Factors Associated with Overutilization of Computed Tomography of the Cervical Spine

Introduction: Despite the wide availability of clinical decision rules for imaging of the cervical spine after a traumatic injury (eg, NEXUS C-spine rule and Canadian C-spine rule), there is significant overutilization of computed tomography (CT) imaging in patients who are deemed to be at low risk for a clinically significant cervical spine injury by these clinical decision rules. The purpose of this study was to identify the major factors associated with the overuse of CT cervical spine imaging using a logistic regression model.Methods: This was a retrospective review of all adult patients who underwent CT cervical spine imaging for evaluation of a traumatic injury at a tertiary academic emergency department (ED) and three affiliate community EDs in January and February 2019. We performed multivariable logistic regression to identify factors associated with obtaining CT cervical spine imaging despite low-risk classification by the NEXUS C-spine Rule.Results: A total of 1,051 patients underwent CT cervical spine imaging for traumatic indications during the study period, and 889 patients were included in the analysis. Of these patients, 376 (42.3%) were negative by the NEXUS C-spine rule. Variables that were associated with increased likelihood of unnecessary imaging included age over 65, Emergency Severity Index (ESI) score 2 and 3, arrival as a walk-in, and anticoagulation status. Patients who presented to the tertiary academic ED had a significantly lower likelihood of unnecessary imaging. Twenty-one patients (2.4%) were found to have cervical spine fractures on imaging, two of whom were negative by the NEXUS C-spine rule, but neither had a clinically significant fracture.Conclusion: Cervical spine imaging is vastly overused in patients presenting to the ED with traumatic injuries, as adjudicated using the NEXUS C-spine rule as a reference standard. Older age, ESI level, arrival as a walk-in, and taking anticoagulation drugs were associated with overutilization of CT imaging. Conversely, presenting to the tertiary academic ED was associated with a lower likelihood of undergoing unnecessary imaging. This model can guide future interventions to optimize ED CT utilization and minimize unnecessary testing

Financial Implications of Boarding: A Call for Research

Boarding, the practice of holding patients in emergency departments (ED) after a decision has been made to admit them to the hospital, is well known to adversely affect patient care. Multiple investigations have shown that boarding negatively impacts quality and patient safety outcomes including mortality, readmission rate, hospital length of stay, and patient satisfaction. In addition, boarding is known to be a major contributor to overall ED crowding, which also has been demonstrated to have significant negative impact on quality and safety. Multiple operational tactics are known to reduce boarding but, concerningly, adoption of them has been inconsistent. Also concerning, ED boarding appears to be worsening over time, based upon our unpublished year-over-year review of two large national ED operations benchmarking databases, the Emergency Department Benchmarking Alliance and the Academy of Administrators in Academic Emergency Medicine/Association of Academic Chairs of Emergency Medicine. The constellation of boarding having been known to adversely affect patient care outcomes for over two decades, inconsistent implementation of tactics known to reduce boarding, and evidence that boarding may be worsening over time naturally raises questions of the barriers to improvement. Chief among these questions is why implementation of boarding-reduction tactics has not consistently occurred, despite their clear benefits. In that regard, some experts have postulated that financial drivers may be at play. To investigate the potential for financial drivers contributing to boarding, we performed a systematic review, pre-registered with PROSPERO (#CRD42016037794)