542 - Improving Provider Documentation of the Cervical Spine Evaluation in Pediatric Trauma Patients

Publication Number: 542.5428

Jessica Serventi-Gleeson, Connecticut Children's Medical Center, West Hartford, CT, United States; Eric Hoppa, University of Connecticut School of Medicine, Hartford, CT, United States; Kathryn Schissler, Hasbro Children's Hospital at Rhode Island Hospital, Providence, RI, United States; Nelson Thomas, UConn Health, West Hartford, CT, United States; Susana Collazo, Cooper Medical School of Rowan University, Moorestown, NJ, United States

Background: Cervical spine (c-spine) injuries can result in significant morbidity and mortality. Patients presenting to the emergency department (ED) following blunt trauma are placed in a cervical collar (c-collar). C-spine clearance involves multiple considerations and subspecialties. Documentation of a thorough evaluation for c-spine clearance is an imperative, though not always completed, task to ensure team members are aware of necessary precautions and track the patient’s phase of care.

Objective: By implementing a standardized c-spine evaluation note and best practice alert (BPA) in the medical record, we aim to improve provider documentation of c-spine evaluations and ensure consistent, appropriate precautions for all trauma patients.

Design/Methods: This QI initiative was exempt from IRB review. A group of pediatric emergency medicine (PEM), neurosurgical, and trauma surgery physicians at a tertiary care, level 1 pediatric trauma center developed a templated note for c-spine evaluation and clearance based on the Nexus criteria. The note is for all blunt trauma patients arriving to the ED in a c-collar or those with concern for a c-spine injury. Elements include indication for c-spine evaluation, GCS, neurologic examination, imaging review and formal c-spine clearance. The note was implemented in October 2023. During a subsequent PDSA cycle, a BPA was implemented in February 2024 and fires for each trauma patient, prompting the provider to document c-spine clearance. A retrospective chart review was completed 10 months prior to implementation, and 10 months post implementation. Prior to note implementation, the study considered proper c-spine documentation to include mechanism of injury, cervical spine exam, and written determination of collar clearance or need for continued use. Patients with penetrating injuries or burns without blunt trauma or who expired in the ED were excluded.

Results: 180 subjects were included. Prior to implementation of a c-spine note, 33.8% percent of clearances were properly documented. After implementation of the new c-spine note there was a significant increase in documentation rate (55.9%; p= 0.018). The combination of the new c-spine note and BPA resulted in an increased documentation rate of 45.6% (p= 0.025), as compared with no intervention. There was no difference in proper documentation rate between the addition of c-spine note alone and the combination of c-spine note with BPA (p=0.24).

Conclusion(s): The use of a standardized note provided a significant increase in proper provider documentation of c-spine evaluation for pediatric trauma patients in the emergency department.