1. Acknowledgements
I would like to thank Dr.Md Saed Mian and all his
department’s colleagues for their support in this audit.
References
1. Pramit M. Phal and James C. Anderson (2006). "Imaging in Spinal Trauma." Elsevier 41(3): 190-195.
2. Ian G. Stiell, George A. Wells, et al. (2002). "Canadian C-Spine Rule study for alert and stable trauma patients: I. Background and rationale." Canadian Journal of Emergency Medicine.
3. Ian G. Stiell, Catherine M. Clement, et al. (2003). "The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma." The New England Journal of Medicine 349: 2510-2518.
An audit of Canadian C-spine Rule (CCSR) for C-spine imaging in
alert and stable trauma patients at the Hospital Sultanah Aminah (HSA)
1.Background
• High discrepancy and
inefficiency exist in clinical
practice regarding the use of
radiography in alert and stable
trauma patients where cervical
spine injury is a concern.
• Insufficient investigation might
underdiagnose C-spine injury
while unnecessary imaging
wastes department’s resources
and affects patient safety.
• CCSR has high sensitivity and
reliability to rule out C-spine
injury in these patients.[1]
2.Aims
• To assess adherence of HSA to
the CCSR on using imaging in
stable and alert trauma patients
with suspected C-spine injury.
3.Methods
• Prospective study of new
traumatic cases which came to
HSA emergency department
during 11/1/2015-6/2/2015.
• Sample eligibility must fulfil
the CCSR criteria.[2]
• Data from hospital records was
collected by using a pro-forma.
.
4.Results
• 21 male and 10 female involved in trauma
cases were included in the analysis (mean
age = 28.1 years) and all patients are adults
(age > 16 years old).
• All low-risk patients are able to rotate neck
45° left and right.
• In all patients with imaging done, only 1
high-risk patient showed significant injury.
Figure 1. Patient Group Classification According To The
CCSR
Figure 2. Percentage Of Imaging Obtained In High-Risk And
Low-Risk Groups
5.Discussion & Conclusions
• Overall, only 17 out of 31 cases fulfilled the CCSR
guidelines.
• 14.3% of high-risk patients did not receive
appropriate imaging while 70.6% of low-risk
patients went for imaging but none of them had
detectable cervical injury; imaging assessment was
over performed in the low-risk group.
• For the best interest of some patients, imaging
assessment may not follow guidelines; meanwhile,
there are other guidelines (e.g. NEXUS criteria)
which are easy and comfortable for physicians to
use and applicable on unstable patients who have
reduced consciousness as well.[3] These might
explain the low adherence to the CCSR.
• The results show that the current clinical practice
at the HSA does not follow the CCSR.
6.Limitations
• CCSR does not cover all scenarios and thus
making risk classification difficult in certain cases.
• Insufficient C-spine view in some plain X-ray
images may reduce fracture detection rate.
7.Recommendations
• CCSR can be introduced to the department to
standardise the clinical judgement among doctors.
• House officers should review the cases with
specialists to avoid unnecessary imaging.
• Re-audit in one year time to evaluate the
interventions.
85.7%
70.6%
14.3%
29.4%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
High Risk Low Risk
C-spine Imaging Obtained C-spine Imaging Not Obtained
5
12
2
12
M5724
14
(45%)
17
(55%)
High-Risk
Low-Risk