ACH YEAR, PHYSICIANS IN CANAdian and US emergency departments (EDs) treat more than 8 million patients with head injury, representing approximately 6.7% of the 120 million total ED visits. 1 Although some of these patients have sustained moderate or severe head injury leading to death or serious morbidity, the vast majority of patients are classified as having minimal or minor head injury. 2,3 Patients with minimal head injury have not experienced loss of consciousness or other neurological alteration. Minor head injury or concussion is defined by a history of loss of consciousness, amnesia, or disorientation See also pp 1519 and 1551 and Patient Page.

For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography.

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Objective To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments. Design Matched pair cluster randomised trial. Setting University and community emergency departments in Canada. Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals. Interventions Six hospitals were randomly allocated to the intervention and six to the control. At the intervention sites, active strategies were used to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions. No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites. Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods. Results Patients were balanced between control and intervention sites. From the before to the after periods, the intervention group showed a relative reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01) and the control group a relative increase of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). These changes were significant when both groups were compared (P<0.001). No fractures were missed and no adverse outcomes occurred.

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