSI prior to arrival in the ED were excluded from the study. A second manual review was done by the lead author (RT) on all charts for patients who met inclusion criteria looking at results from cervical spinal imaging. Data were entered into an Excel document on a Macintosh computer and subsequently reviewed by all investigators. At all points during the study, all investigators had access to the data, the query, and review process.
RESULTS The UNM review initially identified 3,306 patient records. Exact matching to ambulance records resulted in 219 patients who had been transported by ambulance without CSI. Our initial AAS database search queried the contents of a drop down menu in their electronic charting program looking for patient transported without CSI. Upon manual review of the 219 matches it was noted that some EMS crews were
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FIGURE 1. Bernalillo County EMS CSI Protocol.
manually entering the placement of CSI in the body of the history and physical – a nonsearchable field – rather than using the drop-down menu function; this resulted in 118 exclusions.. The final results yielded 101 patients who met inclusion criteria, of whom twothirds were male. Patient demographic information and patient mechanisms of injury are presented in Table 1. The vast majority of patients were category 3 (low acuity) trauma patients. Of the 101 patients, none were found to have true acute injuries. One patient was initially found to have a positive finding on cervical spinal radiograph and
another patient’s CT study results were deemed indeterminate. A more expansive chart review was done on these two patients to investigate cause of injury and subsequent outcomes. The patient with the positive finding was a nonacute, nonunited C2 fracture noted on plain radiographs per the radiology report. This patient was a 59-year-old who sustained a ground level fall from the standing position. The patient did not require further imaging, treatment in the ED, admission, or follow-up. This was not considered a missed acute injury given that the injury was nonacute. The indeterminate CT scan occurred in an elderly 91-year-old
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TABLE 1. Patient demographics and mechanisms of injury Age in years Mean Median Range Gender, No. (%) Male Female Mechanism of injury, No. (%) Assault MVCa Motorcycle accident Bicycle accident Pedestrian vs. motor vehicle Motor vehicle vs. bicycle Pedestrian vs. bicycle Fall from standing Fall from sitting Fall from 15–18 feet Fall down stairs, 4–6 stairs Fall down stairs, 15 stairs Fall from ladder, 20 feet Box fell on head Electrocution Snowboarding accident Unknown Total number of patients a
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51 50 18–97 69 (68.3) 32 (31.7) 23 (22.8) 21 (20.8) 9 (8.9) 4 (4.0) 4 (4.0) 3 (3.0) 1 (1.0) 16 (15.8) 1 (1.0) 1 (1.0) 3 (3.0) 1 (1.0) 1 (1.0) 1 (1.0) 1 (1.0) 1 (1.0) 8 (7.9) 101
MVC, motor vehicle collision.
patient with dementia who also sustained a groundlevel fall from the standing position. The radiology report indicated the CT quality was degraded due to patient motion and no determination of a fracture could be made at that time. The radiologist recommended a repeat CT if there was ongoing clinical concern for fracture. No further imaging studies were completed and the patient was discharged home the next day without treatment or follow-up for a spinal injury. There were no repeat visits during the study period to suggest a missed injury. Of the 101 patients, 94 had CT scanning, while 9 had cervical spinal radiographs (Table 2). Two patients received both modalities of imaging. No magnetic resonance images were performed on any of the patients.
