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Elimination of Unnecessary Cervical Spine Radiographs in the Emergency Department
THE VOICE OF EXPERIENCE
Elimination of Unnecessary Cervical Spine Radiographs in the Emergency Department Mark J. Adams, MD, MBA, Jamie Lynn Adams, BA Multiple studies have consistently demonstrated the poor sensitivity of radiographs of the cervical spine in the detection of fractures, even retrospectively after fractures have been demonstrated by CT [1-8]. In spite of this, they continue to be used in many trauma centers and emergency departments. In view of the recent increasing awareness of over utilization and concern of the risks from medical radiation, we looked for opportunities to eliminate what we believed were unnecessary or inappropriate examinations. One examination that fits this description that we thought could be easily addressed is routine trauma cervical spine radiography after negative results on CT. Not only are these radiographic examinations unwarranted, they consume valuable resources, add an additional burden to emergency department and radiology staff members, and subject patients to unnecessary radiation. At the onset, we considered the implementation of a policy eliminating the unnecessary examinations to be simple and straightforward. We quickly learned that a modification of practice patterns was more difficult than anticipated. At the university medical center, it was observed that a large number of routine trauma radiographs of the cervical spine were requested after CT scans of the cervical spine had demonstrated no significant findings. Initially, we attempted to resolve the issue by discussing the situation on numerous occasions with emergency department, orthopedic, and spine team physicians and midlevel providers. Additional communication was done on a one-to-one basis, partic-
ularly when an inappropriate examination was ordered. Because the logic and intent were clear, we believed this alone would result in the expected change in behavior. After seeing no significant improvement in ordering patterns, we took a slightly more aggressive stance. In February 2007, a policy was jointly created by the trauma council, consisting of emergency physicians, trauma surgeons, orthopedic surgeons, the spine team, and midlevel providers, that provided a clear algorithm as to when radiography was to be used. Pertinent portions are found in Appendix A. The policy was distributed to relevant emergency department and radiology staff and providers and was posted in visible areas in the emergency and imaging departments. The policy was used for approximately 1 year, with only minimal success. As a result, it was thought that a more structured and methodical effort was in order. We then proceeded to formally document the magnitude of the problem as well as the lack of success in changing practice patterns using the criteria found in Appendix B. Using the selection criteria, the data in Table 1 from January 2007 and January 2008 were obtained retrospectively. As a reminder, these data were obtained
© 2010 American College of Radiology 0091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2009.11.021
Table 1. Initial results Inappropriate Date Examinations January 2007 9 of 35 (26%) January 2008 6 of 34 (18%)
before and 1 year subsequent to the casual discussions with emergency department providers. These data, showing little improvement in spite of the initial attempts, were presented to trauma council and the emergency department oversight steering committee, the latter of which the medical director attends, giving the matter a higher profile. With the assistance of the medical director, the policy was refined conjointly with the chairs and division leaders of the involved departments, thus obtaining buy-in. The revised policy, implemented in February 2008, provided a clear algorithm for the radiographic evaluation of post-CT cervical spines. It was distributed from the top down to care providers through their respective departments, not directly from the imaging department. Radiologists and radiology technologists were also encouraged to question all routine cervical spine examinations either ordered new or requested to be completed after cervical spine CT had been performed. One year after the implementation of this policy, data were again collected. These new data demonstrated a significant decrease in the number of unnecessary or inappropriate studies on the basis of the criteria mentioned above. We further confirmed our success by noting the results from February 2009 (Table 2). Formalizing the process, presenting to high-level committees, and a topdown approach vertically through the various departments and divisions with reinforcement from imaging personnel eventually changed behavior and reduced the number of unnecessary cervical spine examinations. 531
532 The Voice of Experience
Table 2. Follow-up results Inappropriate Date Examinations January 2009 1 of 20 (5%) February 2009 0 of 21 (0%) August 2009 2 of 21 (10%)
To ensure long-term conformity with the protocol, data from August 2009 (Table 2) were collected and showed some degree of noncompliance over the ensuing 6 months. We believe this may have been largely the result of the yearly turnover of house staff in July. Intermittently revisiting the policy, particularly after house staff turnover, will likely help ensure compliance. In summary, providing awareness of the lack of utility and the unnecessary radiation risks of radiography after normal results on CT of the cervical spine and developing an algorithm alone did not effect the desired change in practice patterns of physicians in the emergency department. It was necessary to fully engage appropriate medical center individuals and implement a simple, easy-to-follow, and clearly structured algorithm. In addition, continued monitoring of the process will be necessary to ensure compliance with best practices, especially at academic medical centers, where there is frequent turnover of house staff. It is hoped that this simple approach can also be used to address other improper uses of imaging resources, thereby reducing radiation exposure and improving the efficiency
of care in the emergency department and acute care setting. REFERENCES 1. Bailitz J, Starr F, Beecroft M, et al. CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J Trauma 2009;66:1605-9. 2. Fisher A, Young WF. Is the lateral cervical spine x-ray obsolete during the initial evaluation of patients with acute trauma? Surg Neurol 2008;70:53-8. 3. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma 2007;62:1427-31. 4. Gale SC, Gracias VH, Reilly PM, Schwab CW. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma 2005;59:1121-5. 5. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis J Trauma 2005;58:902-5. 6. Besman A, Kaban J, Jacobs L, Jacobs LM. False-negative plain cervical spine x-rays in blunt trauma. Am Surg 2003;69:1010-4. 7. Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma 2003;55:222-7. 8. El-Khoury GY, Kathol MH, Daniel WW. Imaging of acute injuries of the cervical spine: value of plain radiography, CT, and MR imaging. AJR Am J Roentgenol 1995; 164:43-50.
