The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics

Presented at the Society for Academic Emergency Medicine annual scientific meeting, May 2007, Chicago, IL; and the Canadian Association of Emergency Physicians annual meeting, June 2007, Victoria, BC, Canada.

Received 27 August 2008; received in revised form 20 January 2009; accepted 4 March 2009. published online 27 April 2009.

Study objective

We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.

Methods

We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.

Results

The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The κ value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.

Conclusion

This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.

a Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada

b Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada

c Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada

d City of Calgary Emergency Medical Services, Calgary, Alberta, Canada

e Essex-Kent Base Hospital, Hotel Dieu Grace Hospital, Windsor, Ontario, Canada

f Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

g Emergency Health Services, Halifax, Nova Scotia, Canada

h Department of Emergency Medicine, Joseph Brant Hospital, Burlington, Ontario, Canada

i Department of Emergency Medicine, Bluewater Health, Sarnia, Ontario, Canada

j Niagara Base Hospital, Niagara Falls, Ontario, Canada

Address for correspondence: Christian Vaillancourt, MD, MSc, Ottawa Hospital, Civic Campus, Clinical Epidemiology Unit, F658, 1053 Carling Avenue, Ottawa, Ontario, Canada K1Y 4E9; 613-798-5555 ext.17012, fax 613-761-5351

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Supervising editor: Kathy J. Rinnert, MD, MPH

Author contributions: CV and IGS applied for funding. CV and TB helped clean the database. CV monitored study progression, recruited centers, organized training, performed analyses, and wrote the paper. IGS, TB, JM, ARA, PB, EC, AT, MS, ML, DM, EB, JB, and GAW critically reviewed and helped edit the article. IGS developed the original rule and training material. TB acted as study coordinator. JM, ARA, PB, EC, AT, MS, ML, and DM acted as site coordinators, overseeing all local aspects of study site implementation. EB was the study nurse, reviewed all data collection sheets before data entry, and performed patient follow-up. JB acted as interim study coordinator. TB and JB monitored all aspects of the study. CV and GAW helped develop the study methodology. CV takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The authors are indebted to the Physicians' Services Incorporated Foundation and the Ontario Ministry of Health and Long-Term Care for their financial support of this study.

Publication date: Available online April 24, 2009.

Reprints not available from the authors.

PII: S0196-0644(09)00241-8

doi:10.1016/j.annemergmed.2009.03.008

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