BMJ 339: b4146. [Prepared by Nora Shields, CAP Editor.] Question: Does implementation of the Canadian C-spine rule in emergency departments reduce the proportion of patients referred for diagnostic imaging of the cervical spine without Alectinib cost a concurrent increase in unidentified cervical spine injuries or serious adverse outcomes? Design: Matched pair cluster randomised trial. Setting: 12 emergency departments of teaching and community hospitals in Canada. Participants: 11 824 patients with a Glasgow Coma Scale score of 15, normal vital signs, and who had sustained within the previous 48 hours either blunt trauma to the head or neck, or a visible injury above

the clavicles and a mechanism of injury that was considered dangerous. Patients were excluded if they were under the age of 16, had a penetrating trauma, acute paralysis or known vertebral disease, or were a return patient for

reassessment of injury. Randomisation of 11 824 participants allotted 6895 to the intervention group and 4929 to a control group. Interventions: The Canadian C-spine rule was implemented in the 6 intervention group hospital sites using three strategies: (1) policy agreement among physicians on ordering cervical spine imaging, (2) education initiatives including distribution of manuscripts, pocket card, and poster descriptions of the rule, and a 1-hour teaching session, RAD001 datasheet and (3) a mandatory real-time reminder at the point of requisition for imaging. The control group received no intervention although the rule may have been familiar to some clinicians at these sites. Outcome measures: The primary outcome was the proportion of patients referred for diagnostic imaging of the cervical spine. Baseline ordering rates were measured for 12 months. During the following 12-month period, the three strategies were implemented and imaging rates monitored. Secondary outcomes were the numbers of clinically important cervical spine injuries not identified, serious adverse outcomes and misinterpretations of the rule. Results: 11 824 participants

completed the study. From the baseline to implementation periods, the intervention group showed a relative reduction in cervical spine imaging of 13% (95% CI 9 to 16). too This differed significantly from the control group, which showed a relative increase of 12% (95% CI 7 to 18). No patient discharged without imaging was subsequently found to have a clinically important cervical spine injury. No serious adverse outcomes occurred. Doctors interpreted the rule accurately for 83% of patients. Conclusion: Imaging rates for cervical spine injuries were reduced significantly in hospitals that implemented the Canadian C-spine rule compared with control hospitals. No cervical spine fractures were missed and no adverse events occurred.