APPENDIX A Initial Policy In situations in which a radiographic cervical examination was
initiated (but not completed), followed by CT of the cervical spine, it is not necessary to complete the radiographic cervical examination. The requisition should be sent to the radiologist, and the radiographs should be interpreted as a limited cervical spine study, on the basis of the number of images obtained. In situations in which a complete cervical spine CT study has been obtained as the initial examination of the cervical spine, a cervical spine radiographic examination is often not necessary. There may be some circumstances in which a cervical spine radiographic examination may be necessary, particularly after treatment or immobilization. APPENDIX B Selection Criteria The sequence of imaging examinations was determined to be appropriate when: 1. diagnostic radiographs were followed by a CT scan, 2. abnormal results on CT were followed by radiography, and 3. normal results on CT were followed by lateral radiography in flexion or extension investigating for instability. An examination sequence was deemed unnecessary only if it followed a CT scan of the cervical spine read as having no acute findings.
Mark J. Adams, MD, MBA, University of Rochester Medical Center, Department of Imaging Sciences, Box 648, 601 Elmwood Avenue, Rochester, NY 14642; e-mail: [email protected]. Jamie Lynn Adams, BA, University of Rochester School of Medicine and Dentistry, Rochester, New York.
Elimination of Unnecessary Cervical Spine Radiographs in the Emergency Department Mark J. Adams, MD, MBA, Jamie Lynn Adams, BA Multiple studies have consistently demonstrated the poor sensitivity of radiographs of the cervical spine in the detection of fractures, even retrospectively after fractures have been demonstrated by CT [1-8]. In spite of this, they continue to be used in many trauma centers and emergency departments. In view of the recent increasing awareness of over utilization and concern of the risks from medical radiation, we looked for opportunities to eliminate what we believed were unnecessary or inappropriate examinations. One examination that fits this description that we thought could be easily addressed is routine trauma cervical spine radiography after negative results on CT. Not only are these radiographic examinations unwarranted, they consume valuable resources, add an additional burden to emergency department and radiology staff members, and subject patients to unnecessary radiation. At the onset, we considered the implementation of a policy eliminating the unnecessary examinations to be simple and straightforward. We quickly learned that a modification of practice patterns was more difficult than anticipated. At the university medical center, it was observed that a large number of routine trauma radiographs of the cervical spine were requested after CT scans of the cervical spine had demonstrated no significant findings. Initially, we attempted to resolve the issue by discussing the situation on numerous occasions with emergency department, orthopedic, and spine team physicians and midlevel providers. Additional communication was done on a one-to-one basis, partic-
ularly when an inappropriate examination was ordered. Because the logic and intent were clear, we believed this alone would result in the expected change in behavior. After seeing no significant improvement in ordering patterns, we took a slightly more aggressive stance. In February 2007, a policy was jointly created by the trauma council, consisting of emergency physicians, trauma surgeons, orthopedic surgeons, the spine team, and midlevel providers, that provided a clear algorithm as to when radiography was to be used. Pertinent portions are found in Appendix A. The policy was distributed to relevant emergency department and radiology staff and providers and was posted in visible areas in the emergency and imaging departments. The policy was used for approximately 1 year, with only minimal success. As a result, it was thought that a more structured and methodical effort was in order. We then proceeded to formally document the magnitude of the problem as well as the lack of success in changing practice patterns using the criteria found in Appendix B. Using the selection criteria, the data in Table 1 from January 2007 and January 2008 were obtained retrospectively. As a reminder, these data were obtained
© 2010 American College of Radiology 0091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2009.11.021
Table 1. Initial results Inappropriate Date Examinations January 2007 9 of 35 (26%) January 2008 6 of 34 (18%)