TABLE 2. Imaging studies performed and trauma categories Imaging studies Plain cervical radiographs Negative Positive Computed tomography Negative Positive Indeterminate Magnetic resonance Trauma category Category 1 Category 2 Category 3
9 8 1 94 93 0 1 0 15 23 63
DISCUSSION In our quality assurance initiative, secondary CSI and imaging in the ED after paramedics had determined that the patient was not at risk for cervical injury did not identify any additional injuries. However, this imaging added significant time, cost, and radiation exposure. While being a relatively rare event, spinal column injuries can be catastrophic and severe if missed. Due to the possibility of injury, health-care providers have historically taken great care in immobilizing the spinal column in patients after blunt force trauma. In the ED, if a cervical column injury is suspected and the need for imaging is determined, a patient will be placed in a rigid cervical collar, lying supine in bed while waiting for imaging to be completed. Increased intracranial pressure, tissue ischemia, and respiratory compromise have been observed with the use of a rigid cervical collar, and its application may be harmful to the patient.4,14 Due to these complications, guidelines have been developed to safely reduce the number of low-risk patients who are unnecessarily immobilized. The most notable of these are the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-Spine Rule (CCR) criteria.28,29 While these criteria were developed for the use of physicians in the hospital, similar criteria have proven effective for use by prehospital providers.16–23 The prehospital use of selective CSI has been utilized in the Albuquerque metro area as dictated by the Bernalillo County EMS protocols. It has been observed, however, that some patients brought to the ED after selective CSI has been implemented by EMS are subsequently placed in CSI by ED staff. These patients then have cervical spinal imaging to rule out an injury. Thus, patients deemed by EMS crews not to need immobilization are being immobilized and imaged in the ED, often hours after their arrival.30 The UNMH is a training facility where residents manage a large number of patients. The residents’ level of experience and comfort with blunt trauma and possible cervical spine injury may make them uncomfortable not obtaining cervical spinal imaging on patients brought in by EMS without CSI, despite evidence stating the contrary. This statement was corroborated by evidence from Griffith et al., who found that not only are residents ordering CT scans more frequently than attending physicians, but they are also ordering excessive CT scans on patients who meet NEXUS criteria.31 This overuse of CT scanning and secondary CSI may also be driven by fear of potential litigation of a missed injury, as these injuries are often catastrophic to the patient. In 2002, it was found that the litigation settlements for such cases averaged a payout of close to $3 million per patient.32 Another consideration is the ED’s use of secondary CSI is that patients may develop neck pain while in the
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hospital after transport by EMS. This may account for a small fraction of the patients being placed in secondary CSI in the ED. Since the use of CT scanning has entered into the discipline of medicine, its use has steadily increased. This is especially true in emergency departments, where during a 9-year period, CT use for injury related causes increased threefold.33 At UNMH the estimated charge for one CT scan at UNMH is $1,570. This fee excludes radiologist interpretation and room fees, which are often included in the scanning fees. The estimated charges for the 94 CT scans performed after an initial EMS decision not to immobilize was $147,580. The increased use of CT scanning also increases radiation exposure to the patient. A CT scan can typically have a radiation dose of 5–100 mSv per scan.34 According to the International Commission on Radiological Protection, the estimated lifetime risk of fatal cancer induction after radiation exposure is estimated to be around a dose of 5–102 Sv.35 While an individual CT scan represents only a small fraction of the lifetime risk dose, it has been found that risk increases linearly, meaning CT scanning is summative with other radiation exposures during one’s lifetime.35 The lifetime attributable risk of cancer can be calculated using data from the Biological Effects of Ionizing Radiation report (BEIR VII), where the incidence of cancer is calculated based on the age of first exposure, gender, and a linear no-threshold dose response.36 An example of this calculation can be found in a paper recently published by Shah et al., in which they found the maximum lifetime attributable risk to be 1.7% in their cohort study.37 The particular patient of reference was a 28-year-old female who had a total of 11 CT scans. While their study found the vast majority of patients received only 1 CT scan in their lifetime, the increased availability and ease of CT scans in addition to the younger age at which they are used will likely increase the lifetime number of CT scans and overall radiation dose the average person receives. In addition to increasing a patient’s lifetime radiation dose, CT scanning of the cervical spine exposes radiosensitive organs, such as the lens of the eye and the thyroid gland, to unnecessary radiation.38
LIMITATIONS The primary limitations of this study are its retrospective nature and limited sample size. A larger study, ideally prospective, would be required to confirm our findings. Although we were as diligent as possible, it is conceivable that we did not identify every patient who was transported without CSI and/or every patient who had further imaging in the ED. However, the authors, including the EMS section chief at the university hospital, are not anecdotally aware of any missed
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cervical injuries in the EMS system during the study time frame. A study such as this also has limitations that affect external validity. Our selective CSI protocol is similar to that recommended by national organizations, but every protocol is different and the training to use that protocol also varies. Our system has entirely ALS transport, whereas in some systems EMTbasics and EMT-intermediates may be making the immobilization decisions. Furthermore, every receiving hospital ED and its providers have different familiarity with their local EMS providers, protocols, and different risk averseness. Teaching facilities, such as the receiving hospital in this study, are different from community hospitals. It is, therefore, probable that the amount of secondary CSI will vary widely between facilities and may be higher or lower than we reported. Another possible limitation encountered was the exact data matching between the AAS and UNMH data systems. As patients were matched using exact spellings of names and dates of birth, there might have been a small number of patients unknowingly excluded from the study. A few additional patients may have been excluded due to input errors in to the AAS charting system, as paramedics often manually write in whether CSI has been performed or not; we only queried data that were entered via data list selections, not manually entered data.
