Evidence-Based Nursing Care for Spinal Nursing Immobilization: A Systematic Review.

INTRODUCTION: A high degree of suspicion for spinal injury after trauma is commonplace in an emergency department, and spinal immobilization is considered an accepted intervention to prevent the progression of a potential injury. This systematic review was conducted to gain insight into the best research evidence related to nursing interventions for patients with trauma presenting with a suspected spinal injury. METHODS: A systematic search of online databases was conducted in April 2019 for relevant research using specific search terms. The studies were selected on the basis of pre-established eligibility criteria, and the quality was appraised using the Critical Appraisal Skills Programme tool. RESULTS: Nineteen included articles were synthesized thematically on the basis of the outcomes from interventions directed at a suspected spinal injury. The main findings were that spinal immobilization may compromise pulmonary function and airway management, cause pain and pressure ulcers, and be inappropriate with penetrating trauma. Furthermore, there was insufficient evidence to support the safety and efficacy of the hard neck collar and long backboard. DISCUSSION: Patients would benefit from a more selective and cautious approach to spinal immobilization. Emergency nurses should use the evidence to facilitate informed decision-making in balancing the benefits of spinal immobilization against harm when considering the needs and values of the patient.

A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses.

STUDY OBJECTIVE: The Canadian C-Spine Rule has been widely applied by emergency physicians to safely reduce use of cervical spine imaging. Our objective is to evaluate the clinical effect and safety of real-time Canadian C-Spine Rule implementation by emergency department (ED) triage nurses to remove cervical spine immobilization. METHODS: We conducted this multicenter, 2-phase, prospective cohort program at 9 hospital EDs and included alert trauma patients presenting with neck pain or with cervical spine immobilization. During phase 1, ED nurses were trained and then had to demonstrate competence before being certified. During phase 2, certified nurses were empowered by a medical directive to "clear" the cervical spine of patients, allowing them to remove cervical spine immobilization and to triage to a less acute area. The primary outcomes were clinical effect (cervical spine clearance by nurses) and safety (missed clinically important cervical spine injuries). RESULTS: In phase 1, 312 nurses evaluated 3,098 patients. In phase 2, 180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%, collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806 immobilized ambulance patients, the primary outcome of immobilization removal by nurses was 41.1% compared with 0% before the program. The primary safety outcome of cervical spine injuries missed by nurses was 0. Time to discharge was reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization removed. In only 1.3% of cases did nurses indicate their discomfort with applying the Canadian C-Spine Rule. CONCLUSION: We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.

Cervical Spine Collar Removal by Emergency Room Nurses: A Quality Improvement Project.

INTRODUCTION: The Canadian C-Spine Rule (CCR) is a clinical decision aid to facilitate the safe removal of cervical collars in the alert, orientated, low-risk adult trauma patient. Few health care settings have assessed initiatives to train charge nurses to use the CCR. This practice improvement project conducted in a secondary trauma center in Canada aimed to (1) train charge nurses of the emergency room to use the CCR, (2) monitor its use throughout the project period, and (3) compare the assessments of the charge nurses with those of emergency physicians. METHODS: The project began with the creation of an interdisciplinary team. Clinical guidelines were established by the interdisciplinary project team. Nine charge nurses of the emergency room were then trained to use the CCR (3 on each 8-hour shift). The use of the CCR was monitored throughout the project period, from June 1 to October 5, 2016. RESULTS: The 3 aims of this practice improvement project were attained successfully. Over a 5-month period, 114 patients were assessed with the CCR. Charge nurses removed the cervical collars for 54 of 114 patients (47%). A perfect agreement rate (114 of 114 patients, 100%) was attained between the assessments of the nurses and those of physicians. DISCUSSION: This project shows that the charge nurses of a secondary trauma center can use the CCR safely on alert, orientated, and low-risk adult trauma patients as demonstrated by the agreement in the assessments of emergency room nurses and physicians.

