Outcome of Trauma Patients Immobilized by Emergency Department Staff,but Not by Emergency Medical Services Providers: A Quality Assurance Initiative

Abstract

Background. Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol. Methods. This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist on the final imaging report. Results. The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of $1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging. Conclusions. In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings.