Trauma/original research
A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses

https://doi.org/10.1016/j.annemergmed.2018.03.033Get rights and content

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.

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, 8

Editor’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.

Section snippets

Study Design and Setting

We conducted this multicenter, 2-phase, prospective cohort program that evaluated outcomes during a 30-month period in the ED at 9 teaching hospitals in Ontario, the largest province in Canada, with a population of 13.6 million. The 9 hospitals had a combined annual volume of approximately 670,000 ED visits. All EDs were staffed by full-time certified emergency physicians and emergency medicine residents.

During phase 1 (certification), all ED nurses who performed triage activities were trained

Results

The project enrolled a total of 4,506 patients in the 2 phases combined, with each site progressing at its own speed (Table E1, available online at http://www.annemergmed.com). Phase 1 (certification) commenced in December 2010 and finished in October 2011, with a total of 4,546 patients screened for eligibility and 3,098 patients enrolled by 312 nurses (Tables E2 and E3, available online at http://www.annemergmed.com). One hospital withdrew participation after phase 1 because of difficulties

Limitations

The program findings may not be generalizable to different practice environments such as small, rural hospitals. Nevertheless, we are optimistic that this approach to change in nursing practice could be applied directly or with some modifications almost anywhere in North America and Europe. Although we did not use a randomized design, we are confident that the magnitude of the clearance rate shows clear evidence of clinical effect without bias. Nurses did not always apply immobilization to the

Discussion

This large, multicenter implementation program by nursing follows a series of previous studies to derive, validate, and implement the Canadian C-Spine Rule by physicians. The findings confirm the safety and clinical effect of having ED triage nurses apply the Canadian C-Spine Rule to clinically clear the cervical spine of alert and stable trauma patients. Overall, 180 nurses removed immobilization in 41.4% of ambulance patients (N=331) compared with 0% before the program. To our knowledge, few

References (18)

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Cited by (10)

  • Implementation of the Modified Canadian C-Spine Rule by Paramedics

    2023, Annals of Emergency Medicine
    Citation Excerpt :

    The modified Canadian C-spine rule identified 10 of the 11 important injuries, and all 10 patients were transported to the receiving ED with full spinal immobilization. The modified Canadian C-spine rule missed one injury, as noted in Table 2, only the second injury missed by the Canadian C-spine rule after more than 40,079 patients evaluated in various reported studies, including this one.3-8 This patient, a middle-aged (<65 years old) man, was assaulted and fell to the ground, striking his head on an object.

  • Utility of bedside assessment to evaluate for cervical-spine fracture post ground-level fall for patients 65 years and older

    2022, American Journal of Emergency Medicine
    Citation Excerpt :

    In an attempt to screen for clinically significant cervical spine injury, the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) [11] and the Canadian C-spine Rule (CCR) [12] became widely used resources in the emergency medicine community with validation studies favoring the use of the CCR [13-15]. Evidence suggests these clinical decision tools can be efficiently applied in an ED setting [16]. The NEXUS and CCR have both made strides to avoid unnecessary imaging in trauma patients, however, there is still broad use of CT cervical-spine imaging in current practice [7,11-14].

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

    2020, Journal of Emergency Nursing
    Citation Excerpt :

    A selective approach to SI, on the basis of the CCR criteria, demonstrated specificity, efficacy, and safety, when strategically implemented by trained nursing personnel in the emergency department. In addition to avoiding unnecessary adverse effects, SI, on the basis of clinical presentation, results in time and cost-saving benefits.31,32 A research protocol detailing the plan for the systematic review was written before the study’s commencement.

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Please see page 334 for the Editor’s Capsule Summary of this article.

Supervising editor: Donald M. Yealy, MD

Author contributions: IGS conceived the idea and secured research funding. CMC and ML coordinated the study. JM, SA, BB, KP, JL, KR, ST, AA, and CD supervised the recruitment of patients and management of data. All authors supervised the conduct of the trial and data collection, and drafted the article, contributed to its revision, and approved the final version. IGS takes responsibility for the paper as a whole.

All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was funded by a peer-reviewed grant from the Council of Academic Hospitals of Ontario.

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