Outcome of trauma patients immobilized by emergency department staff, but not by emergency medical services providers: a quality assurance initiative

Patient outcomes before and after implementation of a selective pre-hospital spinal immobilization protocol: A comparative cohort pilot study in a level 2 trauma center

BACKGROUND

A new selective preventive spinal immobilization (PSI) protocol was introduced in the Netherlands. This may have led to an increase in non-immobilized spinal fractures (NISFs) and consequently adverse patient outcomes.

AIM

A pilot study was conducted to describe the adverse patient outcomes in NISF of the PSI protocol change and assess the feasibility of a larger effect study.

METHODS

Retrospective comparative cohort pilot study including records of trauma patients with a presumed spinal injury who were presented at the emergency department of a level 2 trauma center by the emergency medical service (EMS). The pre-period 2013-2014 (strict PSI protocol), was compared to the post-period 2017-2018 (selective PSI protocol). Primary outcomes were the percentage of records with a NISF who had an adverse patient outcome such as neurological injuries and mortality before and after the protocol change. Secondary outcomes were the sample size calculation for a larger study and the feasibility of data collection.

RESULTS

1,147 records were included; 442 pre-period, and 705 post-period. The NISF-prevalence was 10% (95% CI 7-16, n = 19) and 8% (95% CI 6-11, n = 33), respectively. In both periods, no neurological injuries or mortality due to NISF were found, by which calculating a sample size is impossible. Data collection showed to be feasible.

CONCLUSIONS

No neurological injuries or mortality due to NISF were found in a strict and a selective PSI protocol. Therefore, a larger study is discouraged. Future studies should focus on which patients really profit from PSI and which patients do not.

Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging

BACKGROUND

Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging.

METHODS

This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016.

RESULTS

There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02).

CONCLUSION

A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

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.

The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury

The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.

Outcomes and characteristics of non-immobilised, spine-injured trauma patients: a systematic review of prehospital selective immobilisation protocols

OBJECTIVES

This review assesses prehospital selective immobilisation protocols across a range of outcomes, including neurological deterioration and characteristics of injured, non-immobilised patients.

METHODS

Six electronic reference databases and eight grey literature sources were systematically searched. We included studies that enrolled acute trauma patients in the prehospital setting who were assessed for spine injury according to predefined clinical criteria and either immobilised or not. Data items included instances of neurological deterioration among patients with spine injuries, as well as available characteristics of those who were injured and not immobilised. Available data and study heterogeneity prevented meta-analyses. Bias was assessed for both individual studies and across studies by outcome.

RESULTS

604 unique articles were retrieved, of which 7 met inclusion criteria. There was moderate or high risk of bias across studies in all outcomes. Of 76 patients with spine injuries who were not immobilised, 72 had no neurological deficit that appeared after emergency medical services contact, and the remaining four were not followed. Within this group, there appears to be a trend towards elderly patients who suffered a thoracic or lumbar injury from a low-risk mechanism of injury. Among studies that report both the results of the protocol assessment and immobilisation status, there is variable correspondence between the two.

CONCLUSIONS

Data limitations and study biases suggest caution when interpreting and applying the results of this review. Its findings are consistent with the conclusions of individual studies. The characteristics of injured, non-immobilised patients point to areas of future research to investigate apparent trends.

Evaluation and treatment of trauma related collapse in athletes

Although blunt traumatic injuries are common in athletes, life-threatening trauma is fortunately rare. Most current literature has focused on nontraumatic causes of athlete death though traumatic injuries may be more common. Although prevention of these injuries may be more difficult than nontraumatic causes, prompt recognition and treatment is paramount. Common traumatic causes of collapse athlete generally involve the head, neck, and trunk and are more frequent in collision sports. Other higher risk sports include track and field, cheerleading, snow sports, and those involving motorized vehicles. Health care providers who participate in sports coverage should be aware of the potential for these injuries as emergency treatment is required to maximize outcomes. Emergency action plans allow providers to expediently activate emergency management services while providing treatment and stabilization.