CONCLUSION In this quality assurance initiative investigating one specific selective CSI protocol in one EMS system, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury or any adverse effects. These patients did, however, incur substantial costs and increased radiation exposure. Our results suggest that in systems such as ours, ED staff should have greater confidence in evidencebased selective immobilization protocols, but continued surveillance and a large-scale, prospective study are needed to confirm our findings.
References 1.
Griffith B, Bolton C, Goyal N, Brown ML, Jain R. Screening cervical spine CT in a level 1 trauma center: overutilization? AJR Am J Roentgenol. 2011 Aug;197(2):463–7. ¨ 2. Bernhard M, Gries A, Kremer P, Bottiger BW. Spinal cord injury (SCI) – prehospital management. Resuscitation. 2005;66:127–39. 3. Kwan I, Bunn F, Roberts IG. Spinal immobilisation for trauma patients (review). The Cochrane Library. 2009; Issue 2. Art. No.:CD002803. DOI: 10.1002/14651858.CD002803. 4. Hauswald M, McNally T. Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers. Air Med J. 2000; 19(4) OctoberDecember:126–7.
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Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23:48–51. Hauswald M, Braude D. Spinal immobilization in trauma patients: is it really necessary? Curr Opin Crit Care. 2002;8:566–70. Cordwell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26(1):31–6. Webber-Jones J, Thomas C, Bordeaux R. The management and prevention of rigid cervical collar complications. Orthop Nurs. 2002;21(4):19–26. Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17(9):915–8. Totten VY, Sugerman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999;3(4):347–52. Nelson JA, Loredo JS, Acosta JA. The obesity-hypoventilation syndrome and respiratory failure in the acute trauma patient. J Emerg Med. 2011;40(4):e67–9. Abram S, Bulstrode C. Routine spinal immobilization in trauma patients? What are the advantages and disadvantages? The Surgeon. 2010;8:218–22. Stone M, Tubridy CM, Curran DC. The effect of rigid cervical collars on internal juglar vein dimensions. Acad Emerg Med. January 2010;17(1):100–2. Leonard JC, Mao J, Jaffe DM. Potential adverse effects of spinal immobilization in children. Prehosp Emerg Care. Sep 2012;16(4):513–8. EMS spinal precautions and the use of the long backboard. National Association of EMS Physicians and American College of Surgeons Committee on Trauma. Prehosp Emerg Care. Jul 2013;17(3):392–3. Domeier R, Fredricksen S, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spinal clearance criteria. Ann Emerg Med. 2005;46(2):123–31. Stroh G, Braude D. Can an out-of-hospital spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001;37(6):609–15. Muhr MD, Seabrook DL, Wittwer LK. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp Emerg Care. 1999;3(1):1–6. Vaillancourt C, Stiell IG, Beaudoin T, Maloney J, Anton AR, Bradford P, Cain E, Travers A, Stempien M, Lees M, Munkley D, Battram E, Banek J, Wells GA. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med. 2009;54(5):663–71. Braude D. Jaramillo, A. Selective spinal immobilization: the use of assessment criteria & protocols to select patients who don’t require complete spinal immobilization. JEMS. 2002;Sep;27(9):70–2, 74–81. Dunn TM, Dalton A, Dorfman T, Dunn WW. Are emergency medical technicain-basics able to use a selective immobilization of the cervical spine protocol? Prehos Emerg Care. 2004;8:207–11. Burton JH, Dunn MG, Harmon NR, Hermanson, TA, Bradshaw JR. A statewide, prehospital emergency medical ser-
