Nurses taking patient's off backboards without doctor clearnce? - page 3

The place I am currently working takes their patients off the back bard before the doctors clear the pt. Dose anyone know or heard of this practice anywhere and what studies have done to backed this... Read More

  1. by   ZippyGBR
    Quote from RN1980
    now i guess thats a slander on our ems system here in poor ole mississippi...gosh darn..heck it's a wonder that folks survive down here. in the real world i'm not a dutch rn...and i don't know nothing of 110hrs of protocols, i'm a asn degree icu/er rn with ccrn and studying for cen..1lt in army nurse in ms nat. guard, thats right 2yr nsg degree..i guess here in mississippi they figure we can learn in 2 yrs what it takes ya'll 4 yrs to learn. and futhermore our hospitals have indoor plumbming in mississippi..
    point being - a reply in the thread said ' if EMS have immobilised then they ought to stay immobilised until cleared by adoctor'

    if the USAn EMS system wasn't based around a significant number of Emergency Ambulance providers having as little as 110 hours of training ( look as the USDOT minimum curriculum for EMT-BASIC) then that sentiment might hold true

    e.g. where Paramedics are health professionals or even to the extreme that the Dutch and Scandinavian systems have where to access 'Paramedic' Training you are required to be an RN with post basic emergency and/or critical care experience and the training is akin to advanced practice - imagine having some of the better flight RNs in left pondia as the standard for Emergency ambulance crew...

    even where Technician ambulance staff have 300 -400 hours of classroom time and a years probation - they can use slective immobilisation protocols/ guidelines well - e.g. the UK and the guideline in JRCALC

    there's been discussion of this nature on EMs focused forums before and yes peopel will defend their own system - but is it right that an alledged 'first world' country still relies on third world EMS provision in large parts ? ( heck even proper 'developing world' countires ant more than 110 contact hours of training from their ambulance staff - and SJA colleague whose 'real job' is a Paramedic training officer for an NHS Ambulance service took a sabbatical last year to go to Sri Lanka to deliver the Ambulance training SJA uses for volunteer crews in the Uk to members over there - so they could provide a decent ambulance service - end to end zero to hero the package is somewhere around 300 hours excluding driver training )
  2. by   RN1980
    again i reinterate, if you take upon yourself to clear a patient from a spinal package "no matter how long they have been on the board" and the patient suffers any deteriation from that action, you will be held liable in court, all the tncc and phtls courses that you've been to will not save you from being slam dunked...now i can't speak of the laws in england but here in the usa you'd be screwed. all you young er nurses out there pay heed...
  3. by   RN1980
    Quote from S.T.A.C.E.Y
    Ok, but my question is.....

    So if you keep the patient on the spinal board until the doctor assesses, and the patient is found to have a fracture.......they don't go back onto the spinal board do they? Do they go back onto the hospital stretcher with c-collar on? So the board is coming off anyways right? Only meant for transport?

    I understand what you're all saying about not wanting to remove the board on your own b/c what if the pt got a fracture during your non-doctor roll. But, when you do roll, a doctor doesn't routinely take the head do they? The nurses are still the ones doing the roll, with the doctor palpating the spine right??
    well it depends on what type of fx they have, cervial,lumbar or if it's a stable fx or not. here is a simple scenerio-to er on spinal package, neuro assessment done, team log roll to assess the backside, reapplied to board to ct, now based on ct report and neuro assessment that determines if the pt is taken off, now if they have a spinal fx we consult neuro to come down and 9 times out of 10, they stay on the board until they get down there either theey eventually clear them after their assessement or they goto surgery or admitted with traction. when we log roll ussually another rn takes the head, so the doc can lay hands on the pt. this seems to be a misconception the board is not only meant for transport, it's there to keep the spinal alignment as immobile as possible, in an attempt to prevent any possible futher damage to the spine. eitheir way let the doc give you an order before you remove the package.
  4. by   ZippyGBR
    Quote from RN1980
    again i reinterate, if you take upon yourself to clear a patient from a spinal package "no matter how long they have been on the board" and the patient suffers any deteriation from that action, you will be held liable in court, all the tncc and phtls courses that you've been to will not save you from being slam dunked...now i can't speak of the laws in england but here in the usa you'd be screwed. all you young er nurses out there pay heed...
    how in that cvase do you counter the accusation of gorss negligence nad professional incompetencne as well as the financial losses the patient without a cord injury suffers due to the pressure sores you have given them by keeping them in