The Use of Clinical Cervical Spine Clearance in Trauma Patients: A Literature Review.

INTRODUCTION: Five million patients in America are placed in spinal immobilization annually, with only 1% to 2% of these patients suffering from an unstable cervical spine injury. Prehospital agencies are employing selective and limited immobilization practices, but there is concern that this practice misses cervical spine injuries and therefore possibly predisposes patients to worsening injuries. METHODS: A systematic review was conducted that examined literature from the last 5 years that reviewed cervical spine immobilization application and/or clearance in alert trauma patients. RESULTS: Prehospital selective immobilization protocols and bedside clinical clearance examinations are becoming more commonplace, with few missed injuries or poor outcomes. Prehospital providers can evaluate patients in the field safely to assess who needs or does not need cervical collars; similar criteria can be used in the emergency department. Harm from cervical collars is increasingly documented, with concerns that risks exceed possible benefits. DISCUSSION: The literature suggests that alert trauma patients can be cleared from cervical spine immobilization safely through a structured algorithm in either the prehospital or ED setting. The evidence is primarily observational. Thus, many providers who fear missing cervical injuries may be reluctant to follow the recommendations despite few or no published cases of sudden deterioration from missed cervical spine injuries.

Perceptions of a clinical psychology support group for spinal injury.

BACKGROUND: A service evaluation was performed exploring nurses' perceptions of a clinical psychology facilitated peer support group in a spinal injury rehabilitation setting. AIMS: To determine whether staff found the meetings useful while, more broadly, to highlight the need to support and supervise nursing staff in psychological care appropriately. METHOD: A questionnaire was developed and distributed to the 30 members of staff who worked on the ward. Seventeen questionnaires were returned (57%). Data was analysed using thematic analysis. RESULTS: The meetings were viewed as a place to discuss issues, and a safe protected space to share stresses. Staff felt the meetings aided team cohesion and helped them share ideas and draw up clinical strategies. Meetings aided stress management and confidence building. Staff considered the meetings to increase their psychological awareness and understanding. CONCLUSION: Staff involved in the acute care and rehabilitation of spinal injured patients are consistently exposed to highly demanding and stressful clinical environments. Support meetings where staff can discuss patient and ward issues are invaluable. Other clinical nursing areas would benefit from similar support systems.

Effect of training in advanced trauma life support on the kinematics of the spine: A simulation study.

More than 7.5 million people in the world are affected by spinal cord injury (SCI). In this study, we aimed to analyze the effect of training in advanced trauma life support (ATLS) on the kinematics of the spine when performing different mobilization and immobilization techniques on patients with suspected SCI. A quasi-experimental study, clinical simulation, was carried out to determine the effect of training in ATLS on 32 students enrolled in the Master's program of Emergency and Special Care Nursing. The evaluation was performed through 2 maneuvers: placing of the scoop stretcher (SS) and spinal board (SB), with an actor who simulated a clinical situation of suspected spinal injury. The misalignment of the spine was measured with the use of a Vicon 3D motion capture system, before (pre-test) and after (post-test) the training. In the overall misalignment of both maneuvers, statistically significant differences were found between the pre-test misalignment of 62.1°â€Š±â€Š25.9°, and the post-test misalignment of 32.3°â€Š±â€Š10.0°, with a difference between means of 29.7° [(95% confidence interval, 95% CI 22.8-36.6°), (P = .001)]. The results obtained for the placing of the SS showed that there was a pre-test misalignment of 65.1°â€Š±â€Š28.7°, and a post-test misalignment of 33.2°â€Š±â€Š10.1°, with a difference of means of 33.9° [(95% CI, 23.1-44.6°), (P = .001)]. During the placing of the SB, a pre-test misalignment of 59.0°â€Š±â€Š28.7° and a post-test misalignment of 33.4°â€Š±â€Š10.0° were obtained, as well as a difference of means of 25.6° [(95% CI 16.6-34.6°), (P = .001)]. The main conclusion of this study is that training in ATLS decreases the misalignment provoked during the utilization of the SS and SB, regardless of the device used.