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vice selective patient spine immobilization protocol. J Trauma. 2006;61:161–7. Armstrong BP, Simpson HK, Crouch R, Deakin CD. Prehospital clearance of the cervical spine: does it need to be a pain in the neck? Emerg Med J. 2007;24:501–3. Meldon SW, Brandt TA, Cydulka RK, Collins TE, Shade BR. Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians. J Trauma. 1998;45(6):1058–61. Malik M, Lovell M. Current spinal board usage in emergency departments across the UK. Injury Int J Care Injured. 2003;34:327–9. Stagg M, Lovell M. A repeat audit of spinal board usage in the emergency department. Injury Int J Care Injured. 2007;39:323–6. United States Census Bureau Quick Facts. Accessed Feb 2013. quickfacts.census.gov/qfd/states/35/3502000.html Hoffman J, Mower W, Wolfson A, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343:94–9. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15)1841–8. Lerner EL, Moscati R. Duration of patient immobilization in the ED. J Emerg Med. 2000;18:28–30. Griffith B, Kelly M, Vallee M, Slezak M, Nagarwala J, Krupp S, Loeckner CP, Schultz LR, Jain R. Screening cervical spine CT in the emergency department, phase 2: a prospective assessment of use. AJNR Am J Neuroradiol. 2012 October 4;Epub ahead of print. Lekovic GP. Litigation of missed cervical spine injuries in patients presenting with blunt traumatic injury. Neurosurgery. 2007;60(3):516–23. Korley FK, Pham JC, Kirsch TD. Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998–2007. JAMA. 2010;304(13):1465–71. Brenner DJ. Slowing the increase in the population dose resulting from CT scans. Radiat Res. 2010;174:809–15. Richards PJ, Summerfield R, George J, Hamid A, Oakley P. Major trauma and cervical clearance radiation doses and cancer induction. Injury Int J Care Injured. 2008;39:347–56. National Research Council (U.S.) and Committee to Assess Health Risks from Exposure to Low Level of Ionizing Radiation. Health risks from exposure to low levels of Ionizing radiation: BEIR VI phase 2. Washington, DC: National Academies; 2006. Shah KH, Slovis BH, Runde D, Godbout B, Newman DH, Lee J. Radiation exposure among patients with the highest CT scan utilization in the emergency department. Emerg Radiol. 2013 July 14 [Epub ahead of print] Mulkens TH, Marchal P, Daineffe S, Salgado R, Bellinck P, te Rijdt B, Kegelaers B, Termote JL. Comparison of low-dose with standard-dose multidetector CT in cervical spine trauma. AJNR Am J Neuroradiol. Sept 2007;28:1444–50.
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Outcome of Trauma Patients Immobilized by Emergency Department Staff, but Not by Emergency Medical Services Providers: A Quality Assurance Initiative Raquel R. Tello MD, EMT-P, Darren Braude MD, MPH, EMT-P, Lynne Fullerton PhD & Philip Froman MD To cite this article: Raquel R. Tello MD, EMT-P, Darren Braude MD, MPH, EMT-P, Lynne Fullerton PhD & Philip Froman MD (2014) Outcome of Trauma Patients Immobilized by Emergency Department Staff, but Not by Emergency Medical Services Providers: A Quality Assurance Initiative, Prehospital Emergency Care, 18:4, 544-549 To link to this article: http://dx.doi.org/10.3109/10903127.2014.912702
Published online: 30 May 2014.
