UMEM Educational Pearls

Category: Neurology

Title: C-Spine Clearance by ED Triage Nurses?

Keywords: cervical, spine, clearance, triage, nurse, trauma (PubMed Search)

Posted: 11/14/2018 by WanTsu Wendy Chang, MD
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  • The Canadian C-Spine Rule (CCR) has been shown to decrease the use of cervical spine imaging in low-risk trauma patients.
  • While developed for use by physicians, CCR has also been validated in ED triage nurses with moderate interrater reliability (kappa 0.78) by Stiell et al. in 2010.
  • Stiell’s group has since implemented the use of CCR by ED triage nurses at 9 teaching hospitals in Ontario with a combined annual volume of approximately 670,000 ED visits.
  • 180 certified nurses evaluated 1408 patients.
    • 806 (57.2%) arrived with c-spine immobilization.
    • 602 (42.8%) had neck pain but no immobilization.
  • Overall, nurses removed immobilization in 331 (41.4%) patients and applied immobilization in 203 (14.4%) patients.
  • Diagnostic imaging was performed in 612 (43.4%) patients and found 16 (1.1%) clinically important and 3 (0.6%) clinically unimportant injuries.
  • There were no missed c-spine injuries to the knowledge of the authors as the study hospitals were closely connected with the regional spine centers.
  • Time from nursing assessment to discharge decreased by 26.0% (3.4h vs. 4.6h)

Bottom Line: ED triage nurses can safely use the Canadian C-Spine Rule.  This approach can improve patient care and decrease length of stay in the ED.


  • Stiell IG, Clement CM, O’Connor A, et al. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ. 2010;182(11):1173-9.
  • Stiell IG, Clement CM, Lowe M, et al. A multicenter program to implement the Canadian C-Spine Rule by emergency department triage nurses. Ann Emerg Med. 2018;72(4):333-41.

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