Analysis of Pediatric Cervical Spine Injury Evaluation Workflow in the Emergency Department

Objectives: The decision to image children for cervical spine injuries (CSI), an uncommon injury with high associated morbidity and mortality, is complex. X-rays and computed tomography are often used to screen for CSI; however, radiation exposure increases lifetime cancer risk. We recently developed a CSI prediction rule to inform pediatric imaging decisions. To guide implementation, we conducted a workflow analysis of CSI screening in children after blunt trauma. Methods: We interviewed emergency departments (ED) and trauma clinicians at 21 hospitals following the applied cognitive task analysis task diagram, knowledge audit, and simulation interview approaches. Interviews were coded using a combined deductive-inductive approach to construct a workflow diagram and identify critical decisions with associated workflow junctures, decision makers, physical locations, and cognitive demands. We noted areas of high, medium, and low variability. Results: We interviewed 48 participants (emergency medicine physicians and advanced practice providers [n = 22], nurses [n = 14], and surgeons [n = 12]) across 21 hospitals located in the Western (n = 15), Northeastern (n = 5), and Midwestern (n = 1) USA. Critical decisions within the pediatric CSI imaging decision workflow included trauma triaging, spinal motion restriction application, clinical clearance, decision to image, and imaging type. There was moderate-to-high variability between hospitals for most workflow junctures and decision makers. However, more consistent patterns emerged, such as a high level of ED and trauma attending involvement throughout the process. The knowledge audit revealed a heavy cognitive load associated with decision making. “Big picture,” “past and future,” “noticing”, “job smarts,” and “equipment” were highly relevant cognitive demands. Conclusion: Moderate-to-high between-hospital variability in workflow for decision making around CSI evaluation for pediatric trauma patients could potentially complicate CSI prediction rule implementation.