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.

Estabilización de la columna vertebral en la víctima de trauma - revisión integrativa / Estabilização da coluna vertebral na vítima de trauma - revisão integrativa / Stabilization of the spine in the trauma victim - integrative review

OBJETIVO: Identificar efectos perjudiciales causados por la estabilización de la columna vertebral en la víctima de trauma y situaciones de trauma sin indicación para estabilización de la columna vertebral en el prehospitalario. MÉTODO: Se trata de una revisión integrativa de literatura orientada por las cuestiones de investigación: ¿Existe evidencia científica de efectos perjudiciales en las víctimas de trauma, causados por la estabilización de la columna vertebral en el cuidado prehospitalario? y ¿Existen situaciones de trauma sin indicación para estabilización de la columna vertebral?. RESULTADOS: Se realizó una investigación booleana en las bases electrónicas Cochrane Library y Pubmed ya través del motor EBSCOhost en las bases de datos CINAHL Plus, MEDLINE, MedicLatina, SPORTDiscus, PsycBras, PsycBOOKS, Psychología y Behavioral Sciences Collection, Academic Search Complete. Se obtuvieron doce artículos y tras la aplicación de los criterios de inclusión y exclusión constituyen la muestra cinco artículos. CONCLUSIONES: Se describen efectos perjudiciales de la estabilización de la columna vertebral en la víctima de trauma relacionados con la gestión de la vía aérea, dolor, malestar y lesiones por presión. Las situaciones de trauma penetrante con circulación inestable y víctimas con lesiones por arma de fuego en la cabeza no carecen de estabilización de la columna vertebral. Se han reunido recomendaciones de apoyo a la decisión prehospitalaria en cuanto a la estabilización de la columna vertebral. Es crucial para la mejora del cuidado prehospitalario, integrar un enfoque individualizado de la víctima que se refiera a su estado clínico y al mecanismo de lesión

OBJETIVO: Identificar efeitos prejudiciais causados pela estabilização da coluna vertebral na vítima de trauma e situações de trauma sem indicação para estabilização da coluna vertebral no pré-hospitalar. MÉTODO: Trata-se de uma revisão integrativa de literatura norteada pelas questões de pesquisa: existe evidência científica de efeitos prejudiciais nas vítimas de trauma, causados pela estabilização da coluna vertebral no cuidado pré-hospitalar? e existem situações de trauma sem indicação para estabilização da coluna vertebral?. RESULTADOS: Foi realizada pesquisa booleana nas bases eletrónicas Cochrane Library e Pubmed e através do motor EBSCOhost nas bases de dados CINAHL Plus, MEDLINE, MedicLatina, SPORTDiscus, PsycARTICLES, PsycBOOKS, Psychology and Behavioral Sciences Collection, Academic Search Complete. Obtiveram-se doze artigos e após aplicação dos critérios de inclusão e exclusão constitui a amostra cinco artigos. CONCLUSÕES: Estão descritos efeitos prejudiciais da estabilização da coluna vertebral na vítima de trauma relacionados com a gestão da via aérea, dor, desconforto e lesões por pressão. Situações de trauma penetrante com circulação instável e vítimas com lesões por arma de fogo na cabeça não carecem de estabilização da coluna vertebral. Foram reunidas recomendações de apoio à decisão pré-hospitalar quanto à estabilização da coluna vertebral. É crucial para a melhoria do cuidado pré-hospitalar, integrar uma abordagem individualizada da vítima que se refira ao seu estado clínico e ao mecanismo de lesão

