Agreement between resident and faculty emergency physicians in the application of NEXUS criteria for suspected cervical spine injuries.

BACKGROUND: The National Emergency X-Radiography Utilization Study (NEXUS) developed a decision rule for when cervical spine radiographs are required in the setting of trauma. To our knowledge, inter-rater reliability between resident and faculty emergency physicians has not been studied.

OBJECTIVE: This study seeks to compare the inter-rater agreement of postgraduate year (PGY) 2-4 emergency medicine (EM) residents vs. EM faculty physicians.

METHODS: A convenience sample of patients presenting to an urban, academic, Level II emergency department (ED) with complaints of cervical spine pain after trauma were enrolled. All subjects received separate examinations by an EM faculty physician and by a PGY 2-4 EM resident in a blinded fashion. Eighty subjects were enrolled in the study.

RESULTS: Agreement for each of the NEXUS components were: posterior midline tenderness (PMT) 85.0% and κ = 0.70, intoxication (TOX) 95.0% and κ = 0.72, altered mental status (AMS) 87.5% and κ = 0.22, focal neurologic deficit (FND) 92.5% and κ = 0.21, and presence of a distracting injury (DIS) 88.8% and κ = 0.13. Overall agreement for need for radiographs was 77.5% and κ = 0.53. Sixty of the subjects received radiography (28 computed tomography, 40 plain films, 8 both). One fracture (C1 lamina) was detected in this dataset. Two of the five NEXUS criteria (PMT, TOX) demonstrated substantial agreement, two (AMS, FND) fair agreement, and one (DIS) slight agreement.

CONCLUSIONS: Based on our findings, there was considerable difference in agreement between staff physicians and residents. This could be due to the level of experience of the provider or the subjectiveness of components the criteria.