Understanding Cervical Spine Injury Imaging Decision-Making in Pediatric Trauma Patients.

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Published in final edited form as: Pediatr Open Sci. 2025 Dec 5;1(4):10.1542/pedsos.2025-000850. doi: 10.1542/pedsos.2025-000850 Search in PMC Search in PubMed View in NLM Catalog Add to search Understanding Cervical Spine Injury Imaging Decision-Making in Pediatric Trauma Patients Fahd A Ahmad Fahd A Ahmad , MD MSCI 1 Washington University School of Medicine in St. Louis & St. Louis Children’s Hospital Find articles by Fahd A Ahmad 1 , Sara Malone Sara Malone , PhD LCSW 2 Washington University in St. Louis, School of Public Health Find articles by Sara Malone 2 , Ana Baumann Ana Baumann , PhD 3 Washington University School of Medicine, Department of Surgery Find articles by Ana Baumann 3 , Megan E Gregory Megan E Gregory , PhD 4 University of Florida College of Medicine, Department of Health Outcomes & Biomedical Informatics, Gainesville, FL Find articles by Megan E Gregory 4 , Jack Stevens Jack Stevens , PhD 5 Department of Pediatrics, The Ohio State College of Medicine and Nationwide Children’s Hospital, Columbus, OH Find articles by Jack Stevens 5 , Christopher R Carpenter Christopher R Carpenter , MD MSc 6 Department of Emergency Medicine, Mayo Clinic School of Medicine, Rochester MN Find articles by Christopher R Carpenter 6 , Annie J Truelove Annie J Truelove , MPH 7 Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH Find articles by Annie J Truelove 7 , Julie C Leonard Julie C Leonard , MD MPH 8 Department of Pediatrics, Division of Emergency Medicine, The Ohio State College of Medicine and Nationwide Children’s Hospital, Columbus, OH Find articles by Julie C Leonard 8 Author information Article notes Copyright and License information 1 Washington University School of Medicine in St. Louis & St. Louis Children’s Hospital 2 Washington University in St. Louis, School of Public Health 3 Washington University School of Medicine, Department of Surgery 4 University of Florida College of Medicine, Department of Health Outcomes & Biomedical Informatics, Gainesville, FL 5 Department of Pediatrics, The Ohio State College of Medicine and Nationwide Children’s Hospital, Columbus, OH 6 Department of Emergency Medicine, Mayo Clinic School of Medicine, Rochester MN 7 Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH 8 Department of Pediatrics, Division of Emergency Medicine, The Ohio State College of Medicine and Nationwide Children’s Hospital, Columbus, OH ✉ Corresponding Author: Fahd A. Ahmad, MD, MSCI, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO 63109, [email protected] Issue date 2026. PMC Copyright notice PMCID: PMC13056386  NIHMSID: NIHMS2155873  PMID: 41953504 The publisher's version of this article is available at Pediatr Open Sci Abstract Objectives The Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury (CSI) clinical prediction rule (CPR) was developed to reduce unnecessary imaging in pediatric trauma patients while ensuring accurate diagnosis. This study aimed to identify barriers and facilitators to future implementation of this rule in diverse emergency department settings. Methods We conducted 40 interviews with 48 clinicians, including emergency department physicians, surgeons, nurses, and advanced practice providers at 21 healthcare facilities across the United States. Semi-structured interviews explored determinants impacting implementation, guided by the Tailored Implementation for Chronic Diseases (TICD) framework. We conducted a deductive thematic analysis using the TICD domains as a priori codes. Three researchers independently coded the transcripts and identified key themes aligned with the TICD framework. Results Barriers included limited guideline accessibility, workflow disruptions, and inconsistent integration with electronic health records. Clinicians’ concerns regarding the applicability and adherence to guidelines were also significant. Facilitators identified included institutional support, stakeholder engagement, and targeted education that addressed knowledge gaps. Implementation strategies varied by context, with suggestions for electronic health record-based decision tools in resource-equipped facilities and external aids, such as pocket cards, in lower-resource settings. Addressing legal concerns, clinician resistance, and workflow alignment emerged as critical priorities. Conclusion Implementing the PECARN CSI clinical prediction rule requires addressing contextual barriers such as workflow challenges, clinician adherence, and technology integration. Context-sensitive strategies are essential for successful adoption and improved decision-making in pediatric trauma care. Future research should evaluate the impact of these strategies on clinician behavior and patient outcomes. Introduction Cervical spine injuries (CSIs) in children, though relatively uncommon, pose a significant risk of poor outcomes, including paralysis and death. 