title: Agreement between resident and faculty emergency physicians in the application of NEXUS criteria for suspected cervical spine injuries.
abstract: BACKGROUND
  The National Emergency X-Radiography Utilization Study (NEXUS) developed a decision rule for when cervical spine radiographs are required in the setting of trauma. To our knowledge, inter-rater reliability between resident and faculty emergency physicians has not been studied.
  
  
  OBJECTIVE
  This study seeks to compare the inter-rater agreement of postgraduate year (PGY) 2-4 emergency medicine (EM) residents vs. EM faculty physicians.
  
  
  METHODS
  A convenience sample of patients presenting to an urban, academic, Level II emergency department (ED) with complaints of cervical spine pain after trauma were enrolled. All subjects received separate examinations by an EM faculty physician and by a PGY 2-4 EM resident in a blinded fashion. Eighty subjects were enrolled in the study.
  
  
  RESULTS
  Agreement for each of the NEXUS components were: posterior midline tenderness (PMT) 85.0% and κ = 0.70, intoxication (TOX) 95.0% and κ = 0.72, altered mental status (AMS) 87.5% and κ = 0.22, focal neurologic deficit (FND) 92.5% and κ = 0.21, and presence of a distracting injury (DIS) 88.8% and κ = 0.13. Overall agreement for need for radiographs was 77.5% and κ = 0.53. Sixty of the subjects received radiography (28 computed tomography, 40 plain films, 8 both). One fracture (C1 lamina) was detected in this dataset. Two of the five NEXUS criteria (PMT, TOX) demonstrated substantial agreement, two (AMS, FND) fair agreement, and one (DIS) slight agreement.
  
  
  CONCLUSIONS
  Based on our findings, there was considerable difference in agreement between staff physicians and residents. This could be due to the level of experience of the provider or the subjectiveness of components the criteria.
authors.affiliation: Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Matteucci
authors.affiliation: Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California.
authors.forename: Danielle
authors.initials: D
authors.lastname: Moszyk
authors.affiliation: Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California.
authors.forename: Salvatore A
authors.initials: SA
authors.lastname: Migliore
mesh_terms: D000328:Adult; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D002983:Clinical Competence / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005178:Faculty / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007396:Internship and Residency / Q000706:statistics & numerical data*; D008297:Male; D019838:Neck Injuries / Q000000981:diagnostic imaging; D019547:Neck Pain / Q000000981:diagnostic imaging; D015588:Observer Variation; D011446:Prospective Studies; D015203:Reproducibility of Results; D013124:Spinal Injuries / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed
keywords: National Emergency X-Radiography Utilization Study; cervical spine injury; cervical spine radiographs; clinical decision rule; inter-rater reliability