Variation in the self-reported use of computed tomography in clearing the cervical spine of pediatric trauma patients

Is spinal computed tomography necessary in pediatric trauma patients?

BACKGROUND

To investigate the prevalence of findings of spinal injury on computed tomography (CT) images of pediatric trauma patients and to define indicators for the possible presence of spinal injuries.

METHODS

Spinal CT for pediatric trauma patients (age ≤ 12 years) over a 2-year period was retrospectively evaluated for the presence of findings suggestive of spinal injury.

RESULTS

Of the 773 patients reviewed, 19 (2.4%) showed traumatic spinal lesions on their spinal CT images. These patients were significantly older than those without spinal lesions (mean age 7.9 ± 3.3 years vs 6.1 ± 3.3 years; P = 0.02). The prevalence of spinal trauma was significantly lower in patients aged 0-8 years than in those aged 9-12 years (P = 0.025). Spinal injury was significantly higher in female patients (P = 0.014). Most of the spinal injuries were located at the lumbar and sacral vertebral levels, and most did not cause neurological complications or require surgical treatment. Important indicators of the possible presence of spinal injuries were pain, tenderness, or ecchymosis over the spine, a low Glasgow Coma Scale score (≤12), head injury (for cervical injuries), or intrathoracic injuries and pelvic fractures (for lumbar and sacral injuries).

CONCLUSIONS

Most spinal CT examinations for the diagnosis of spinal injuries in children did not show positive findings. Thus, many children were exposed to an unnecessary high dose of radiation. New clinical evaluation criteria and indicators should be defined to diagnose spinal injuries and avoid unnecessary radiological examinations.

Associations Among Practice Variation, Clinician Characteristics, and Care Algorithm Usage: A Multispecialty Vignette Study

The objective was to quantitatively evaluate clinician characteristics associated with unwarranted practice variation, and how clinical care algorithms influence this variation. Participants (142 physicians, 53 nurse practitioners, and 9 physician assistants in family medicine, internal medicine, and cardiology) described their management of 4 clinical vignettes, first based on their own practice (unguided), then using care algorithms (guided). The authors quantitatively estimated variation in management. Cardiologists demonstrated 17% lower variation in unguided responses than generalists (fold-change 0.83 [95% confidence interval (CI) 0.68, 0.97]), and those who agreed that practice variation can realistically be reduced had 16% lower variation than those who did not (fold-change 0.84 [CI, 0.71, 0.99]). A 17% reduction in variation was observed for guided responses compared with baseline (unguided) responses (fold-change 0.83 [CI, 0.76, 0.90]). Differences were otherwise similar across clinician subgroups and attitudes. Unwarranted practice variation was similar across most clinician subgroups. The authors conclude that care algorithms can reduce variation in management.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time

BACKGROUND

The emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children.

OBJECTIVES

To describe the trends of emergency care for children in the United States from 2006-2014 in EDs across different pediatric volumes.

METHODS

We analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006-2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics.

RESULTS

From 2006-2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (-3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%).

CONCLUSIONS

Overall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.

Cervical spine computed tomography utilization in pediatric trauma patients

BACKGROUND

Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs).

METHODS

Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression.

RESULTS

5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p<0.05) and more frequent ICU admissions (44.3% vs. 26.1% p<0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI=8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI=25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT.

CONCLUSIONS

Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED.

An analysis of cervical spine magnetic resonance imaging findings after normal computed tomographic imaging findings in pediatric trauma patients: ten-year experience of a level I pediatric trauma center

BACKGROUND

A variety of radiologic screening protocols exist for evaluation of pediatric trauma patients with potential cervical spine (c-spine) injuries. The purpose of this study was to describe findings on c-spine magnetic resonance imaging (MRI) after previously normal c-spine computed tomographic (CT) scan findings at a Level 1 trauma center.

METHODS

A retrospective chart review of trauma patients evaluated at Rady Children's Hospital, San Diego, between January 2000 and February 2010 was conducted. Trauma patients who were younger than 18 years, placed in c-spine precautions, had a normal c-spine CT scan, who subsequently had a c-spine MRI were included. The sample was subdivided into patients who underwent CT scans between January 1, 2000 to July 31, 2005 (early group), and August 1, 2005 to February 28, 2010 (late group), to compare results between different CT scan resolutions.

RESULTS

A total of 173 patients met inclusion criteria. With 100% of patients demonstrating normal c-spine CT scan findings, 83% of c-spine MRI findings were also negative (p < 0.001). Thirty patients (17%) demonstrated significant abnormalities on MRI. Of the 30, 5 (2.9%) required operative c-spine stabilization. Eighty-five patients underwent CT scan in the early group, and 88 in the late group. All 5 patients with unstable injuries not discovered on CT scan were from the early group, compared with none in the late group (p = 0.027).

CONCLUSION

Our results suggest that high-resolution CT scan with sagittal and coronal reconstructions may be comparable with MRI for the detection of unstable c-spine injuries in pediatric trauma patients. Although minimizing CT scan radiation exposure remains essential, high-resolution c-spine CT scan may allow for earlier c-spine clearance with reduction of associated hard collar comorbidities in centers where MRI is not available or in situations where the patient's clinical stability precludes obtaining MRI.

LEVEL OF EVIDENCE

Diagnostic study, level III.