    1. unnecessary immobilisation - a a long board is a transfer device - there is discussion whether it is ever indicated when you don't need it for extrication (e.g. vs scoop / roll / move to a vacuum mattress or even as was practied until a few years ago scoop to strolley stretcher and head blocks on there ... )

    2. imobilisation which is not clinically indicated - especially if the neck is 'cleared' soley by physical and clinical examination - or is the 'standard of care' to unnecessarily expose everyone who some cook book following glorified first aider has decided to collar... Arguements around 'if EMS has decided' fall down where EMS is Only Certified and follows protocols rather than clinical guidelines

    how much additional risk is posed to the otherwise stable patient by a second well conducted log roll to allow clinical examination of the back if you have already rolled the patient once to remove the backboard 'therapeutically' but continued with immobilisation ... (even then they don't NEED to be rolled as they can be de boarded with a scoop stretcher or scoop hoist - with no significant 'rolling' ...

    it's interesting how people on here are prepared to advocate a course of action which will unequivocably cause harm to the patient, especially when the justifications they use to continue this practice fall down becasue of the adequacy or otherwise of the pre-hospital providers.

    this of course is a further problem with fee for service systems - if the radiologists are getting to bill of course the gold standard is that everyone with the slightest twinge of neck pain gets a CT scan and damn the risks from unnecessary irradiation vs clinicla examination or the simple 3 shot (lat, AP, Open mouth peg) plain film c-spine series

    so much for professionalism,
    so much for evidence base,
    so much for patient advocacy ...

    go and take a long look at what you are doing
  5. by   RN1980
    Quote from ZippyGBR
    how in that cvase do you counter the accusation of gorss negligence nad professional incompetencne as well as the financial losses the patient without a cord injury suffers due to the pressure sores you have given them by keeping them in

    1. unnecessary immobilisation - a a long board is a transfer device - there is discussion whether it is ever indicated when you don't need it for extrication (e.g. vs scoop / roll / move to a vacuum mattress or even as was practied until a few years ago scoop to strolley stretcher and head blocks on there ... )

    2. imobilisation which is not clinically indicated - especially if the neck is 'cleared' soley by physical and clinical examination - or is the 'standard of care' to unnecessarily expose everyone who some cook book following glorified first aider has decided to collar... Arguements around 'if EMS has decided' fall down where EMS is Only Certified and follows protocols rather than clinical guidelines

    how much additional risk is posed to the otherwise stable patient by a second well conducted log roll to allow clinical examination of the back if you have already rolled the patient once to remove the backboard 'therapeutically' but continued with immobilisation ... (even then they don't NEED to be rolled as they can be de boarded with a scoop stretcher or scoop hoist - with no significant 'rolling' ...

    it's interesting how people on here are prepared to advocate a course of action which will unequivocably cause harm to the patient, especially when the justifications they use to continue this practice fall down becasue of the adequacy or otherwise of the pre-hospital providers.

    this of course is a further problem with fee for service systems - if the radiologists are getting to bill of course the gold standard is that everyone with the slightest twinge of neck pain gets a CT scan and damn the risks from unnecessary irradiation vs clinicla examination or the simple 3 shot (lat, AP, Open mouth peg) plain film c-spine series

    so much for professionalism,
    so much for evidence base,
    so much for patient advocacy ...

    go and take a long look at what you are doing
    well i don't have the issue of negligence, the patient stays on the board unitl it's cleared now you on the other hand can preech all of this evidence based bull crap you want, by the way are you one of those nurses with a msn that discovered all this evidence based stuff? i am being proffessinal, being that i'm going to prevent futher damage to the patient, and i am the advocate for the patient and me, lets settle this once and for all, you take yourself to med school come to work here in the er with me in mississippi and i'll actually start to give a crap about what you're saying concerning this issue, but until then,keep taking patients off the board, and be sure to bring all that evidence based practice stuff up when you are in a litigation issue, yep that'll be about as useful as jimmy carter as president in preventing you from getting the green weenie.
  6. by   ZippyGBR
    Quote from RN1980
    well i don't have the issue of negligence, the patient stays on the board unitl it's cleared now you on the other hand can preech all of this evidence based bull crap you want, by the way are you one of those nurses with a msn that discovered all this evidence based stuff?
    i don't have a Masters, does a Nurse need to be a Nurse-Academic

    to apply some critical thinking and look at the evidence base behind something

    i am being proffessinal, being that i'm going to prevent futher damage to the patient,
    ARE YOU?