GOAL: To identify harmful effects caused by the stabilization of the vertebral column in a trauma victim and in trauma situations without indication for stabilization of the spine in the prehospital. METHOD: It was perform an integrative literature review guided by research questions: is there a scientific evidence of harmful effects on trauma victims caused by spinal stabilization in prehospital care? and are there situations of trauma with no indication for stabilization of the spine?. RESULTS: We have performed a Boolean search in the electronic bases Cochrane Library and Pubmed and through the EBSCOhost engine in the databases CINAHL Plus, MEDLINE, MedicLatina, SPORTDiscus, PsycARTICLES, PsycBOOKS, Psychology and Behavioral Sciences Collection, Academic Search Complete. Twelve articles were obtained and after applying the inclusion and exclusion criteria, the sample was five articles. CONCLUSIONS: Harmful effects of spinal stabilization on the victim of trauma related to airway management, pain, discomfort and pressure injuries are described. Situations of penetrating trauma with unstable circulation and victims with gunshot injuries to the head do not require stabilization of the spine. Recommendations to support the prehospital decision regarding stabilization of the spine were collected.It is crucial for the improvement of prehospital care to integrate an individualized approach of the victim that refers to its clinical state and mechanism of injury

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.

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.

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.

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.

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.

Managing hyperactive delirium and spinal immobilisation in the intensive care setting: a case study and reflective discussion of the literature.

The management of ventilated patients on intensive care has, at its core, a care bundle; an evidence based group of actions designed to reduce the risk of ventilator-associated pneumonia. One of these is the daily cessation of sedation medication to expedite weaning from ventilatory support. A reflection-on-action exercise was carried out when a spinally injured patient became physically active during a sedation hold. This was attributed to hyperactive delirium. The concern was the conflict between providing evidence based Intensive Care Unit (ICU) therapy care and maintaining spinal immobility. Reflection on this incident led to a literature search for guidance on the likelihood of delirium causing secondary spinal injury in patients with unstable fractures. There was plentiful research on delirium and its consequences but very little examining the link between spinal injury and delirium. In order to be able to provide evidence-based care to future trauma patients the research supporting spinal immobilisation was also examined. The research showed that compliance with ventilator care bundles reduced the risks of acquiring ventilator-associated pneumonia. Research surrounding spinal immobilisation was conflicting and there were no studies linking the consequences of immobilised patients experiencing hyperactive delirium. Through a case study approach the research was reviewed in relation to a particular patient and although literature was lacking some implications for practice could be identified to promote the best possible outcomes. Sedation cessation episodes are an essential part of patient care on intensive care. For spinally injured patients' these may need to be modified to sedation reductions to prevent sudden wakening and uncontrolled movement should the patient be experiencing hyperactive delirium. This case study clearly highlights the need for further research in this area as the consequences of both ventilator associated pneumonia and extending spinal injuries is costly for both patients and hospitals.

Epidemiologia do trauma raquimedular em emergências públicas no município do Rio de Janeiro / Spinal cord injury epidemiology in public emergency rooms in the municipality of Rio de Janeiro

O objetivo do presente estudo foi avaliar as taxas de mortalidade por trauma raquimedular (TRM) e estimar padrões diferenciados de características das internações hospitalares por TRM em hospitais públicos municipais e estaduais no município do Rio de Janeiro. Foram analisados dados do SIH-SUS sobre valor médio das internações, média de permanência, proporção de internações e taxa de mortalidade de hospitais municipais e estaduais, no período de 1996 a 2011. Em relação ao valor gasto nas internações, média de permanência e número de internação, a rede estadual apresentou um maior comparativo em relação à rede municipal. Já em relação à mortalidade dos pacientes, os hospitais estaduais tiveram uma menor taxa de mortalidade. As evidências apontadas proporcionarão reflexões sobre a distribuição dos casos, taxa de mortalidade e o tipo de atendimento demandado, contribuindo para a organização da rede assistencial de emergências do município do Rio de Janeiro.

The aim of this study was to assess mortality rates for spinal cord injury (SCI) and to estimate the characteristics of different patterns of hospital admissions for TRM in municipal and state public hospitals in the city of Rio de Janeiro. We analyzed data from SIH-SUS on average of admissions, length of stay, hospitalization and mortality rates of municipal and state hospitals, from 1996 to 2011. Regarding the amount spent on hospital admissions, length of stay and number of admissions, the state system had a higher comparative regarding the municipal net. In relation to patient mortality, the state hospitals had a lower mortality rate. The evidence presented will provide reflections on the distribution of cases, mortality rate and the type of care required, contributing to the organization's emergency care network in the municipality of Rio de Janeiro.