Submit your article to this journal
Article views: 328
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipec20 Download by: [University of Lethbridge]
Date: 12 November 2015, At: 13:56
OUTCOME OF TRAUMA PATIENTS IMMOBILIZED BY EMERGENCY DEPARTMENT STAFF, BUT NOT BY EMERGENCY MEDICAL SERVICES PROVIDERS: A QUALITY ASSURANCE INITIATIVE Raquel R. Tello, MD, EMT-P, Darren Braude, MD, MPH, EMT-P, Lynne Fullerton, PhD, Philip Froman, MD
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ABSTRACT
on the final imaging report. Results. The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of $1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging. Conclusions. In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings. Key words: spinal injury; immobilization; prehospital emergency care; spine clearance
Background. Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol. Methods. This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist
PREHOSPITAL EMERGENCY CARE 2014;18:544–549
INTRODUCTION Of the one million cases of blunt force trauma occurring each year in the United States, only an estimated 1% of patients evaluated at a trauma center have significant cervical injuries and 0.5% of these patients have a spinal cord injury; presumably the number presenting to community hospitals is much smaller.1,2 Despite the rarity of these injuries, the management of blunt trauma patients has generally involved the liberal use of cervical spinal immobilization (CSI), with the presumed benefit of preventing secondary spinal cord injury, though there is very little evidence supporting its use.3 CSI is not without risks, including pain – which may result in additional radiographs – tissue ischemia, increased intracranial pressure, and respiratory compromise.4–14 As a result, selective use of CSI only for patients at risk for injury has been recommended by national guidelines from the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma.15 These guidelines are based on research that indicates such protocols are highly accurate and easily employed by emergency medical services (EMS) personnel.16–23 Evidence exists that prehospital personnel are as accurate as physicians at determining whether spinal immobilization should be withheld.24 Despite this, patients who have been deemed by EMS to not need immobilization are being placed in spinal precautions
Received June 21, 2013 from the University of New Mexico School of Medicine, Albuquerque, New Mexico (RT), University of New Mexico, Department of Emergency Medicine, Albuquerque, New Mexico (DB, LF), and Albuquerque Ambulance Service, Albuquerque, New Mexico (PF). Revision received March 11, 2014; accepted for publication March 13, 2014. An abstract of this paper was presented by Raquel R. Tello at the American Federation for Medical Research 2013 Western Regional Meeting on January 24, 2013, in Carmel, California under the title “Outcome of patients immobilized by ED staff, but not by EMS providers.” The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Thank you to Albuquerque Ambulance Service for their participation in this study. We would also like to thank UNMH for allowing us to access their data system. Raquel R. Tello is currently a resident physician at the University of Hawaii, Honolulu, Hawaii. Address correspondence to Darren Braude, MD, MSC 11 6025, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA. E-mail: [email protected] doi: 10.3109/10903127.2014.912702
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in the emergency department (ED) after their arrival – secondary CSI – as much as 45–67% of the time.24–26 This practice of secondary CSI suggests that either the prehospital assessment is not trusted or the patient has developed new important symptoms over time. We conducted a retrospective quality assurance initiative to investigate whether blunt force trauma patients brought to the ED in our EMS system without CSI, who then underwent secondary CSI, had cervical spine injuries that were initially missed by our prehospital selective CSI protocol. We hypothesized that secondary CSI would not identify any missed acute injuries, but would add substantial additional costs and radiation exposure.
