RSNA: Collaboration, education curbs cervical spine CT overuse in the ED

CHICAGO—Emergency department (ED) physicians reduced inappropriate orders for screening cervical spine CT after implementation of a pre-imaging checklist and educational intervention, researchers reported Nov. 26 at the Radiological Society of North America (RSNA) meeting.

The National Emergency X-Radiography Utilization Study (NEXUS) criteria were introduced in 2000 with the aim of identifying patients with a low probability of cervical spine injury for whom imaging was unnecessary. The criteria have been included as part of the American College of Radiology Appropriateness Criteria for imaging of patients with suspected spine trauma. However, many patients continue to undergo imaging without meeting these criteria, according to Brent Griffith, MD, chief radiology resident at Henry Ford Health System in Detroit.

Griffith and colleagues devised a multi-phase analysis to determine the number of potentially avoidable screening cervical spine CT exams, identify indications for ordering studies in the absence of these criteria and assess whether a clinical education program could improve appropriate utilization.

During phase 1 of the study, the researchers reviewed 1,589 cervical spine CTs and notes for the presence of fracture or ligamentous injury. They also assessed documentation for the NEXUS criteria. Of these exams, 1,524 had no acute injury; and 23.9 percent of these had no documentation of any of the NEXUS criteria and potentially could have been avoided, Griffith told Health Imaging.

In phase 2, Griffith and colleagues completed a prospective analysis in collaboration with the ED and focused on all patients presenting to the trauma center for whom a screening cervical CT was ordered for blunt trauma. Clinicians completed a survey detailing mechanism of injury, indication for the CT exam and clinical suspicion of injury for each patient. Radiologists blinded to the survey evaluated these 507 CT exams.

Of the 502 exams with no injury, 16.1 percent had no NEXUS criteria. Strict application of NEXUS criteria before cervical spine imaging would have eliminated these exams, according to Griffith.

Griffith suggested the drop in inappropriate imaging between phase 1 and phase 2 was multifactorial, and may be tied to improved documentation in phase 2. “The heightened awareness created by the survey likely played a significant role in the drop as well,” Griffith said. “This also highlights the fact that heightened awareness, even when it is created by a simple survey could improve documentation and hence, affect physician ordering practices. This stresses the importance of continued education of referring physicians about appropriateness criteria for ordering imaging studies.”

The final phase of the project entailed a clinician education program, comprised of a lecture focused on educating clinicians regarding appropriate guidelines for cervical spine CT. Clinicians were not instructed to follow specific criteria. In addition, flyers were posted throughout the ED to remind clinicians of the criteria. The researchers reassessed utilization rates and evaluated changes in practice habits after the educational intervention.

Phase 3 demonstrated strict application of the NEXUS criteria would have reduced the number of negative studies 13.9 percent, Griffith said. The researchers also observed the cervical spine injury rate increasing from 1 percent in phase 1 to 2.8 percent in phase 3.

The poster LL-QSE-MO2B can be found in the Lakeside Learning Center.