before and 1 year subsequent to the casual discussions with emergency department providers. These data, showing little improvement in spite of the initial attempts, were presented to trauma council and the emergency department oversight steering committee, the latter of which the medical director attends, giving the matter a higher profile. With the assistance of the medical director, the policy was refined conjointly with the chairs and division leaders of the involved departments, thus obtaining buy-in. The revised policy, implemented in February 2008, provided a clear algorithm for the radiographic evaluation of post-CT cervical spines. It was distributed from the top down to care providers through their respective departments, not directly from the imaging department. Radiologists and radiology technologists were also encouraged to question all routine cervical spine examinations either ordered new or requested to be completed after cervical spine CT had been performed. One year after the implementation of this policy, data were again collected. These new data demonstrated a significant decrease in the number of unnecessary or inappropriate studies on the basis of the criteria mentioned above. We further confirmed our success by noting the results from February 2009 (Table 2). Formalizing the process, presenting to high-level committees, and a topdown approach vertically through the various departments and divisions with reinforcement from imaging personnel eventually changed behavior and reduced the number of unnecessary cervical spine examinations. 531
532 The Voice of Experience
Table 2. Follow-up results Inappropriate Date Examinations January 2009 1 of 20 (5%) February 2009 0 of 21 (0%) August 2009 2 of 21 (10%)
To ensure long-term conformity with the protocol, data from August 2009 (Table 2) were collected and showed some degree of noncompliance over the ensuing 6 months. We believe this may have been largely the result of the yearly turnover of house staff in July. Intermittently revisiting the policy, particularly after house staff turnover, will likely help ensure compliance. In summary, providing awareness of the lack of utility and the unnecessary radiation risks of radiography after normal results on CT of the cervical spine and developing an algorithm alone did not effect the desired change in practice patterns of physicians in the emergency department. It was necessary to fully engage appropriate medical center individuals and implement a simple, easy-to-follow, and clearly structured algorithm. In addition, continued monitoring of the process will be necessary to ensure compliance with best practices, especially at academic medical centers, where there is frequent turnover of house staff. It is hoped that this simple approach can also be used to address other improper uses of imaging resources, thereby reducing radiation exposure and improving the efficiency
of care in the emergency department and acute care setting. REFERENCES 1. Bailitz J, Starr F, Beecroft M, et al. CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J Trauma 2009;66:1605-9. 2. Fisher A, Young WF. Is the lateral cervical spine x-ray obsolete during the initial evaluation of patients with acute trauma? Surg Neurol 2008;70:53-8. 3. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma 2007;62:1427-31. 4. Gale SC, Gracias VH, Reilly PM, Schwab CW. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma 2005;59:1121-5. 5. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis J Trauma 2005;58:902-5. 6. Besman A, Kaban J, Jacobs L, Jacobs LM. False-negative plain cervical spine x-rays in blunt trauma. Am Surg 2003;69:1010-4. 7. Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma 2003;55:222-7. 8. El-Khoury GY, Kathol MH, Daniel WW. Imaging of acute injuries of the cervical spine: value of plain radiography, CT, and MR imaging. AJR Am J Roentgenol 1995; 164:43-50.
APPENDIX A Initial Policy In situations in which a radiographic cervical examination was
initiated (but not completed), followed by CT of the cervical spine, it is not necessary to complete the radiographic cervical examination. The requisition should be sent to the radiologist, and the radiographs should be interpreted as a limited cervical spine study, on the basis of the number of images obtained. In situations in which a complete cervical spine CT study has been obtained as the initial examination of the cervical spine, a cervical spine radiographic examination is often not necessary. There may be some circumstances in which a cervical spine radiographic examination may be necessary, particularly after treatment or immobilization. APPENDIX B Selection Criteria The sequence of imaging examinations was determined to be appropriate when: 1. diagnostic radiographs were followed by a CT scan, 2. abnormal results on CT were followed by radiography, and 3. normal results on CT were followed by lateral radiography in flexion or extension investigating for instability. An examination sequence was deemed unnecessary only if it followed a CT scan of the cervical spine read as having no acute findings.
Mark J. Adams, MD, MBA, University of Rochester Medical Center, Department of Imaging Sciences, Box 648, 601 Elmwood Avenue, Rochester, NY 14642; e-mail: [email protected]. Jamie Lynn Adams, BA, University of Rochester School of Medicine and Dentistry, Rochester, New York.