1 – 3 In children, CSIs are most frequently seen following blunt trauma, such as motor vehicle crashes, falls, or sporting collisions. Pediatric patients present unique diagnostic challenges due to age-related differences in anatomy and injury patterns. Young children’s cervical spines are more flexible and less ossified, leading to injury mechanisms and presentations that differ from those of older children and adults. 4 , 5 Clinicians must balance accurate diagnosis with minimizing the risks associated with unnecessary diagnostic procedures, particularly radiographic imaging. In the emergency department (ED), computed tomography (CT) scans have become a standard modality for evaluating children at risk of CSI due to their high sensitivity for detecting injuries. 6 However, concerns have been raised about using CT imaging in children, primarily due to the potential risks of ionizing radiation. 7 , 8 Children are more vulnerable to the harmful effects of radiation due to smaller body size and longer life expectancy, increasing their life-time risk of radiation-induced malignancies. 9 These concerns underscore the need for more refined diagnostic strategies to reduce unnecessary radiation exposure without compromising patient safety. 10 Clinical prediction rules (CPRs) have been developed to guide imaging decision-making. Implementation of CPRs can impact care, as prior studies demonstrated reduced radiographic screening for ankle, knee, cervical spine, and head injuries in different populations, including children. 11 , 12 Two widely recommended CPRs for cervical spine injuries are the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-Spine Rule (CCR). 13 , 14 However, while validated in adults, the NEXUS criteria may be less applicable in children, particularly at younger ages, due to the low number of injured children included in the study. 4 Similarly, the CCR study did not include children and has limited applicability in the pediatric setting. 15 To address this gap, the Pediatric Emergency Care Applied Research Network (PECARN) recently derived and validated a pediatric-specific CPR for CSI to reduce unnecessary imaging while ensuring that significant injuries are not missed. 16 , 17 PECARN is a national research network that has developed and validated several CPRs, providing robust, multi-center data to inform clinical decision-making in children. 18 – 21 While the PECARN CSI CPR holds significant promise, implementation in diverse ED settings must be successful to realize the full impact of this work. There is significant interinstitutional variation in the use of cervical spine imaging, with CT use increasing at pediatric trauma centers. 6 Prior work from Gregory et al. 17 examined how ED–trauma team dynamics influence cervical spine imaging decisions. Building on that analysis, our study focuses on broader multilevel determinants of implementation. CT in adult trauma patients is prevalent in general EDs and major trauma centers, often influenced by institutional practice patterns rather than strict clinical necessity. 22 , 23 These practice patterns are influenced by the medicolegal and societal perspective of the ED, which can engender increased testing in order to reduce liability or avoid “missed” diagnoses. 24 , 25 Concerns over missed diagnoses, even when not related to error or negligence, can drive imaging decisions and increase the use of CT scans in children. As the majority of pediatric trauma patients receive care in general EDs by non-pediatric specialists, they are likely to be exposed to cervical spine CTs at a rate similar to or higher than in pediatric EDs. 26 The current study takes the first step for rigorous implementation by identifying barriers and facilitators to the uptake of the PECARN CSI CPR. While the rule has been validated for clinical use, the complexity of ED workflows, variations in clinician acceptance and adherence to CPRs, and differences in institutional resources may impact its successful adoption. Our study applies the Tailored Implementation for Chronic Diseases 27 (TICD) implementation science framework to examine the factors that influence CPR uptake. Whereas Gregory et al. focused only on team dynamics, the TICD framework provides a structured approach to assess a broader range of determinants—spanning individual, organizational, and external factors—that can inform tailored implementation strategies. Understanding these determinants and contextual factors will inform future strategies for integrating the PECARN CSI CPR into practice, ultimately reducing unnecessary imaging and improving the quality of care for pediatric trauma patients. Methods Study Design and Framework We conducted a secondary analysis of semi-structured interviews to explore barriers and facilitators to implementing the PECARN CSI CPR. The original purpose of these interviews was to examine team dynamics and workflow in pediatric trauma care. Our findings are reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies (COREQ). 