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METHODS Location Albuquerque, New Mexico, is located within Bernalillo County, which are the state’s most populous city and county, respectively.27 Albuquerque has a population of just over 550,000, while Bernalillo county’s total population is approximately 670,000.27 Bernalillo County accounts for one-third of New Mexico’s population.27 Albuquerque Ambulance Service (AAS) provides transport of the majority of 9-1-1 patients within Albuquerque, as well as Bernalillo County. AAS works in conjunction with the Albuquerque Fire Department (AFD) and the Bernalillo County Fire Department (BCFD). The emergency response system in Albuquerque is a two-tier system, whereby AFD or BCFD is the first responder and AAS is the second responder and transporting unit. Depending on the nature of the 9-1-1 call, AFD and/or BCFD send basic life support (BLS) units or advanced life support (ALS) units. All AAS 9-1-1 response units are ALS. On average, AAS responds to approximately 100,000 calls annually and they transport to several large hospitals in the area, including University of New Mexico Hospital (UNMH). UNMH has the state’s only level I trauma center, and is located in Albuquerque.
Study Design We performed a retrospective data analysis of all blunt trauma patients transported by AAS to the UNMH from March 2009 until February 2012, without CSI, who subsequently had cervical spinal imaging done in the ED. This study was approved by the Human Research Review Committee at the University of New Mexico Health Sciences Center. All EMS agencies within Bernalillo County, including AAS, adhere to the same protocol for selective CSI, which has been approved by the local EMS Medical Control Board. This protocol is similar to the National
Association of EMS Physicians and American College of Surgeons Committee on Trauma practice guidelines and is included in Figure 1.15 A computerized data query was performed on UNMH ED patient records to identify all category 1–3 trauma patients – a trauma classification scheme used in Bernalillo County to rank the severity of trauma, with category 1 being the most severe and category 3 the least severe – who were transported by AAS to the ED from March 2009 to February 2012, and who also received cervical spinal imaging. Cervical spinal imaging included plain cervical spinal radiographs, computed tomography (CT), and magnetic resonance imaging as confirmed by an attending radiologist. A positive finding was defined as any acute abnormality found on the cervical spinal imaging studies. AAS uses the Zoll electronic charting system, which can provide patient demographic information, diagnoses, chief complaints, and procedures performed. A separate data search was done with the assistance of the AAS computer analyst who queried their database for patients in the study period who met the following inclusion criteria: blunt trauma, age 18 years and older, and transported by AAS without CSI. Patients were excluded if they were pediatric, interfacility transports, or prisoners, only had penetrating trauma, or refused CSI. The UNMH and AAS databases were linked using exact matching of first and last names, date of birth, and date of service within one day. Data were then hand reviewed by one of the primary investigators (LF) to identify and remove false matches. The lead author (RT) then manually reviewed the prehospital care reports and the hospital trauma/nursing report for all patients identified by this linkage, looking for whether CSI was placed prior to arrival at the ED. Patients who were found to have CSI prior to arrival in the ED were excluded from the study. A second manual review was done by the lead author (RT) on all charts for patients who met inclusion criteria looking at results from cervical spinal imaging. Data were entered into an Excel document on a Macintosh computer and subsequently reviewed by all investigators. At all points during the study, all investigators had access to the data, the query, and review process.
RESULTS The UNM review initially identified 3,306 patient records. Exact matching to ambulance records resulted in 219 patients who had been transported by ambulance without CSI. Our initial AAS database search queried the contents of a drop down menu in their electronic charting program looking for patient transported without CSI. Upon manual review of the 219 matches it was noted that some EMS crews were
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FIGURE 1. Bernalillo County EMS CSI Protocol.