Removal of C-spine protection by A&E triage nurses: a prospective trial of a clinical decision making instrument.

OBJECTIVE: To investigate if triage nurses could safely apply a set of clinical criteria, removing hard collars and spinal boards at initial triage assessment. METHODS: The Nexus clinical decision rules were applied by trained triage nurses to patients who attended the department with cervical collars and/or on spinal boards. Patients were excluded if they were felt to be in need of immediate medical assessment. Data were collected on the time to nursing assessment, time to medical assessment and time spent restrained. Patients were followed up until discharge and their radiological diagnosis confirmed. Hospital records were checked to ensure that no patients re-presented with injuries that had been missed at initial assessment. RESULTS: In total, 112 patients were included in the study. Clinical criteria were met in 59 patients and their collar removed at triage assessment. For low risk patients, this reflects a mean reduction in time spent restrained of 23.3 minutes (p<0.005; 95% confidence interval 20.18 to 26.54). No patient who had a collar removed was found to have a significant injury. CONCLUSIONS: Simple criteria can be applied by accident and emergency triage nurses to allow safe removal of cervical collars and spinal boards. The reduced time patients spent immobilised represents an important improvement in patient care.

Can emergency nurses use the Canadian cervical spine rule to reduce unnecessary patient immobilisation?

The Canadian c-spine rule (CCR) allows safe, reproducible use of radiography in alert, stable patients with potential c-spine injury in the emergency setting [Stiell, I., Clement, C., McKnight, R., Brison, R., Schull, M., Lowe, B., Worthington, J., Eisenhauer, M., Cass, D., Greenberg, G., MacPhail, I., Dreyer, J., Lee, J., Bandiera, G., Reardon, M., Holroyd, B., Lesiuk, H., G. Wells, 2003. The Canadian c-spine rule versus the nexus low-risk criteria in patients with trauma. The New England journal of medicine 349 (26), 2510-2518; Stiell, I., Wells, G., Vandemheen, K., Clement, C., 2001. The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA 286 (15), 1841]. This paper reports on a study of emergency nurses' ability to identify patients requiring immobilisation using the CCR. Emergency department triage nurses (N = 112) were trained in the use of the CCR and then asked to use the tool over the following 14 months in the assessment of 460 patients who presented with potential c-spine injury. Trained medical staff repeated 55% of the clinical assessments independently using the rule. The level of agreement between nurse and medical judgement was calculated. The inter-rater reliability using the kappa statistic was 0.6 (95% CI 0.50-0.62 N = 254) indicating a 'good' level of agreement. The majority of nurses indicated they were comfortable using the rule. The results suggest that UK emergency department nurses were able to use the Canadian c-spine rule to successfully guide selective immobilisation. A 25% reduction in immobilisation rates would have been achieved if the rule had been followed. Further studies are needed to test the reduction in levels of immobilisation that could be achieved in clinical practice.

Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: An integrative review.

BACKGROUND: Well validated clinical decision rules exist to facilitate the safe removal of collars in the alert, orientated, low risk adult trauma patient, however this practice is traditionally conducted by medical staff. The aim of this review is to synthesise current evidence to determine the efficacy of emergency nurses in safely and accurately removing cervical spine collars using cervical spine rules, in alert, orientated, low risk trauma adult patients. METHODS: A multi-method search strategy was used to find primary research studies followed by a rigorous screening and quality appraisal process. Data from included articles were extracted, grouped and synthesised. RESULTS: Nine quantitative research articles resulted in four key findings: the inter-rater reliability between nurses and doctors clearing the cervical spine was high (kappa range (0.61-0.80)); nurses can safely implement the cervical spine clinical decision rule; use of a cervical spine clinical decision rule decreases the time patients are immobilised and; nurses felt confident applying a cervical spine clinical decision rule. CONCLUSION: Appropriately trained emergency nurses can safely apply cervical spine rules to alert, orientated, low risk adult trauma patients. Implementation of nurses clearing cervical spines should include training and ongoing monitoring.