28 Our analysis was guided by the TICD framework, 27 a comprehensive checklist of seven overarching domains and 57 determinants of professional practice, These determinants represent specific areas that can facilitate or hinder implementation efforts. Though developed in the context of chronic disease, it is intended for broad applicability across healthcare domains and has been used in acute care. 29 We selected TICD for its breadth, integration of constructs from other frameworks, and structured format, which supports systematic categorization of barriers and facilitators. Table 1 provides an overview of the domains. Table 1. Overview of TICD Domains with study specific definitions Domain name Overview Guideline Factors Focuses on the characteristics of the guideline or intervention being implemented. Factors such as the clarity, credibility, and accessibility of the guideline, as well as the strength of the supporting evidence, can significantly influence its adoption. The domain examines whether the guideline is perceived as practical, relevant, and applicable to the intended context. Individual Healthcare Professional Factors Pertains to the attributes of individual clinicians that affect their adherence to the guideline. It includes their knowledge, skills, attitudes, beliefs, and motivation. Personal factors, such as confidence in applying the guideline (self-efficacy) or familiarity with the recommendations, play a crucial role in influencing behavior. Patient Factors Examines the characteristics of patients or their families that may impact guideline implementation. Factors include patient preferences, behaviors, health literacy, and their willingness or ability to follow the recommendations. These factors may require adjustments to the guideline to meet patient-specific needs. Professional Interactions about imaging protocols. Explores the dynamics between healthcare professionals, such as collaboration, communication, and alignment within teams or across disciplines. Effective professional interactions can facilitate implementation, while conflicts or misunderstandings may act as barriers. Incentives and Resources Addresses the availability and adequacy of resources—both financial and non-financial—that support the implementation of guidelines. Factors include physical resources, technology, and incentives (e.g., financial or recognition-based) that enable or motivate adherence to the guideline. Capacity for Organizational Change Reflects the readiness and ability of the organization to adopt and sustain changes. It includes factors such as leadership support, institutional policies, infrastructure, and the presence of systems to monitor and reinforce the implementation process. Social, Political, and Legal Factors Considers external influences on guideline implementation, including societal norms, regulatory requirements, legal considerations, and broader political or economic contexts. These factors can create constraints or opportunities that affect how easily a guideline is adopted and maintained. Open in a new tab * TICD - tailored implementation of chronic disease Within each domain, specific determinants—context-specific factors or conditions—help clarify barriers and facilitators to successful implementation. These determinants can be used to support the implementation of CPRs in diverse healthcare settings. For this work, we defined the recommendation and evidence-based practice of interest as the CSI CPR. Because the CSI CPR was still under development at the time of the interviews, participants were not given a draft of the criteria. Rather, they were asked about their current imaging decision-making and how a future clinical decision support tool, such as the CSI CPR, could be integrated into practice. Data Collection Interviews were conducted by study team members JCL and AJT, who have training in qualitative methods and knowledge of the ED as a clinical practice environment. All interviews were audio-recorded and transcribed verbatim to ensure accuracy. Our interviews were semi-structured, using predetermined open-ended questions. A codebook was developed based on the TICD framework and pilot-tested with two clinicians to provide clarity and relevance ( Appendix 1 ). Participants were purposively sampled from diverse EDs in the United States, ranging from critical access hospitals without trauma capabilities to large freestanding children’s hospitals verified by the American College of Surgeons as pediatric trauma centers. Data collection occurred in person in private office settings. Participants were contacted by email or phone and scheduled at a convenient time. The interviewers had no prior relationship with the participants. Data Analysis Study team members FAA, SM, and LS independently coded the transcripts using MaxQDA version 22.2.0. We conducted a deductive thematic analysis, using the TICD domains as a priori codes. A coding tree was developed based on the TICD framework and refined through an iterative coding process. If a coding discrepancy occurred, it was adjudicated through direct discussion between the coders. We performed a content evaluation to identify which TICD determinants emerged during the interviews. Through this process, we created context-specific definitions when needed to guide our coding. Otherwise, we relied on the definitions