3.15 Spine Evaluation

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Description of Indicator

Relationship to Quality Medical care should be safe, timely and effective
Type of Indicator Hospital process, Hospital level
Proposed Data Source Hospital Medical Record
Definition Number of patients with evaluations and decisions regarding immobilization of the spine within 36 hours of hospital admission per 100 patients
Numerator All patients age 18 years and older admitted to hospital with an injury diagnosis from a blunt force mechanism AND documented assessment of the cervical, thoracic and lumbar spine AND decision to continue OR discontinue spine immobilization within 36 hours of admission to hospital*
Denominator All patients age 18 years and older admitted to hospital with an injury diagnosis from a blunt force mechanism
Benchmark Not specified at present
Risk Adjustment Not applicable

* Documented decision making regarding spine immobilization within 36 hours could include any of the following: 1) decision to discontinue all precautions, 2) decision to continue all precautions or 3) decision to discontinue some precautions, but continue others (e.g. discontinue thoracic and lumbar spine precautions, but continue cervical spine immobilization with a collar).

This indicator is intended to monitor whether spine evaluation and decision making regarding immobilization is performed in a timely fashion. The indicator does not prescribe the mechanism of spine evaluation given evolving scientific evidence. The indicator does not pertain to assessment and decision-making regarding the use of spine boards, which is a separate process.

Panel Review
Panelists noted the evolving nature of evidence for spine immobilization. They discussed that the systems should evaluate and make decisions regarding spine immobilization in an efficient manner.
Panelists debated the most appropriate time threshold for the indicator and suggested one of 24, 36 or 48 hours as potentially acceptable for the indicator to be clinically relevant. In addition, panelists emphasized the importance that documentation of both spine evaluation and immobilization decisions be included in the indicator due to a perception that written communication is often poorly done (i.e. clinical team evaluates and decides on whether to continue or discontinue immobilization but this is not clearly documented in the medical record and other health care providers are unclear about the care plan). As controversy exists regarding the best mechanisms for spine evaluation, the panelists suggested that the most practical measure may be to leave the precise method (clinical and/or radiographic) of spine evaluation to local practice.

Trauma Center Review
The trauma centers noted that the indicator may be challenging to implement and interpret given the multidimensional nature of the definition and data elements. It was noted that current practices and documentation tools might need to be altered in order for this information to be consistently documented and accessible.
In relation to the time frame, the majority of trauma centers reported that a 24 hour time frame would be most appropriate. It was noted by several trauma centers that the indicator incorporates evaluation of multiple components of trauma care (i.e. timeliness of imaging, timeliness of radiology reports, timeliness of decision making).

Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: Two studies demonstrated that the implementation of a trauma quality improvement program that included the quality indicator was associated with reduced hospital mortality44,45.
Reliability: No studies identified.
Risk Adjustment: Not applicable.
Utilization: Indicators to evaluate spine evaluation are used by a moderate number of trauma centers: USA 39% (77/200), Canada 63% (22/35), Australasia 33% (4/12).
The majority of the studies recommended that clearance be performed within 72 hours of admission to minimize immobilization associated complications75,76, although mortality wasn’t reduced77,78. Some studies recommended the use of helical CT scan of the cervical spine79,80.

The Quality Indicator Consensus Panel proposed the indicator Time to Cervical Spine Clearance and subsequently revised it to Spine Evaluation.


44. Chadbunchachai W, Saranrittichai S, Sriwiwat S, Chumsri J, Kulleab S, Jaikwang P. Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai. 2003;86(1):1-7.
45. Chadbunchachai W, Sriwiwat S, Kulleab S, Saranrittichai S, Chumsri J, Jaikwang P. The comparative study for quality of trauma treatment before and after the revision of trauma audit filter, Khon Kaen hospital 1998. J Med Assoc Thai. 2001;84(6):782-790.
75. Orlando Regional Medical Center Department of Surgical Education. Cervical spine clearance. 2009; http://www.surgicalcriticalcare.net/guidelines.php. Accessed September 26, 2011.
76. Albrecht RM, Kingsley D, Schermer CR, Demarest GB, Benzel EC, Hart BL. Evaluation of cervical spine in intensive care patients following blunt trauma. World J Surg. 2001;25(8):1089-1096.
77. Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003;55(2):222-226.
78. Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G, Registry GT. Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome. J Trauma. 2006;61(1):156-160; discussion 160.
79. Barba CA, Taggert J, Morgan AS, et al. A new cervical spine clearance protocol using computed tomography. J Trauma. 2001;51(4):652-656.
80. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma. 2005;58(5):890-895; discussion 895-896.