El objetivo del presente estudio fue evaluar las tasas de mortalidad por trauma espinal (TRE) y estimar las características de los diferentes patrones de ingresos hospitalarios por TRE en hospitales públicos, municipales y estaduales, en la ciudad de Rio de Janeiro. Se analizaron los datos del SIH-SUS sobre el valor promedio de hospitalizaciones, la duración de la estancia media, la proporción de los ingresos hospitalarios y la mortalidad en los hospitales municipales y estaduales en el período de 1996 a 2011. En relación a la cantidad gastada en los ingresos hospitalarios, duración de la estancia y la hospitalización, la red estadual presentó un mayor comparativo en relación con la red municipal. En cuanto a la mortalidad de los pacientes, los hospitales del estado tuvieron una tasa de mortalidad más baja. Las evidencias apuntadas van a proporcionar reflexiones sobre la distribución de los casos, la tasa de mortalidad y el tipo de atención requerida, lo que contribuye a la organización del sistema de atención sanitaria de emergencia en el municipio de Rio de Janeiro.

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.

Helmet and shoulder pad removal in football players with unstable cervical spine injuries.

Football, one of the country's most popular team sports, is associated with the largest overall number of sports-related, catastrophic, cervical spine injuries in the United States (Mueller, 2007). Patient handling can be hindered by the protective sports equipment worn by the athlete. Improper stabilization of these patients can exacerbate neurologic injury. Because of the lack of consensus on the best method for equipment removal, a study was performed comparing three techniques: full body levitation, upper torso tilt, and log roll. These techniques were performed on an intact and lesioned cervical spine cadaveric model simulating conditions in the emergency department. The levitation technique was found to produce motion in the anterior and right lateral directions. The tilt technique resulted in motions in the posterior left lateral directions, and the log roll technique generated motions in the right lateral direction and had the largest amount of increased instability when comparing the intact and lesioned specimen. These findings suggest that each method of equipment removal displays unique weaknesses that the practitioner should take into account, possibly on a patient-by-patient basis.

Introduction to reading and clearing cervical spines for advanced practice nurses, Part I.

This article is Part I of a two-part series and will focus on the key concepts of radiographic interpretation, functional cervical anatomy, and the interpretation and clearance of cervical spines in emergency care. In the subsequent issue, Part II will cover the additional epidemiology of cervical-spine injuries, specific injuries, case studies, and advanced diagnostic imaging.

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.

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.

The practice of out-lying patients is dangerous: a multicentre comparison study of nursing care provided for trauma patients.

Pressure for acute hospital beds is a national problem with many acute trauma patients being admitted to non-trauma wards. This prospective multicentre questionnaire study of 220 qualified trauma and non-trauma nurses aims to compare the quality of nursing care that trauma patients receive when admitted to trauma wards and non-trauma wards. The questions included the nursing management of common fractures and post-operative conditions. The completed questionnaires were scored and the results analysed. Hundred percent of the questionnaires were completed and returned. The trauma nurses conveyed the importance of ice (85%) and elevation (97%) in the initial management of limb fractures. This compares with ice (10%) and elevation (50%) on the outlying wards. Trauma nurses correctly monitor for potentially devastating post-operative complications and compartment syndrome 87% of the time compared with 42% on outlying wards. Spinal injuries are managed appropriately 88% of the time on trauma wards compared with 36% on outlying wards. Trauma patients receive better nursing care when admitted to a trauma ward and are nursed by trauma nurses. Many of the out-lying wards provide sub-optimal trauma nursing care and a few are positively dangerous. We suggest that trauma patients should not be nursed on outlying wards.

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.