from the original TICD determinant list. A comprehensive list of domains and their determinants, along with the original descriptions and examples, as well as our study-specific definitions, can be found in Appendix Table 2 . Participant quotations illustrated key themes and were identified by participant role, such as ‘MD’ (physician) or ‘RN’ (nurse). We used descriptive counts to illustrate which determinants emerged as most prominent in the interviews. Ethical Considerations Institutional Review Board (IRB) approval was obtained from the University of Utah Central IRB. All participants provided verbal informed consent before participating in the study, and confidentiality was maintained throughout the research process. Results We previously published the characteristics of interview participants. 17 We conducted 40 interviews with 48 participants (May to November 2019), including eight interviews that had two participants each. We interviewed 12 surgeons (including general, trauma, orthopedic, and neurosurgery), 19 emergency physicians, three advanced practice providers, and 14 nurses. All cared for children in the ED setting. Practice experience varied, with most in practice 5–10 years. Participants represented 21 healthcare facilities across the United States, including Level I (n=7), Level II (n=6), Level III (n=4), and non-trauma centers (n=4). Sites were primarily located in the West (n=15) and Northeast (n=5), with one in the Midwest, and represented communities ranging in size from <25,000 to >500,000. This study evaluated the determinants within each of the seven TICD domains. Table 2 provides the primary TICD determinants represented in our interviews. Appendix Table 1 provides representative quotes for determinants in each domain, accompanied by additional information specific to each domain, as described below. Appendix Table 2 shows the frequency of each of the 57 TICD determinants. Table 2. TICD domains and most common TICD determinants in interviews TICD Domain Most common determinants within domain * Guideline Factors Source of the recommendation; Accessibility of the recommendation Individual Healthcare Professional Factors Intention and motivation; Learning style; Effort; Awareness and familiarity with the recommendation; Attitudes towards guidelines in general; Domain knowledge; Self-efficacy; Continuing education system; Knowledge about own practice; Nature of the behavior Patient Factors Patient beliefs and knowledge; Patient needs Professional Interactions Referral processes; Communication and influence; Team processes Incentives and Resources Availability of necessary resources; Information system Capacity for Organizational Change Quality assurance and patient safety systems Social, Political, and Legal Factors Regulations, rules, policies Open in a new tab * Any determinant coded 10 or more times in the interviews TICD - Tailored Implementation of Chronic Disease Domain 1: Guideline Factors Clinicians stressed that “strong evidence” was essential, often defining it as large, multicenter data or randomized trials supporting the PECARN CSI CPR. One clinician noted, “Everything has to be evidence-based and really good evidence. We have some really smart trauma surgeons here… they keep up on the literature” (MD). However, others highlighted the practical aspect, noting that ease of access to CPRs and their incorporation into daily practice varied by institution. Accessibility to CPRs and guidelines varied, with some clinicians relying on paper systems: “We are very algorithm-driven here so if you gave us an algorithm…we would pull it out” (RN). Others expressed concern about remembering the specifics of different CPRs, “There are a lot of them, so remembering them is impossible. There needs to be something where I can be triggered to know that” (MD). These findings highlight that guideline credibility alone was insufficient; accessibility and ease of use were also important in determining whether clinicians would apply the CSI CPR. Domain 2: Individual Healthcare Professional Factors Individual decision-making was central, and often shaped by peer knowledge and behavior. Several participants reported a tendency to extrapolate from adult trauma literature in pediatric cases, which they acknowledged may not always be appropriate. For example, one physician indicated, “ Yeah, the decision point…we probably extrapolate more from the adult literature than we probably should” (MD). Resistance to change was also reported as impacting whether clinicians adopted new guidelines, with one clinician noting, “Some of the older docs… would be like, I haven’t needed to use this for my whole career” (MD). These quotes underscored how variability in clinician knowledge and attitudes translated directly into variability in imaging practices. Domain 3: Patient Factors Clinicians prioritized minimizing radiation in children and weighing risks in context. Clinicians perceived that assessment of the clinical context is important and potentially provides relevant information for decision-making is not always captured in CPRs. However, clinicians