Recovery of coliforms from the hands of nurses and patients: activities leading to contamination.

Coliform type organisms were recovered from the hands of nurses and patients in an Orthopaedic Hospital. Coliforms were frequently recovered from nurses' hands after touching patients' washing materials and clothing as well as after bed making, sluice room activities and handling clean or dirty linen and curtains. The recovery rates were higher in wards for spinally injured patients than in the surgical wards. Coliforms were recovered with similar frequencies, to those from nurses, from the hands of patients in both types of wards.

Developing the nurse's role in patient education: rehabilitation as a case example.

Over the past decade considerable emphasis has been placed on the nurse's role in patient education. Despite this numerous studies have suggested that this aspect of nursing practice is under-developed. Using rehabilitation as a case example this paper explores the nursing contribution to patient education in five conditions: multiple sclerosis; arthritis; myocardial infarction; spinal injury and stroke. Although the literature identifies considerable potential for nurses to take a lead role in patient education this is rarely achieved in practice. Analyses of printed curricula from a range of courses indicate that nurses are not adequately prepared for patient education and that a reorientation of nurse education is required.

Clearance of cervical spines in adult trauma patients.

Clearing the cervical spine in adult trauma patients must be done cautiously and methodically. Practitioners must be able to recognize abnormalities not only in the patient's neurological examination but also on the radiographic views obtained. A missed cervical spine injury can be a significant and catastrophic error. Nurse practitioners in the emergency department, as well as those working on an inpatient trauma service, should be confident in their ability to manage the cervical spine in the adult trauma patient population.

Logrolling: establishing consistent practice.

Logrolling is a common patient care procedure performed by many health care workers. The purpose of logrolling is to maintain alignment of the spine while turning and moving the patient who has had spinal surgery or suspected or documented spinal injury. Achieving consistency in logrolling practice across patient care settings is particularly challenging, but necessary for patient safety and satisfaction. A multidisciplinary group of health care providers developed regional policies and procedures for logrolling, logrolling with cervical spine (C-spine) precautions, and collar care. The process used for establishing best practice, staff education, and implementation is described.

Dilemma--volunteering help.

Last Saturday afternoon I was playing with my family on the beach of a British seaside resort. It became clear that an incident had occurred in the water, when the beach patrol drove very quickly onto the sands closely followed by police cars. The policemen ran straight into the water to pull a small speedboat up on to the beach. I considered joining them to see if any assistance was required, but felt slightly uncomfortable about pushing myself forward, despite being trained in the management of patients with major injuries. A couple of minutes later, two paramedics arrived in an ambulance. Everyone seemed to converge on the small speedboat and I decided to approach the scene in case assistance was required to lift the casualty. When I approached the side of the boat I saw a great deal of blood everywhere and 8 or 10 people leaning over the patient. I asked 'Can I help?' There was no reply. I looked at a woman and said 'Do you need me or do you know what you are doing?' The lady replied to me 'No, I think it's okay, there's a doctor and two paramedics.' I backed off immediately, concerned about treading on people's toes. Twenty minutes later a police helicopter arrived at the scene and the patient had still not been taken out of the boat. Ten minutes after the helicopter had arrived and the patient had still not been moved, I once again, approached the scene and spoke to a police officer. 'I am trained to lift and turn patients with potential spinal injuries. Do you think they need any assistance?' The young policewoman went off to talk to a more senior policeman nearer to the incident, however, she did not speak to the paramedics. After five minutes, I approached both policemen again, and asked if I was required. The policemen both said no and waved me away. It was a further fifteen minutes before the patient was removed on the spine board from the boat, and put into the helicopter. I remained uncomfortable for the rest of the weekend about my response. I realize I tried hard not to offend other health care professionals at the scene, but am anxious that in doing so, I jeopardized the safety of the patient. I have no idea what training the medical bystander had or whether the paramedics were pre-hospital trauma life support trained. Should I have made more effort to satisfy myself that the most appropriate people looked after the patient?

