Evaluation of the Nursing C-Spine (Phase IV)
Evaluation of the Nursing C-Spine (Phase IV)
Neck injuries are a common problem among blunt trauma victims with more than 8,000,000 cases
 being seen annually in U.S. and Canadian EDs. While the majority of these cases represent
 soft tissue injuries, 30,000 patients suffer cervical spine fractures or dislocations and
 approximately 10,000 suffer spinal cord injury. There are no readily available national
 Canadian data on ED visits such as those provided by the U.S. National Hospital Ambulatory
 Medical Care Survey. The prevalence of potential neck injury can, however, be reasonably
 estimated for Canadian EDs. Extrapolation, on a population basis, from reliable U.S. figures
 suggests that 1.3 million potential neck injury patients are seen annually in Canada. Only
 0.9% of these patients are found to have cervical spine fractures or dislocations.
Background: Canadian emergency departments (EDs) annually treat 1.3 million patients who have
 suffered blunt trauma from falls or motor vehicle collisions and who are at risk for cervical
 spine injury. Most such cases are alert and stable adults and less than 1% has a c-spine
 fracture. Most trauma victims transported in ambulances are protected by a backboard, collar,
 and sandbags and, on arrival at the ED, are sent to high acuity resuscitation rooms, where
 they remain fully immobilized for hours until physician assessment and radiography are
 complete. This prolonged immobilization is often unnecessary and adds considerably to patient
 discomfort and also adds to the burden of our overcrowded Canadian EDs in an era when they
 are under unprecedented pressures. These patients use valuable ED resuscitation room space.

 Nurses usually do not evaluate the c-spine of trauma patients but the investigators believe
 that they should be able to safely assess alert and stable ambulance patients and "clear" the
 c-spine of low-risk cases on arrival at the triage station. Patients could then be much more
 rapidly, comfortably, and efficiently managed in other areas of the ED. An expanded role for
 nurse decision-making has the potential to improve trauma care efficiency in all Canadian
 hospitals. Very little research has been done in this area of nurses' clearing patient
 c-spines.

 A clinical decision rule is derived from original research and is defined as a decision
 making tool that incorporates three or more variables from the history, examination, or
 simple tests. This Canadian C-Spine Rule (CCR) is comprised of simple clinical variables and
 was designed to allow clinicians to "clear" the c-spine without radiography and to decrease
 immobilization times. The investigators also validated the accuracy of the rule when used by
 physicians. The investigators have now finished a funded study to validate the accuracy and
 reliability of the CCR when used by ED triage nurses at 6 hospitals. The investigators
 completed a funded implementation trial at 12 Canadian hospitals to evaluate the impact on
 patients of the CCR when used by physicians.

 Objectives: The goal of phase IV of the Canadian C-Spine Rule project is to evaluate the
 safety and potential impact of an active strategy to empower ED triage nurses to evaluate and
 clear the c-spine of very low-risk trauma patients. Specific objectives are to: 1) Determine
 safety by screening for: a) Missed fractures and b) Serious adverse outcomes; 2) Determine
 clinical impact by measuring: a) C-spine clearance rates by nurses, b) Length of time until
 c-spine clearance; 3) Evaluate performance of the Canadian C-Spine Rule for: a) Accuracy, b)
 Nurse accuracy in interpretation, and c) Nurse comfort and compliance.

 Methods: The investigators propose a cohort study which evaluates outcomes during a 12-month
 period at 5 hospital EDs, including 3 community and 2 teaching hospital sites. Enrolled will
 be consecutive, alert and stable adult trauma patients presenting to the ED with neck pain or
 with c-spine immobilization on an ambulance stretcher. Participating will be ED triage nurses
 who previously underwent a structured educational strategy to learn the CCR and who
 successfully participated in the 24-month phase IIb validation study at the same sites. These
 nurses will be empowered by medical directive to "clear" the c-spine of patients according to
 the CCR, thus allowing them to remove c-spine immobilization and to triage patients to a less
 acute area of the ED. These outcomes will be assessed: 1) Measures of safety: a) Number of
 missed fractures, b) Number of serious adverse outcomes; 2) Measures of clinical impact: a)
 C-spine clearance rates by nurses, b) Length of stay in ED, and c) Patient satisfaction; 3)
 Performance of the Canadian C-Spine Rule: a) Accuracy, b) Nurse accuracy of interpretation,
 and c) Nurse comfort. The investigators estimate a sample size of 1,500 patients will be
 accrued.

 Importance: This evaluation study (phase IV) is an essential step in the process of
 developing a new clinical decision rule / guideline for nurses to clear the c-spine. Once the
 investigators have established safety and potential impact in phase IV, the investigators can
 move to the final step (phase V), a multicenter implementation across Canada to study actual
 impact. The investigators believe that teaching ED triage nurses to clear the c-spine of very
 low-risk trauma patients has the potential to significantly improve the efficiency and
 comfort of patient care in our busy Canadian EDs. Ultimately, the investigators expect the
 results of this study to be used by ED triage nurses throughout Canada.
Inclusion Criteria:

 The investigators will enroll consecutive alert, stable adults presenting to the study
 hospital EDs with potential c-spine injury after sustaining acute blunt trauma. These will
 be patients presenting with neck pain or with c-spine immobilization on an ambulance
 stretcher. Patient eligibility will be determined based on these criteria at the time of
 arrival in the ED.

 -  "Potential c-spine injury after sustaining acute blunt trauma" will include patients
 with either: i) neck pain with any mechanism of injury (subjective complaint by the
 patient of any pain in the posterior aspect of the neck), and/or ii) presentation by
 ambulance with c-spine immobilization after injury (typically backboard and collar).

 -  "Alert" is defined as a Glasgow Coma Scale103 score of 15 (converses, fully oriented,
 and follows commands).

 -  "Stable" refers to normal vital signs as defined by the Revised Trauma Score31
 (systolic blood pressure 90 mm Hg or greater and respiratory rate between 10 and 24
 breaths per minute).

 -  "Acute" refers to injury within the past 48 hours.

 Exclusion Criteria:

 -  Patients under the age of 16 years,

 -  Patients who do not satisfy the definition of "potential c-spine injury" as defined
 above (for example, patients with neither neck pain nor arriving with ambulance
 c-spine immobilization will be excluded),

 -  Patients with Glasgow Coma Scale score less than 15,

 -  Patients with unstable vital signs (systolic BP < 90; respiratory rate less than 10 or
 more than 24),

 -  Patients whose injury occurred more than 48 hours previously,

 -  Patients with penetrating trauma from stabbing or gunshot wound,

 -  Patients with acute paralysis (paraplegia, quadriplegia),

 -  Patients with known vertebral disease (ankylosing spondylitis, rheumatoid arthritis,
 spinal stenosis, or previous cervical spine surgery),

 -  Patients who return for reassessment of the same injury, or

 -  Patients referred from another hospital.