also described their perspectives on how to weigh the risk of intervention, with one participant stating, “Irradiating children for no real reason is not helping them necessarily” (MD). Many emphasized real-time communication with parents: “We always have parents back here when we can…We don’t like to give children a lot of radiation. We would like not to scan him right now” (RN). While less frequently discussed, patient-related determinants emphasized that minimizing radiation risk was a unifying principle shaping clinicians’ decisions. Domain 4: Professional Interactions Intra- and inter- team communication strongly influenced imaging decisions. Effective teamwork, coordination, and communication were noted as vital in trauma settings. Clinicians could articulate settings where this was positive and instances where communication and coordination led to poor patient outcomes, frustration, and a lack of timely, coordinated care. Notably, individuals described ongoing debates between specialties about the necessity of imaging. One participant said, “We do a lot of debating and discussion on whether we need to scan. They [surgeons] prefer to pan-scan” (MD). Another clinician described the negotiation process: “It’s almost kind of a negotiation now…we’re advocating less imaging, and they’re advocating more imaging” (MD). Professional dynamics often magnified individual-level differences, illustrating how specialty perspectives and team communication could either reinforce or undermine guideline-based decision-making. Domain 5: Incentives/Resources Electronic health records (EHR) were viewed as a double-edged sword. One participant explained, “For the trauma activation…because we’re still on paper…some of the electronic decision rules…don’t activate because we’re on paper” (MD). Clinicians recognized the importance of having quick access to CPRs, however raised concerns about the burden of using them within the EHR: “If it were something that just popped up and said, hey, this patient meets this criteria, but if it says you need to take 5 minutes and click these buttons…it would be just easier to remember the rules” (MD). Perspectives varied by role, however most agreed rapid, low-friction access to the CPR was essential. Overall, participants described resources such as the EHR as double-edged—tools that could facilitate safer care but also add friction, depending on how they were integrated. Domain 6: Capacity for Organizational Change Clinicians felt adoption often hinged on leadership and culture. One clinician remarked, “I don’t carry algorithms with me … you practice, you learn, you make mistakes, and you learn from that… ultimately it’s a cultural thing change that has to happen” (MD). It was perceived that these changes were needed at the institution level and needed to be driven by leadership and champions. Multidisciplinary buy-in and collaboration were seen as essential for implementing CPRs. “We have a trauma team where these protocols would come in… it’s a collaboration between Peds Surgery and Emergency Medicine” (MD). These perspectives reflected the view that institutional culture and leadership buy-in were essential for sustainable adoption of the CSI CPR. Domain 7: Social, Political, and Legal Factors TICD highlights the role of these external factors, although most providers spoke much more about the individual and organizational level factors that influence changing care practices. Although only mentioned in six interviews, a fear of malpractice did emerge as a driver of decision making. One clinician highlighted the fear of litigation: “[No] matter what we do with our criteria, we’re going to miss an injury and there’ll be an injury and it’s that one in a million thing. [N]o one gives a crap about us doing a million things right…they care about the one time we screw up, especially their lawyers” (MD). This defensive practice can influence imaging decisions, with some clinicians ordering additional imaging to avoid legal repercussions. Although less prominent, these concerns revealed how broader medico-legal pressures could still shape decision-making at the bedside.” Discussion Our interviews with diverse ED and trauma clinicians revealed critical insights into the perceived utility and facilitators and barriers to implementing the PECARN CSI CPR. Clinicians recognized the rule’s potential to reduce unnecessary radiographic imaging and minimize radiation exposure in children. However, successful implementation will depend on addressing practical challenges within diverse clinical settings. 4 These findings complement Gregory et al., 17 which emphasized team dynamics and workflow factors. By applying the TICD framework, our analysis situates those team-based insights within a wider context that includes resources, leadership, and organizational readiness, highlighting the multilevel nature of implementation. Issues related to workflow integration, clinician adherence, communication among team members, and EHR limitations were frequently mentioned. As the CPR is implemented, it is essential to consider these factors. Although TICD was originally developed in the context of chronic disease, it has also been applied in acute care, including ED stroke thrombolysis, 29 demonstrating its broader applicability. TICD’s structure and breadth allowed us to capture contextual factors relevant to cervical spine imaging decision making, and provides additional evidence of how implementation science can accelerate the scaling up of best practices in the ED setting. 