    becasue if the patient remains on the long board they will get tissue damage to their skin , and potnetially of course this leads to

    a pressure sore

    which is, an iatrogenic WOUND which

    - provides a route for infection

    - will require treatment evn if it doesn't get infected

    - is entirely preventable

    - have you ever seen what happens with pressure sores in those with spinal cord injuries ... and leads them to extra hospitalisations for months at a time

    and i am the advocate for the patient and me,
    are you ?

    if you were to use a long board in a law enforcement setting

    or without the flimsy (lack ) of justification you are using it would probably beedeemed an act of torture

    but then again the US has some funny ideas aobut torture and risk management in healthcare ( four point restraints anyone - something seen only in a museum in most other places ...)

    lets settle this once and for all, you take yourself to med school come to work here in the er with me in mississippi and i'll actually start to give a crap about what you're saying concerning this issue, but until then,keep taking patients off the board, and be sure to bring all that evidence based practice stuff up when you are in a litigation issue, yep that'll be about as useful as jimmy carter as president in preventing you from getting the green weenie.
    I am unaware of any case where early removal from a longboard has resulted in litigation and i cannot see any reason why if it is done correctly that there would be any reason for litigation.

    I am aware of plenty of cases where unjustified and uncalled for restraint and the iastrogenic injury of patients has resulted in litigation, criminal charges and /or professional misconduct hearings...
  7. by   BULLYDAWGRN
    It seems to me that it comes down to pressure sore or a busted spine. I'll take a pressure sore, at least I'll be able to wipe my own butt. But I take offense to that torture comment you made. So you're saying by me using restraints to keep some drug head in bed is torture....well that right there tells me all I need to know about how this thread is going. Well goto go, got to find someone to torture, cause thats how we do it in the USA "Iraq in my case"...
  8. by   bigsyis
    Quote from RN1980
    again i reinterate, if you take upon yourself to clear a patient from a spinal package "no matter how long they have been on the board" and the patient suffers any deteriation from that action, you will be held liable in court, all the tncc and phtls courses that you've been to will not save you from being slam dunked...now i can't speak of the laws in england but here in the usa you'd be screwed. all you young er nurses out there pay heed...
    All of you young/inexperienced ER nurses be sure to listen to RN1980. There may be varying degrees of latitude permitted in the various job descriptions/scope of practice in other countries, but in the good old US of A (and I LOVE my country) you will get your butt sued in no time flat if any kind of problem occurs because of a premature or inexperienced move off the board. As I said in an earlier post, protocols are just that-they are not the Board of Nursing approved best practice guidelines that you should use to protect your license. The "Big Old doctors" get my vote every time to decide when the board comes out from under the pt.
    BTW, I only ever saw one skin compromise from a pt on a backboard, and it was from a very emaciated elderly woman who had a fx/rotated hip. I have been on a backboard twice in my life. They ARE NOT comfortable, and I would never tell anyone to suck it up and stay there. Almost every time I told someone what could possibly happen if the board was to be removed prematurely that was the end of their complaining. The hospitals I worked in had considerate ERPs who either manually cleared the c-spine, or we got the xray films done ASAP to clear them
  9. by   S.T.A.C.E.Y
    Quote from RN1980
    well it depends on what type of fx they have, cervial,lumbar or if it's a stable fx or not. here is a simple scenerio-to er on spinal package, neuro assessment done, team log roll to assess the backside, reapplied to board to ct, now based on ct report and neuro assessment that determines if the pt is taken off, now if they have a spinal fx we consult neuro to come down and 9 times out of 10, they stay on the board until they get down there either theey eventually clear them after their assessement or they goto surgery or admitted with traction. when we log roll ussually another rn takes the head, so the doc can lay hands on the pt. this seems to be a misconception the board is not only meant for transport, it's there to keep the spinal alignment as immobile as possible, in an attempt to prevent any possible futher damage to the spine. eitheir way let the doc give you an order before you remove the package.

    Well I think thats part of the difference. At my ER people are taken off the backboard very quickly--sometimes at Triage. We then use a slide board to transfer to hospital stretcher, for CT, and wherever. Log roll always. Even if they have a confirmed fracture, they don't remain on the backboard

    I could be wrong, but in the 7 months I've been there I haven't seen anyone pt BACK onto a backboard, after logroll, and I've never seen a doctor gripe that a logroll was done.

