title: A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results.
abstract: OBJECTIVE
  Assessment of potential spine injuries is inconsistent and controversial. Subsequent morbidity includes prolonged immobilization and missed injuries. To address these issues, a multidisciplinary team was organized to design a cervical spine management/clearance pathway. The process, algorithm, and initial results are described.
  
  
  METHODS
  Team members consisted of pediatric surgeons, orthopedic surgeons, neurosurgeons, emergency room physicians, and trauma nurse practitioners. Nationwide standards, guidelines, and experiences across disciplines were reviewed, and a consensus pathway evolved for cervical spine clearance in children 8 years and younger. A short-term retrospective review (5 months) was performed to assess initial performance. Time required for clearance, number and type of imaging studies, and number of missed injuries were compared between a group of patients before (n = 71) and after (n = 56) the implementation of the pathway.
  
  
  RESULTS
  Strict guidelines for cervical spine immobilization and clearance criteria were defined. After implementation of this pathway, time required for cervical clearance in nonintubated children decreased (before, 12.3 +/- 1.5 v after, 7.5 +/- 0.9 hours; P =.014). A clear trend toward earlier clearance in intubated patients existed (before [n = 6], 40.0 +/- 16.8 v after [n = 6], 19.4 +/- 8.1 hours; P =.10); there need to be larger numbers to determine statistical significance. The 2 study groups were similar in age; mechanism of injury; Glasgow coma scale score; and number of plain x-rays, computed tomography scans, and magnetic resonance imaging studies obtained. Neither group had missed injuries.
  
  
  CONCLUSIONS
  standards for cervical spine immobilization, assessment, and clearance. Implementation of such guidelines decreased time for cervical spine clearance, and ongoing analysis of sensitivity is encouraging.
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, University of California at Davis, Medical Center, Sacramento, California 95819, USA.
authors.forename: Steven L
authors.initials: SL
authors.lastname: Lee
authors.forename: Matthew
authors.initials: M
authors.lastname: Sena
authors.forename: Stephen K
authors.initials: SK
authors.lastname: Greenholz
authors.forename: Marti
authors.initials: M
authors.lastname: Fledderman
mesh_terms: D000465:Algorithms; D001915:Braces; D019090:Case Management / Q000592:standards; D002574:Cervical Vertebrae; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D003955:Diagnostic Tests, Routine; D004632:Emergency Medical Services; D013502:General Surgery; D015600:Glasgow Coma Scale; D006801:Humans; D007103:Immobilization; D007223:Infant; D033183:Interdisciplinary Communication; D009722:Nurse Practitioners; D009985:Orthopedics; D010348:Patient Care Team; D010372:Pediatrics; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013124:Spinal Injuries / Q000175:diagnosis* / Q000628:therapy; D014474:Unconsciousness / Q000628:therapy