manually entering the placement of CSI in the body of the history and physical – a nonsearchable field – rather than using the drop-down menu function; this resulted in 118 exclusions.. The final results yielded 101 patients who met inclusion criteria, of whom twothirds were male. Patient demographic information and patient mechanisms of injury are presented in Table 1. The vast majority of patients were category 3 (low acuity) trauma patients. Of the 101 patients, none were found to have true acute injuries. One patient was initially found to have a positive finding on cervical spinal radiograph and
another patient’s CT study results were deemed indeterminate. A more expansive chart review was done on these two patients to investigate cause of injury and subsequent outcomes. The patient with the positive finding was a nonacute, nonunited C2 fracture noted on plain radiographs per the radiology report. This patient was a 59-year-old who sustained a ground level fall from the standing position. The patient did not require further imaging, treatment in the ED, admission, or follow-up. This was not considered a missed acute injury given that the injury was nonacute. The indeterminate CT scan occurred in an elderly 91-year-old
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TABLE 1. Patient demographics and mechanisms of injury Age in years Mean Median Range Gender, No. (%) Male Female Mechanism of injury, No. (%) Assault MVCa Motorcycle accident Bicycle accident Pedestrian vs. motor vehicle Motor vehicle vs. bicycle Pedestrian vs. bicycle Fall from standing Fall from sitting Fall from 15–18 feet Fall down stairs, 4–6 stairs Fall down stairs, 15 stairs Fall from ladder, 20 feet Box fell on head Electrocution Snowboarding accident Unknown Total number of patients a
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51 50 18–97 69 (68.3) 32 (31.7) 23 (22.8) 21 (20.8) 9 (8.9) 4 (4.0) 4 (4.0) 3 (3.0) 1 (1.0) 16 (15.8) 1 (1.0) 1 (1.0) 3 (3.0) 1 (1.0) 1 (1.0) 1 (1.0) 1 (1.0) 1 (1.0) 8 (7.9) 101
MVC, motor vehicle collision.
patient with dementia who also sustained a groundlevel fall from the standing position. The radiology report indicated the CT quality was degraded due to patient motion and no determination of a fracture could be made at that time. The radiologist recommended a repeat CT if there was ongoing clinical concern for fracture. No further imaging studies were completed and the patient was discharged home the next day without treatment or follow-up for a spinal injury. There were no repeat visits during the study period to suggest a missed injury. Of the 101 patients, 94 had CT scanning, while 9 had cervical spinal radiographs (Table 2). Two patients received both modalities of imaging. No magnetic resonance images were performed on any of the patients.
TABLE 2. Imaging studies performed and trauma categories Imaging studies Plain cervical radiographs Negative Positive Computed tomography Negative Positive Indeterminate Magnetic resonance Trauma category Category 1 Category 2 Category 3
9 8 1 94 93 0 1 0 15 23 63
DISCUSSION In our quality assurance initiative, secondary CSI and imaging in the ED after paramedics had determined that the patient was not at risk for cervical injury did not identify any additional injuries. However, this imaging added significant time, cost, and radiation exposure. While being a relatively rare event, spinal column injuries can be catastrophic and severe if missed. Due to the possibility of injury, health-care providers have historically taken great care in immobilizing the spinal column in patients after blunt force trauma. In the ED, if a cervical column injury is suspected and the need for imaging is determined, a patient will be placed in a rigid cervical collar, lying supine in bed while waiting for imaging to be completed. Increased intracranial pressure, tissue ischemia, and respiratory compromise have been observed with the use of a rigid cervical collar, and its application may be harmful to the patient.4,14 Due to these complications, guidelines have been developed to safely reduce the number of low-risk patients who are unnecessarily immobilized. The most notable of these are the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-Spine Rule (CCR) criteria.28,29 While these criteria were developed for the use of physicians in the hospital, similar criteria have proven effective for use by prehospital providers.16–23 The prehospital use of selective CSI has been utilized in the Albuquerque metro area as dictated by the Bernalillo County EMS protocols. It has been observed, however, that some patients brought to the ED after selective CSI has been implemented by EMS are subsequently placed in CSI by ED staff. These patients then have cervical spinal imaging to rule out an injury. Thus, patients deemed by EMS crews not to need immobilization are being immobilized and imaged in the ED, often hours after their arrival.30 The UNMH is a training facility where residents manage a large number of patients. The residents’ level of experience and comfort with blunt trauma and possible cervical spine injury may make them uncomfortable not obtaining cervical spinal imaging on patients brought in by EMS without CSI, despite evidence stating the contrary. This statement was corroborated by evidence from Griffith et al., who found that not only are residents ordering CT scans more frequently than attending physicians, but they are also ordering excessive CT scans on patients who meet NEXUS criteria.31 This overuse of CT scanning and secondary CSI may also be driven by fear of potential litigation of a missed injury, as these injuries are often catastrophic to the patient. In 2002, it was found that the litigation settlements for such cases averaged a payout of close to $3 million per patient.32 Another consideration is the ED’s use of secondary CSI is that patients may develop neck pain while in the
