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Performance improvement and patient safety program–guided quality improvement initiatives can significantly reduce computed tomography imaging in pediatric trauma patients

Connelly, Christopher R. MD; Yonge, John D. MD; Eastes, Lynn E. MS, RN, ACNP-BC; Bilyeu, Pamela E. MN, RN; Kemp Bohan, Phillip M.; Schreiber, Martin A. MD; Azarow, Kenneth S. MD; Watters, Jennifer M. MD; Jafri, Mubeen A. MD

Journal of Trauma and Acute Care Surgery: August 2016 - Volume 81 - Issue 2 - p 278–284
doi: 10.1097/TA.0000000000001071
PTS 2015 Plenary Papers

Background 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.

Methods 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.

Results 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).

Conclusions 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.

LEVEL OF EVIDENCE Therapeutic study, level IV; diagnostic study, level III.

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.

Submitted: November 18, 2015, Revised: January 15, 2016, Accepted: March 9, 2016, Published online: March 30, 2016.

This study was presented at the 2nd annual meeting of the Pediatric Trauma Society, November 6–7, 2015, in Scottsdale, Arizona.

Address for reprints: Christopher R. Connelly, MD, Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code L611, Portland, OR 97239; email:

© 2016 Lippincott Williams & Wilkins, Inc.