Understanding Cervical Spine Injury Imaging Decision-Making in Pediatric Trauma Patients

OBJECTIVES The Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury (CSI) clinical prediction rule (CPR) was developed to reduce unnecessary imaging in pediatric trauma patients and ensure accurate diagnosis. This study aimed to identify barriers and facilitators to future implementation of this rule in diverse emergency department (ED) settings. METHODS We conducted 40 interviews with 48 clinicians, including ED physicians, surgeons, nurses, and advanced practice providers at 21 health care facilities across the United States. Semistructured interviews explored determinants impacting implementation, guided by the Tailored Implementation for Chronic Diseases (TICD) framework. We conducted a deductive thematic analysis using the TICD domains as a priori codes. Three researchers independently coded the transcripts and identified key themes aligned with the TICD framework. RESULTS Barriers included limited guideline accessibility, workflow disruptions, and inconsistent integration with electronic health records. Clinicians’ concerns regarding the applicability and adherence to guidelines were also significant. Facilitators identified included institutional support, stakeholder engagement, and targeted education that addressed knowledge gaps. Implementation strategies varied by context, with suggestions for electronic health record-based decision tools in resource-equipped facilities and external aids, such as pocket cards, in lower-resource settings. Addressing legal concerns, clinician resistance, and workflow alignment emerged as critical priorities. CONCLUSION Implementing the PECARN CSI CPRs requires addressing contextual barriers such as workflow challenges, clinician adherence, and technology integration. Context-sensitive strategies are essential for successful adoption and improved decision-making in pediatric trauma care. Future research should evaluate the impact of these strategies on clinician behavior and patient outcomes.