30 , 31 Similar to our findings, previous studies highlight that the credibility and usability of CPRs impact clinician acceptance, highlighting the role of stakeholder engagement. 32 While the PECARN CSI CPR has not yet been validated outside of academic pediatric EDs, this is a goal of future studies, which should further improve the credibility of the rule across ED settings. 33 Probst et al. noted that many emergency physicians are unfamiliar with specific criteria and validated scoring systems of CPRs, limiting their use in clinical practice. 34 Comprehensive education and training are essential to bridge this knowledge gap. Integrating CPRs into existing ED workflows can be challenging; Gimbel et al. reported that decision support tools may add steps with little value, leading to resistance. 35 Effective integration requires seamless incorporation into EHRs to avoid disrupting clinical workflows. 36 , 37 Our interviews revealed differing clinician perspectives: some viewed EHR-based decision tools as cumbersome within trauma workflows, while others saw potential benefits if tools supported decision-making without adding extra steps. Implementation hurdles we identified mirror those reported in adult cervical spine rule studies, reinforcing that the key obstacles are less about the specific algorithm and more about ED context. Urban EDs, particularly academic centers, tend to have clinicians who are more familiar with and trusting of CPRs. 38 Compared to urban EDs, rural EDs may face challenges implementing CPRs due to limited access to education or peer support, and less ability to modify the EHR to integrate CPRs into workflows. 30 , 39 Several studies of the CCR illustrate that many structural barriers can be mitigated when frontline staff are trained and empowered. A multi-site qualitative survey of Canadian ED physicians and nurses identified overcrowding and lack of training as the most common obstacles to CCR use, with local champions, teamwork between clinicians and management, and signage and reminders as among the most helpful facilitators. 40 A subsequent multi-site implementation program by Stiell et al. certified ED nurses to safely remove cervical spine immobilization, with nurses showing the ability to independently clear low-risk patients without adverse events. 41 These findings are complementary to our demonstration of high interrater agreement between emergency medical service providers, ED clinicians’ and trauma surgeons’ evaluation of children for PECARN CSI CPR criteria. In combination these data along with the findings from our current study suggest physicians and staff are both able and willing to identify patients at low-risk for injury. The Stiell et al. data also shows that low-tech, leadership-endorsed aids can have a significant clinical impact with appropriate institutional support, independent of the ability to work with the EHR. Fear of litigation drives clinicians to order imaging tests even when CPRs suggest they are unnecessary, a defensive practice highlighted by Raja et al. 42 Legal issues related to malpractice were not a focused part of our interviews; however, they did emerge as a concern, and it is possible this topic was underrepresented in our findings. Defensive-imaging patterns have been quantified elsewhere: in a national survey of 435 emergency physicians, 91% indicated malpractice concerns influenced their image ordering practices, with 64.3% indicating avoiding of malpractice issues “almost always” contributed to ordering medically unnecessary advanced imaging. 43 Implementation plans for the PECARN CSI CPR should therefore pair education with institutional risk-management messaging. Based on the evidence of their success in other clinical contexts, nudges – such as electronic alerts within the EHR or external aids like laminated guidelines - could be deployed to improve clinician adherence while minimizing workflow disruption. Quasi-experimental research has shown that external aids, such as pocket cards and laminated treatment guidelines, improved adherence to medication prescribing. 