title: Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department.
abstract: OBJECTIVE
  The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospectively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses.
  
  
  METHODS
  We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form.
  
  
  RESULTS
  Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%-100.0%) and specificity of 43.4% (95% CI 42.0%-45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%-95.0%) and a specificity of 43.9% (95% CI 42.0%-46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases.
  
  
  CONCLUSIONS
  Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.
authors.affiliation: Department of Emergency Medicine, University of Ottawa, and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Department of Nursing, Ottawa Hospital, Ottawa, Ontario. istiell@ohri.ca
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Clement
authors.forename: Annette
authors.initials: A
authors.lastname: O'Connor
authors.forename: Barbara
authors.initials: B
authors.lastname: Davies
authors.forename: Christine
authors.initials: C
authors.lastname: Leclair
authors.forename: Pamela
authors.initials: P
authors.lastname: Sheehan
authors.forename: Tamara
authors.initials: T
authors.lastname: Clavet
authors.forename: Christine
authors.initials: C
authors.lastname: Beland
authors.forename: Taryn
authors.initials: T
authors.lastname: MacKenzie
authors.forename: George A
authors.initials: GA
authors.lastname: Wells
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital; D011859:Radiography; D015203:Reproducibility of Results; D013124:Spinal Injuries / Q000000981:diagnostic imaging*; D014218:Triage; D000078329:Workforce; D055815:Young Adult
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