Management of suspected cervical spine injuries--the paediatric perspective.

Paediatric cervical spine immobilisation and management is one of the most difficult tasks to master in the paediatric trauma population. The Royal Children's Hospital--Melbourne has admitted 54 patients with diagnosed cervical spine injuries since January 1999. The management of such patients admitted to acute care facilities with suspected cervical spine injuries is inconsistent and at times sub-optimal. Management controversies centre around, application of cervical collars, clearance of the c-spine, patient movement and general care principles. In an endeavour to address these issues, the Royal Children's Hospital Trauma Service, in conjunction with the Emergency Department developed cervical spine guidelines. Teams consulted in the formulation of these guidelines included, Emergency Department, Intensive Care Unit, Orthopaedics, Neurosurgery, Radiology and General Surgery. These guidelines were developed as a clinical tool to guide management and standardise the approach of care for these patients. Specifically, the guidelines address: immobilisation of the paediatric cervical spine; radiology; clearing the cervical spine of injury; suspected or proven cervical spine injury; guidelines for times to fitting Philadelphia collar; ongoing care.

Common spinal injuries in athletes.

Special needs of athletes with spine injuries must be considered when planning for treatment of these patients. The patients wish to return to competition safely but rapidly. Nurses must understand the patients'/athletes' need but put them into perspective with respect to the diagnosis, treatment, and degree of disability. Support, encouragement, and understanding from a knowledgeable health professional are invaluable.

Traumatic injuries to the head and spine 2: nursing considerations.

Trauma to the central nervous system can have devastating consequences for both the person who sustained the injury and his/her family/loved ones. This article first discusses pathophysiology in relation to altered cerebral haemodynamics and changes that occur after spinal injury. Following on from the underpinning theoretical perspectives, the article reviews the nursing care and management strategies required by patients who have sustained either a traumatic head injury or acute spinal injury, with the aim of controlling secondary injury, which is preventable. This ensures the patient will have the best possible prognosis and outcome.

Immobilizing the cervical spine using a collar. Complications and nursing management.

Using a collar to immobilize the cervical spine is a standard health care intervention for patients with cervical spine injuries. Although there is little research into the nature and extent of possible iatrogenic complications resulting from this intervention, anecdotal information suggests that prolonged use a cervical collar may case skin ulcers and infections. Further, the stabilizing effect of a cervical collar may impart a false sense of security as it permits fine flexion and extension movements. Compounding the potential untoward effects of this intervention, is the lack of research concerning nursing care implications. As a first step to examining the problem, the author surveyed trauma and neuroscience centres throughout Canada to determine: what immobilization devices are currently used; patient problems associated with these devices; nursing care interventions employed including hygiene and transfer techniques; and the outcomes of these interventions. The findings describe the relative efficacy of different products and nursing interventions as reported by the surveyed groups. Further, the findings offer direction for future research that will quantitatively investigate the patient care outcomes associated with specific interventions.

Humour as a nursing intervention.

Extensive study of the brain has resulted in the development of interventions to augment and preserve function. However, there exists a phenomenon that affects the vital brain centres including speech and memory the control of vital functions, and the immune system. What has this power? Humour. Recognized as hazardous to illness, humour leads to laughing, smiling and good feelings. Humour has been described as a basic need, a coping mechanism, and a form of communication, all integral in the care of patients and families. The use of humour gives one the permission to laugh, and to relax. While the value of humour is unique to each person and culture, its deliberate use is an effective nursing intervention to decrease tension and anxiety. This paper will examine the use of humour as a nursing intervention in the care of neuroscience patients. It will look at using humour as an adjunct to pain control and an augment to the efficacy of treatment. Nurses will learn what constitutes therapeutic humour, and the pathways to humour. Participants will come away with a repertoire of strategies to incorporate humour in neurosciences nursing care infusing it with joy.