44 , 45 Similarly, within the EHR, strategies such as strongly worded best practice alerts, 46 pre-checked electronic order sets for recommended care, 47 and accountable justifications requiring providers to document rationales for deviation decisions 48 were associated with greater adherence to practice guidelines. Future implementation research is needed to evaluate if these derived approaches increase the use of the PECARN CSI CPR. Limitations Our interview guide was not created initially with an implementation science lens; applying TICD post-hoc may have led to over- or under-emphasis of some domains. Potentially underrepresented determinants include institutional culture, workload/burnout, malpractice concerns, and patient-family preferences. While these factors were not the primary focus of this study, they may significantly influence the successful implementation of the PECARN CSI CPR and merit further exploration in future research. This was a secondary analysis of interviews originally designed to examine team dynamics and workflow, as a result, not all TICD domains were explored with the same depth, which may limit the generalizability of findings. Additionally, our study may be subject to selection bias despite efforts to interview a diverse sample of clinicians. We conducted the interviews contemporaneously with the effort to develop the CPR. As clinicians were reacting to the CSI CPR as a hypothetical tool still in development, their perceptions may therefore differ from how they would respond to a validated, published rule. Some barriers such as uncertainty about guideline credibility or workflow impact, may lessen once the rule is disseminated, whereas new could emerge during real-world implementation. Conclusion Integrating the PECARN CSI CPR could enhance clinical decision-making and reduce unnecessary imaging. However, successful implementation requires addressing significant barriers related to workflow integration, clinician adherence, and EHR capabilities. By leveraging targeted strategies and ongoing research, healthcare institutions can improve the adoption of this valuable tool, ultimately enhancing care for pediatric trauma patients. Supplementary Material Appendix 1 NIHMS2155873-supplement-Appendix_1.docx (28.8KB, docx) Appendix 2 NIHMS2155873-supplement-Appendix_2.xlsx (16.8KB, xlsx) What’s Known on this Subject: Use of the recently derived and validated PECARN cervical spine clinical prediction rule could significantly reduce unnecessary imaging in pediatric trauma patients. However, implementing this rule presents challenges due to variations in clinician behavior, institutional resources, and workflow integration. What This Study Adds: This qualitative study identifies multilevel barriers and facilitators anticipated in the implementation of the PECARN cervical spine clinical prediction rule, which was still under development at the time of the interviews. Findings highlight the importance of tailoring implementation strategies to local contexts, emphasizing clinician engagement, workflow alignment, and decision support integration. Acknowledgments We would like to thank Lena Stevens for her contributions to developing our codebook and qualitative coding of the transcripts. Funding: This study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; 5R01HD091347 Development and Testing of a Pediatric Cervical Spine Injury Risk Assessment Tool). This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by NICHD or the US Government. The study was also funded by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS), in the Maternal and Child Health Bureau, under the Emergency Medical Services for Children program through the following cooperative agreements: Data Coordinating Center at the University of Utah (Salt Lake City, UT, USA; UJ5MC30824), Great Lakes Emergency Medical Services for Children Research Node (GLEMSCRN) at Nationwide Children’s Hospital (Columbus, OH USA; U03MC28844), Hospitals of the Midwest Emergency Research Node (HOMERUN) at Cincinnati Children’s Hospital Medical Center (Cincinnati, OH, USA; U03MC22684), Pediatric Emergency Medicine Northeast, West and South (PEMNEWS) at Columbia University Medical Center (New York, NY, USA; U03MC00007), Pediatric Research in Injuries and Medical Emergencies (PRIME) at University of California at Davis Medical Center (Sacramento, CA, USA; U03MC00001), Charlotte, Houston, Milwaukee Prehospital EMS Research Node (CHaMP) node at the State University of New York at Buffalo (Buffalo, NY, USA; U03MC33154), West/ Southwest Pediatric Emergency Medicine Research (WPEMR) at Seattle Children’s Hospital (Seattle, WA, USA; U03MC33156), and San Francisco-Oakland, Providence, Atlanta Research Collaborative (SPARC) at Rhode Island Hospital and Hasbro Children’s Hospital (Providence, RI, USA; U03MC33155). This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government. Abbreviations: PECARN Pediatric Emergency Care Applied Research Network CSI Cervical spine injury TICD Tailored Implementation for Chronic Diseases ED Emergency department CT Computed tomography CPRs Clinical prediction rules NEXUS National Emergency X-Radiography Utilization Study CCR Canadian C-Spine Rule COREQ Consolidated Criteria for Reporting Qualitative Studies IRB Institutional Review Board MD Medical Doctor RN Registered Nurse Footnotes Ethics Statement: The authors have no conflicts of interest Presentations : Preliminary data from this study were presented at the Society for Academic Medicine conference in May 2024 (Phoenix, AZ). Contributor Information Fahd A. Ahmad, Washington University School of Medicine in St. Louis & St. Louis Children’s Hospital. 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