We assessed the reliability of paramedic interpretation of the rule among 155 paramedics by measuring the kappa coefficient for interobserver agreement for each element of the rule. The kappa value for the overall interpretation of the rule was 0.93 (95% CI, 0.87 to 0.99). In addition, agreement for the 8 individual components of the CCR was also very good, with kappa values ranging from 0.66 to 1.00. The paramedics were asked to Inhibitors,research,lifescience,medical indicate on a five-point Likert scale how comfortable they would be

in applying the CCR to this patient. The results were very supportive: Paramedics were “very uncomfortable” or “uncomfortable” applying the Canadian sellekchem c-spine Rule in 9.5% of cases; they were “comfortable” or “very comfortable” in 81.7% of cases. We evaluated the potential impact of the rule on the number of necessary immobilizations. If paramedics were allowed to use the rule, 62.2% (95% CI, 60 Inhibitors,research,lifescience,medical to 64) of recruited patients would have required immobilization compared to the actual immobilization rate of 100%. Rationale for the study We have previously derived (phase I) [75] and validated the CCR in physician (phase Inhibitors,research,lifescience,medical IIa) [70], ED triage nurse (phase IIb) [79] and in paramedic (phase IIc) [77] groups. We currently recently demonstrated successful implementation of

the CCR by physicians in multiple hospitals (phase IIIa) [76], with a decrease in diagnostic imaging use by physicians and no adverse events. An implementation study using ED triage nurses is under way (phase IIIb). While we hope to demonstrate that ED triage nurses can safely remove patient’s cervical immobilization devices, it would be significantly more valuable if we could empower Inhibitors,research,lifescience,medical the paramedics to selectively forego immobilization in the first place, and avoid great discomfort to patients. This is a practice already adopted by a number of U.S. and Canadian EMS services. We now hope to move the

Inhibitors,research,lifescience,medical CCR project forward to the next level (phase IIIc) by carefully preparing paramedics to selectively immobilize the c-spine of very low-risk trauma patients who are alert and stable. Many decision rules in the past have not been widely adopted because of a failure to study implementation issues. We believe that this proposed safety evaluation study is an essential step towards the widespread implementation of the CCR by paramedics across Canada. Carfilzomib If this evaluation study is successful, we can then plan wider dissemination of paramedic clearance in a future effectiveness trial. However, the current proposed study must demonstrate both safety and efficacy before dissemination can occur. Methods/Design Design The proposed study will be a prospective cohort study comprised of a five-month training period followed by six-month run-in (could be shorter if no issues are identified) and 36-month evaluation periods in Ottawa, Canada.