Improving Cervical Spine Clearance Documentation in the Pediatric Trauma Patient: A Quality Improvement Project.

Background: Cervical spine clearance of pediatric trauma patients requires consistent, clear documentation for multidisciplinary trauma team members to provide safe care. Yet, cervical spine clearance often remains inconsistently and inappropriately documented.

Objective: This study evaluated the effects of a cervical spine clearance documentation initiative on documentation adherence rates.

Methods: This quality improvement study used a Plan-Do-Study-Act with iterative cycles and prospective data collection conducted from May 2022 to September 2023 in a large urban freestanding, Midwestern, U.S. Level I pediatric trauma center. The inclusion criteria were pediatric trauma patients aged 0-18 years with Glasgow Coma Scale scores ≥14 at clearance who required cervical collar placement. The multicomponent intervention comprised a standardized electronic note, enhanced multidisciplinary education, updated clinical guidelines, and weekly chart reviews with Pareto analysis. Outcome measures were adherence rates with a goal set at greater than 80% compliance.

Results: A total of 550 patients were included in the study time period. The cervical spine documentation rate improved from a baseline pre-implementation rate of 10% to a post-implementation rate of 85% and has been sustained for the past 13.5 months.

Conclusions: Implementing a standardized cervical spine clearance note increased the percentage of appropriate documentation, reducing the uncertainty regarding safe collar removal.