Interrater reliability between surgeons and pediatric emergency providers in the cervical spine assessment of injured children

Fahd A Ahmad; Lorin R Browne; Nicolaus W Glomb; Monica Harding; Lawrence J Cook; Rebecca K Burger; Pradip P Chaudhari; Alexander J Rogers; Caleb E Ward; Daniel Rubalcava; Kenneth Yen; Nathan Kuppermann; Julie C Leonard

doi:10.1097/TA.0000000000004695

Interrater reliability between surgeons and pediatric emergency providers in the cervical spine assessment of injured children

J Trauma Acute Care Surg. 2025 Jun 19. doi: 10.1097/TA.0000000000004695. Online ahead of print.

Authors

Fahd A Ahmad¹, Lorin R Browne, Nicolaus W Glomb, Monica Harding, Lawrence J Cook, Rebecca K Burger, Pradip P Chaudhari, Alexander J Rogers, Caleb E Ward, Daniel Rubalcava, Kenneth Yen, Nathan Kuppermann, Julie C Leonard

Affiliation

¹ From the Washington University School of Medicine in St. Louis & St. Louis Children's Hospital (F.A.A.), St. Louis, Missouri; Departments of Pediatric and Emergency Medicine (L.R.B.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Emergency Medicine and Pediatrics (N.W.G.), University of California, San Francisco, San Francisco, California; Division of Pediatric Emergency Medicine, Department of Emergency Medicine (M.H., L.J.C.), University of Utah School of Medicine, Salt Lake City, Utah; Division of Emergency Medicine, Department of Pediatrics (R.K.B.), Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia; Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics (P.P.C.), Keck School of Medicine of the University of Southern California, Los Angeles, California; Departments of Emergency Medicine and Pediatrics (A.J.R.), C.S. Mott Children's Hospital, University of Michigan Health, Ann Arbor, Michigan; Children's National Hospital & The George Washington University School of Medicine and Health Sciences (C.E.W.), Washington, District Columbia; Division of Pediatric Emergency Medicine, Department of Pediatrics (D.R.), Baylor College of Medicine, Texas Children's Hospital, Houston; Division of Pediatric Emergency Medicine, Department of Pediatrics (K.Y.), UT Southwestern Medical Center, Children's Health, Dallas, Texas; Departments of Pediatrics and Emergency Medicine, GW School of Medicine and Health Sciences and Children's National Hospital (N.K.), Washington D.C.; and Division of Emergency Medicine, Department of Pediatrics (J.C.L.), The Ohio State College of Medicine and Nationwide Children's Hospital, Columbus, Ohio.

PMID: 40536503
DOI: 10.1097/TA.0000000000004695

Abstract

Background: Cervical spine injury (CSI) is uncommon in children but an important consideration during trauma evaluation. The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated a CSI prediction rule to guide cervical spine imaging decisions in children after blunt trauma. Our objective was to determine the interrater reliability between EM providers and surgeons for history and physical examination findings used to evaluate children for CSI after blunt trauma.

Methods: This was a planned secondary analysis of a prospective, observational multicenter study that enrolled children aged 0 year to 17 years evaluated for blunt trauma in 18 PECARN emergency departments (EDs). We collected data on injury mechanisms, history and physical examination findings, imaging ordered, and suspicion of CSI from EM and surgery providers. Kappa, prevalence, and bias-adjusted kappa (PABAK) were used to compare interrater reliability of variables associated with CSI.

Results: Surgeons cared for 8,041 of the 22,430 children enrolled in the parent study. About 18.6% (1494/8041) had data collection forms completed by both EM providers and surgeons and were included in the analysis. Agreement between EM and surgery providers per kappa was moderate (kappa 0.41-0.6) to substantial (kappa 0.61-0.8), while PABAK analyses showed substantial to almost perfect agreement for variables in the PECARN CSI prediction rule. There was agreement between EM and surgery providers in overall clinical suspicion for CSI in 64.2% (959/1494) of patients. Retrospective application of the PECARN Rule indicated that ED and surgical provider assessments would have led to the same imaging decision in 73.7% (1101/1494) of patients.

Conclusion: We identified moderate to substantial agreement between EM providers and surgeons for clinical findings that comprise the PECARN Cervical Spine Injury Prediction Rule. Agreement between providers during shared decision-making will strengthen the use of the prediction rule and may lead to decreased cervical spine imaging in EDs.

Level of evidence: Prognostic and Epidemiologic; Level II.

Keywords: Cervical spine injury; emergency medicine; interrater reliability; pediatric; surgeon.