322 - Interrater Reliability between Surgical and Emergency Department Providers When Evaluating Children for Cervical Spine Injury

Saturday, April 29, 2023

3:30 PM – 6:00 PM ET

Poster Number: 322
Publication Number: 322.208

Fahd A. Ahmad, Washington University in St. Louis, St. Louis, MO, United States; Lorin R. Browne, Medical College of Wisconsin, Milwaukee, WI, United States; Nicolaus W. Glomb, University of California, San Francisco, School of Medicine, San Francisco, CA, United States; Monica Harding, University of Utah, SAINT JOHNS, FL, United States; Lawrence J. Cook, University of Utah, Salt Lake City, UT, United States; Nathan Kuppermann, UC Davis, Davis, CA, United States; Rebecca K. Burger, Emory University School of Medicine, Atlanta, GA, United States; Pradip P.. Chaudhari, Children's Hospital Los Angeles, Los Angeles, CA, United States; Alexander J. Rogers, University of Michigan Medical School, Ann Arbor, MI, United States; Caleb E. Ward, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States; Kenneth Yen, UT Southwestern Medical Center, Dallas, TX, United States; Julie C.. Leonard, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, United States

Presenting Author(s)

FA

Fahd A. Ahmad, MD, MSCI (he/him/his)

Associate Professor of Pediatrics
Washington University in St. Louis
St. Louis, Missouri, United States

Background:

Cervical spine injury (CSI) is uncommon in children but remains a leading cause of morbidity and mortality after blunt trauma. We recently completed a multicenter, prospective study to derive and validate a cervical spine injury (CSI) decision rule in the Pediatric Emergency Care Applied Research Network (PECARN) to guide imaging decisions. Application of this rule could decrease cervical spine imaging use; however, it relies on the ability of emergency department (ED) and surgical providers to agree on history and exam findings and make joint decisions.

Objective:

Our objective was to determine the interrater reliability of history and physical exam findings used to evaluate for CSI, among ED and surgical providers caring for children experiencing blunt trauma.

Design/Methods:

This was a planned secondary analysis of a prospective, observational study which enrolled children ages 0-17 years who were evaluated for blunt trauma in 18 PECARN EDs. We collected information on mechanism of injury, history and physical exam findings, imaging ordered (if any), and suspicion of CSI from ED and surgical providers. Children were included in this analysis if both the ED and surgical provider questionnaires were completed. We used kappa and prevalence and bias adjusted kappa (PABAK) to compare interrater reliability of key findings.

Results:

Surgeons were involved in the care of 8041 patients, of whom 18.6% (1494/8041) had case report forms completed by the surgeon and were eligible for inclusion. Table 1 provides percent agreement and kappa results on key history and exam findings from the PECARN CSI decision rule, as well as relevant variables from the Canadian C-Spine and NEXUS studies. Agreement between ED and surgical providers per the kappa statistic was moderate to strong, while agreement per PABAK analyses was substantial to almost perfect in the key variables for the new rule. Table 2 provides a comparison of the suspicion of CSI between ED and surgical providers. There was agreement in clinical suspicion in 64.2% (959/1494) of patients (highlighted cells). Table 3 shows the imaging recommendations if the decisions were based on the ED and surgical provider assessments of the PECARN CSI decision rule. ED and surgical provider assessments would have led to the same imaging decision in 73.7% (1101/1494) of patients (highlighted cells).

Conclusion(s):

We demonstrated high agreement between ED and surgical providers for findings that comprise the PECARN CSI decision rule. These findings will strengthen the use of the decision rule and may lead to decreased cervical spine imaging in EDs.