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A Standardized Protocol For The Evaluation Of Cervical Spine Injuries Reduces Radiation Exposure And Hospital Charges
Christopher Pennell1, L. Grier Arthur1, Martin Herman1, Jayesh Gupta2, Michael March2, Erika Lindholm1, Rajeev Prasad1, Sean Ciullo1, *Harsh Grewal1
1St. Christopher's Hospital for Children, Philadelphia, PA;2Drexel University College of Medicine, Philadelphia, PA

Background (issue): Cervical spine injuries (CSI) can cause severe morbidity in children. Multiple imaging studies are used during evaluation but come at a cost financially and in radiation exposure. To reduce these, we implemented a standardized protocol (SP) for evaluating CSIs.
Methods: Children <18 years old presenting with concern for CSI to a pediatric trauma center were reviewed before (July 2015-May 2016) and after (November 2017-June 2018) protocol implementation. The primary outcomes were the proportion cleared by clinical exam, and the proportion undergoing x-ray, CT, or MRI. The secondary outcome was the difference in hospital charges based on the estimated reduction in radiographic studies.
Findings: 359 children were evaluated for CSIs (248 pre-SP, 111 post-SP). Protocol adherence was 87.4%. The prevalence of CSIs was similar in the pre and post-SP cohorts (2.8% vs. 1.8%, p=0.567). Children treated after implementation were more likely to be cleared by clinical exam (15.3% vs. 43.2%, p<0.001). Significantly fewer children had x-rays (70.2% vs 55.0%, p=0.005) and CT scans (14.5% vs. 5.4%, p=0.013) in the post-SP period. There was no difference in the utilization of MRI (6.9% vs. 7.2%, p=0.904) or the proportion discharged with a cervical collar (10.1% vs. 12.6%, p=0.476). No patients in either group had a previously undiagnosed injury identified at follow up. The reduction in radiographic studies translates to an estimated annual reduction in hospital charges of $396,476.39.
Conclusions (implications for practice): A standardized protocol for evaluating CSIs reduced the number of radiographic studies performed and estimated hospital charges while reliably identifying CSIs.


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