Article Text
Abstract
Background For years, controversy has existed about the ideal approach for cervical spine clearance in obtunded, blunt trauma patients. However, recent national guidelines suggest that MRI is not necessary for collar clearance in these patients. The purpose of this study was to identify the extent of national variation in the use of MRI and assess patient-specific and hospital-specific factors associated with the practice.
Methods We performed a retrospective review of the National Trauma Data Bank from 2007 to 2012. We included blunt trauma patients aged ≥18 years, admitted to level 1 or 2 trauma centers (TCs), with a Glasgow Coma Scale <8, Abbreviated Injury Scale >3 for the head and mechanically ventilated for more than 72 hours. Multilevel modeling was used to identify patient-level and hospital-level factors associated with spine MRI use.
Results 32 125 obtunded, blunt trauma patients treated at 395 unique TCs met our inclusion criteria. The mean proportion of patients who received MRI over the entire sample was 9.9%. The proportions of patients at each hospital who received a spine MRI ranged from 0.5% to 68.7%. Younger patients, with injuries from motor vehicle collisions and pedestrian injuries, were more likely to receive MRI. When controlling for other variables, Injury Severity Score (ISS) was not associated with MRI use. Hospitals in the Northeast, level 1 TCs and non-teaching hospitals were more likely to obtain MRIs in this patient population.
Conclusion After controlling for patient-level characteristics, variation remained in MRI use based on geography, trauma center level and teaching status. This evidence suggests that current national guidelines limiting the use of MRI for cervical spine evaluation following blunt trauma are not being followed consistently. This may be due to physicians not being up to date with best practice care, unavailability of locally adopted protocols in institutions or lack of consensus among clinical providers.
Level of evidence Prognostic and epidemiological, level III.
- blunt trauma
- cervical spine
- magnetic resonance imaging
- variation
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Footnotes
Presented at This work was originally presented at the 2016 Academic Surgical Congress in Jacksonville, Florida, USA.
Twitter @IraLeeds_MD @candeux @JosephSakran @elliotthaut
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests ERH is supported by a grant from the AHRQ (1R01HS024547) entitled ‘Individualized Performance Feedback on Venous Thromboembolism Prevention Practice’, a contract (CE-12-11-4489) from the Patient Centered Outcomes Research Institute (PCORI) entitled ‘Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology’, a contract from PCORI entitled ‘Preventing Venous Thromboembolism (VTE): Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis’ and a grant from the NIH/NHLBI (R21HL129028) entitled ‘Analysis of the Impact of Missed Doses of Venous Thromboembolism Prophylaxis’. ERH is a paid consultant and speaker for the ‘Preventing Avoidable Venous Thromboembolism—Every Patient, Every Time’ VHA/Vizient IMPERATIV® Advantage Performance Improvement Collaborative. ERH receives royalties from Lippincott, Williams, Wilkins for a book—‘Avoiding Common ICU Errors’. Dr Haut was the paid author of a paper commissioned by the National Academies of Medicine titled ‘Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making’ which was used to support the report titled ‘A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury’.
Patient consent for publication Not required.
Ethics approval Institutional review board approval was obtained from Johns Hopkins Medicine Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data may be obtained from a third party and are not publicly available.