Cervical spine injuries (CSI) are serious, but rare events in children. In contrast, spinal immobilization for transport of pediatric trauma patients followed by radiographic clearance in the emergency department (ED) is common and known to be associated with adverse effects. As a result, more than 99% of immobilized children have no CSI and are exposed to harm with no demonstrable benefit. The nation's EMS systems need a set of CSI screening criteria that can be applied in both the prehospital and ED settings to reduce the number of children who are immobilized and irradiated unnecessarily. Leonard et al and the Pediatric Emergency Care Applied Research Network (PECARN) have identified 8 sensitive risk factors that predict cervical spine injury in children. These risk factors require prospective evaluation prior to implementation as a decision support tool. The logical next step in preparation for this large multi-center study is to establish the feasibility of collecting paird observations of CSI risk factors from EMS providers and emergency physicians and prospectivel validate the PECARN model. Goal: Develop and test the infrastructure necessary for collecting prospective observational data from EMS providers and emergency physicians who care for children with blunt trauma as a prerequisite for conducting a large prospective study to refine, validate and implement a Pediatric CSI Risk Assessment Tool.
Specific Aims : 1) To construct a data collection system for prehospital provider and emergency physician observations of children who receive medical care after blunt trauma;2) To determine the observability and inter-rater reliability of variables that are used by prehospital providers and emergency physicians for the assessment of CSI in children;3) To prospectively validate a previously identified model for CSI prediction in children for use as a prediction tool. Coordination: This work will be conducted at 3 level-one pediatric trauma centers and their affiliated EMS-systems within the PECARN Hospitals of the Midwest Emergency Research Node (HOMERUN): St. Louis Children's Hospital, Cincinnati Children's Medical Center, and Children's Hospital of Wisconsin. Methodology: Each study site will form a research team that will engage EMS personnel in developing the necessary research materials and methods for collecting prospective observational data from EMS prehospital providers and emergency physicians regarding cervical spine injury risk factors in children. We will pilot test the materias and methods on a sample of 4,500 injured children who are transported to HOMERUN emergency departments for evaluation following blunt trauma. Evaluation: We will track missed eligible patients and report the capture rates for EMS provider and emergency physician observations. We will also compare the characteristics of those enrolled to the missed eligible patients. We will report measures of inter-rater agreement for all paired EMS provider and physician observations. We will report the predictive value of a proposed prediction model for CSI in children and incorporate the model into an electronic Pediatric CSI Risk Assessment Tool.
This project uses study sites within a pre-existing research network to develop the infrastructure necessary to conduct a large, prospective observational study, which engages EMS prehospital providers and emergency physicians in the development of a Pediatric Cervical Spine Injury (CSI) Risk Assessment Tool. Such a tool can be used to determine which injured children can be safely transported without spinal immobilization and forgo radiographic evaluation in the emergency department. This project has the potential to benefit millions of injured children at negligible risk for CSI, but who are subject to the unnecessary harms of immobilization and/or neck irradiation.