Connelly Christopher R, Yonge John D, Eastes Lynn E, Bilyeu Pamela E, Kemp Bohan Phillip M, Schreiber Martin A, Azarow Kenneth S, Watters Jennifer M, Jafri Mubeen A
From the Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (C.R.C., J.D.Y., L.E.E., P.E.B., P.M.K.B., M.A.S., J.M.W.), Oregon Health & Science University, Portland, Oregon; Division of Pediatric Surgery, Department of Surgery (K.S.A., M.A.J.), Oregon Health & Science University, Portland, Oregon; Doernbecher Children's Hospital, Randall Children's Hospital (M.A.J.), Oregon Health & Science University, Portland, Oregon.
J Trauma Acute Care Surg. 2016 Aug;81(2):278-84. doi: 10.1097/TA.0000000000001071.
Morbidity and mortality of cervical spine (C-spine) injury in pediatric trauma patients are high, necessitating quick and accurate diagnosis. Best practices emphasize minimizing radiation exposure through decreased reliance on computed tomography (CT), instead using clinical assessment, physical examination, and alternate imaging techniques. We implemented an institutional performance improvement and patient safety (PIPS) program initiative for C-spine clearance in 2010 because of high rates of CT scans among pediatric trauma patients.
A retrospective review of pediatric trauma patients, aged 0 years to 14 years, in the pre- and post-PIPS implementation periods was conducted. Rates of C-spine CT, overall CT, other imaging modalities, radiation exposure, patient characteristics, and injury severity were compared, and compliance with PIPS protocol was reviewed.
Patient characteristics and injury severity were similar before and after PIPS implementation. C-spine CT rates decreased significantly between groups (30% vs. 13%, p < 0.001), whereas C-spine plain x-ray rates increased significantly (7% vs. 25%, p < 0.001). There was no difference in C-spine magnetic resonance imaging between groups (12% vs. 10%, p = 0.11). In 2007, 71% of patients received a CT scan for any reason. However, the overall CT rate decreased significantly between groups (60% vs. 45%, p < 0.001). There was an estimated 22% decrease in lifetime attributable risk (LAR) for any cancer due to ionizing imaging exposure in males and 38% decrease in females between the pre- and post-PIPS groups. There was a 54% decrease in LAR for thyroid cancer in males and females between groups; 2014 compliance with the protocol was excellent (82-90% per quarter).
Performance improvement and patient safety program-generated protocol can significantly decrease ionizing radiation exposure. We demonstrate that a simple protocol focused on C-spine imaging has high compliance, decreased C-spine CT scans, and decreased LAR for thyroid cancer. A secondary benefit is a reduction in total CT imaging, with an associated decrease in LAR for all cancers.
Therapeutic study, level IV; diagnostic study, level III.
小儿创伤患者颈椎（C 脊柱）损伤的发病率和死亡率很高，因此需要快速准确的诊断。最佳实践强调通过减少对计算机断层扫描（CT）的依赖来尽量减少辐射暴露，转而采用临床评估、体格检查和其他成像技术。由于小儿创伤患者中 CT 扫描的使用率很高，我们于 2010 年实施了一项针对 C 脊柱检查的机构绩效改进和患者安全（PIPS）计划倡议。
对 PIPS 实施前后 0 至 14 岁的小儿创伤患者进行回顾性研究。比较 C 脊柱 CT、总体 CT、其他成像方式、辐射暴露、患者特征和损伤严重程度的发生率，并审查对 PIPS 方案准则的遵守情况。
PIPS 实施前后患者特征和损伤严重程度相似。两组之间 C 脊柱 CT 使用率显著下降（30%对 13%，p<0.001），而 C 脊柱平片使用率显著上升（7%对 25%，p<0.001）。两组之间 C 脊柱磁共振成像没有差异（12%对 10%，p = 0.11）。2007 年，71%的患者因任何原因接受了 CT 扫描。然而，两组之间总体 CT 使用率显著下降（60%对 45%，p<0.001）。在 PIPS 实施前和实施后的组间，男性因电离成像暴露导致的任何癌症的终生归因风险（LAR）估计下降了 22%，女性下降了 38%。两组间男性和女性甲状腺癌的 LAR 下降了 54%；2014 年对该方案准则的遵守情况良好（每季度 82 - 90%）。
绩效改进和患者安全计划生成的方案准则可显著减少电离辐射暴露。我们证明，一个专注于 C 脊柱成像的简单方案具有高遵守率、减少了 C 脊柱 CT 扫描以及降低了甲状腺癌的 LAR。第二个好处是减少了总体 CT 成像，同时所有癌症的 LAR 也相应降低。
治疗性研究，IV 级；诊断性研究，III 级。