    I agree that a protocol or order should be in place, and this is something I have to look into, as I am unfamiliar with what is currently going on, as Triage usually initiates the process.
  10. by   EricJRN
    While I don't think anyone can reasonably recommend disregarding hospital protocol, I think it's productive to discuss exactly what research has and has not proven regarding our interventions, especially when those interventions are "what we've always done."

    Here's a column that deals with the lack of research evidence related to prehospital spinal immobilization. Spinal motion restriction seems logical, but as Dr. David Jaslow (firefighter/paramedic/ER physican) ponts out, the randomized controlled trials showing decreased morbidity and mortality just aren't there.

    http://publicsafety.com/article/arti...&siteSection=7
  11. by   TRAMA1RN
    Having worked in numerous different ER's under many different situations, as a nurse part of my assessment requires proper inspection and palpation of areas of injury, backboards can be removed safely by experienced RN's, C-collars should never be removed unitl C1-7 can be cleared visually by x-ray or CT scan. Backboards are used for immobilization and ease of transport as stated above, but proper inspection and palpationa and trauma assessment needs to be followed very carefully. DavidnurseEMT stated it correctly.
  12. by   ZippyGBR
    Quote from BULLYDAWGRN
    It seems to me that it comes down to pressure sore or a busted spine. I'll take a pressure sore, at least I'll be able to wipe my own butt.
    okay what is the corrspondance between spinal immobilisation being applied by EMS and proven Spinal cord injury...

    if you leave someone on a board long enough you will cause them iatrogenic injury whether pressure sores or the otheriatrogenic sequale of prolong immobilisation

    But I take offense to that torture comment you made. So you're saying by me using restraints to keep some drug head in bed is torture
    yes it is, and a sad inditement of your nursing practice and the system you work in

    in these situations either a patient requires close observation and nursing in a suitable environment - some thing which the NHS manages despite it's socialised healthcare nature or the patient requires sufficient sedation or even anaesthesia and a critical care bed rather than being chained to the bed...

    ....well that right there tells me all I need to know about how this thread is going. Well goto go, got to find someone to torture, cause thats how we do it in the USA "Iraq in my case"...
    perhaps if parts of the USAn contingent weren't making out how dreadful other systems are and how backward and /or 'dangerous' Nurses in other countries are ...
  13. by   ZippyGBR
    Quote from S.T.A.C.E.Y
    Well I think thats part of the difference. At my ER people are taken off the backboard very quickly--sometimes at Triage. We then use a slide board to transfer to hospital stretcher, for CT, and wherever. Log roll always. Even if they have a confirmed fracture, they don't remain on the backboard

    I could be wrong, but in the 7 months I've been there I haven't seen anyone pt BACK onto a backboard, after logroll, and I've never seen a doctor gripe that a logroll was done.

    I agree that a protocol or order should be in place, and this is something I have to look into, as I am unfamiliar with what is currently going on, as Triage usually initiates the process.
    i'dbe inclinced to agree with S.T.A.C.E.Y that this is a sensible approach rather than blindly stating that the patientremians o nthe board until cleared by the physician following radiologicial examination.

    1. there is no requirement for the patient to remain on the long board once they have been transferred to the ED trolley , some EMS systems will debate whether the patient needs to remain o nthe board following extrication rather than being immobilised on the ambulance trolley or on a vacuum matress

    2. as i have previously said - immobilised by EMS does not mean spinal fracture or cord injury - even with selective immobilisation guidelines in place in EMS and at ED triage in the UK it is still a small proprtion of patients whosustain a spinal fracture and an even smaller proprtion who sustain last ing cord injury - when you change full time health professionam EMS prividers to part timers with as little as 110 hours of training i suspect the 'hit rate' will drop further

    3. a properly conducted long roll, slidboard or scoop stretcher removal poses little risk of exacerbating any existing injury - epsecially a scoop or slide board transfer , current ATLS and PHTLS doctrine suggests that the log roll be reserved for inspecting the posterior rather than be the default move to place people on the board , lifts /drags / use of th scoop stretcher may bemore approrpaite as may theuse of a vacuum mattress where there isn't the requirement for a 'spatula' to aid extrication ...

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