Introduction
Canadian emergency departments (EDs) annually treat 1.3 million patients who have experienced blunt trauma from falls or motor vehicle collisions and who are at risk for cervical spine injury.1 Most such patients are alert and stable adults and less than 1% have a cervical spine fracture.2 Most trauma victims transported in ambulances are protected by a backboard, collar, and head restraints. On arrival at the ED, they are sent to high-acuity resuscitation rooms, where they remain fully immobilized for hours until physician assessment and diagnostic imaging are complete. This lengthy immobilization is often unnecessary, adds significantly to patient discomfort, and also adds to the burden of crowded EDs.3, 4, 5 These patients also occupy valuable space in ED acute areas. We previously developed the Canadian C-Spine Rule, a clinical decision rule composed of simple clinical variables.6 The Canadian C-Spine Rule was designed to allow clinicians to “clear” the cervical spine without diagnostic imaging and to decrease immobilization times. We validated the accuracy of the rule when used by physicians and successfully implemented it at 12 hospitals to demonstrate safe decreased use of diagnostic imaging, in a cluster-randomized design.7, 8Editor’s Capsule Summary
What is already known on this topic
The Canadian C-Spine Rule can safely aid physicians in deciding who does not need cervical spine imaging after trauma, but physicians may be delayed arriving to the bedside.
What question this study addressed
Can nurses safely use the Canadian C-Spine Rule during emergency department care?
What this study adds to our knowledge
In a 2-phase, multisite trial, nurses successfully trained on use and then removed cervical collars for 41% of 806 injured patients, without any missed spine lesions, resulting in a shorter time until immobilization removal and until discharge.
How this is relevant to clinical practice
With nurse training, early use of the Canadian C-Spine Rule is feasible and safe.
Nurses normally do not evaluate the cervical spine of trauma patients, but we believe that they should be able to safely evaluate alert and stable ambulance patients by using the Canadian C-Spine Rule on patient arrival to the triage station. This would allow them to remove cervical spine immobilization of low-risk patients on arrival and triage them to a less acute area. Consequently, these patients could then be managed much more rapidly, comfortably, and efficiently in other areas of the ED. An expanded role for nurse decisionmaking has the potential to improve trauma care efficiency in all Canadian hospitals. However, little research has been conducted on the ability of ED triage nurses to clear patient cervical spines.9, 10, 11, 12 We previously showed the accuracy of the Canadian C-Spine Rule when used by ED triage nurses at 6 hospitals, but nurses were not permitted to remove immobilization.13 In addition, there is very little evidence about the role of nurses in applying immobilization to injured patients who present without cervical spine collars.
Our goal was to prospectively evaluate the effect on patient care of real-time Canadian C-Spine Rule implementation by ED triage nurses assessing stable trauma patients at multiple hospitals. In this 2-phase program, our primary objectives were to evaluate the clinical effect (clearance and lengths of stay) and safety of removing cervical spine immobilization from patients arriving by ambulance. Our secondary goal was to evaluate the effect of nurses using the Canadian C-Spine Rule to apply collars to patients who arrive without immobilization. In addition, we sought to assess nurse compliance in applying the Canadian C-Spine Rule, as well as their comfort in doing so.