LO83: Effectiveness of implementing evidence based interventions to reduce C-spine imaging in the emergency department: a systematic review

Abstract

Introduction: Unnecessary imaging of adult cervical spine (C-spine) injury patients in the Emergency Department (ED) is a concern. Guidance for C-spine image ordering exists; however, the effectiveness and safety of their implementation in the ED is not well studied. This review examines their implementation and effectiveness at reducing C-spine imaging in adults presenting to the ED with stable neck trauma. Methods: Six electronic databases and the grey literature were searched. Comparative studies examining interventions to reduce C-spine imaging were eligible for inclusion. Two independent reviewers screened for study eligibility, assessed study quality, and extracted data. Data were analyzed using RevMan (Version 5.3) to explore the effectiveness of these interventions in safely reducing C-Spine radiography. Results: A total of 848 unique citations were screened of which six before-after studies and one randomized controlled trial were included. The study population varied with respect to injury severity (i.e., stability status). None of the studies were assessed as high quality. The interventions employed included locally developed guidelines and clinical decision rules, specifically the National X-radiography Utilization Study (NEXUS) criteria and the Canadian C-Spine Rule (CCR). Various implementation strategies, such as teaching sessions, pocket reminder cards, posters and computerized decision support were used. Several studies used multi-faceted interventions. Overall, of the five study groups that examined change in x-ray ordering, three groups reported a significant reduction in c-spine radiography. The remaining two showed no change in imaging. A pooled estimate of the effectiveness of the interventions was prohibited by significant heterogeneity. Conclusion: The evidence regarding the effectiveness of interventions to reduce C-spine imaging in adult ED patients with stable neck trauma is inconclusive. Given the national and international focus on improving appropriateness and reducing unnecessary imaging through campaigns such as Choosing Wisely®, additional interventional research in this field is warranted.