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hospital after transport by EMS. This may account for a small fraction of the patients being placed in secondary CSI in the ED. Since the use of CT scanning has entered into the discipline of medicine, its use has steadily increased. This is especially true in emergency departments, where during a 9-year period, CT use for injury related causes increased threefold.33 At UNMH the estimated charge for one CT scan at UNMH is $1,570. This fee excludes radiologist interpretation and room fees, which are often included in the scanning fees. The estimated charges for the 94 CT scans performed after an initial EMS decision not to immobilize was $147,580. The increased use of CT scanning also increases radiation exposure to the patient. A CT scan can typically have a radiation dose of 5–100 mSv per scan.34 According to the International Commission on Radiological Protection, the estimated lifetime risk of fatal cancer induction after radiation exposure is estimated to be around a dose of 5–102 Sv.35 While an individual CT scan represents only a small fraction of the lifetime risk dose, it has been found that risk increases linearly, meaning CT scanning is summative with other radiation exposures during one’s lifetime.35 The lifetime attributable risk of cancer can be calculated using data from the Biological Effects of Ionizing Radiation report (BEIR VII), where the incidence of cancer is calculated based on the age of first exposure, gender, and a linear no-threshold dose response.36 An example of this calculation can be found in a paper recently published by Shah et al., in which they found the maximum lifetime attributable risk to be 1.7% in their cohort study.37 The particular patient of reference was a 28-year-old female who had a total of 11 CT scans. While their study found the vast majority of patients received only 1 CT scan in their lifetime, the increased availability and ease of CT scans in addition to the younger age at which they are used will likely increase the lifetime number of CT scans and overall radiation dose the average person receives. In addition to increasing a patient’s lifetime radiation dose, CT scanning of the cervical spine exposes radiosensitive organs, such as the lens of the eye and the thyroid gland, to unnecessary radiation.38
LIMITATIONS The primary limitations of this study are its retrospective nature and limited sample size. A larger study, ideally prospective, would be required to confirm our findings. Although we were as diligent as possible, it is conceivable that we did not identify every patient who was transported without CSI and/or every patient who had further imaging in the ED. However, the authors, including the EMS section chief at the university hospital, are not anecdotally aware of any missed
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cervical injuries in the EMS system during the study time frame. A study such as this also has limitations that affect external validity. Our selective CSI protocol is similar to that recommended by national organizations, but every protocol is different and the training to use that protocol also varies. Our system has entirely ALS transport, whereas in some systems EMTbasics and EMT-intermediates may be making the immobilization decisions. Furthermore, every receiving hospital ED and its providers have different familiarity with their local EMS providers, protocols, and different risk averseness. Teaching facilities, such as the receiving hospital in this study, are different from community hospitals. It is, therefore, probable that the amount of secondary CSI will vary widely between facilities and may be higher or lower than we reported. Another possible limitation encountered was the exact data matching between the AAS and UNMH data systems. As patients were matched using exact spellings of names and dates of birth, there might have been a small number of patients unknowingly excluded from the study. A few additional patients may have been excluded due to input errors in to the AAS charting system, as paramedics often manually write in whether CSI has been performed or not; we only queried data that were entered via data list selections, not manually entered data.
CONCLUSION In this quality assurance initiative investigating one specific selective CSI protocol in one EMS system, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury or any adverse effects. These patients did, however, incur substantial costs and increased radiation exposure. Our results suggest that in systems such as ours, ED staff should have greater confidence in evidencebased selective immobilization protocols, but continued surveillance and a large-scale, prospective study are needed to confirm our findings.
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