Nurses taking patient's off backboards without doctor clearnce? - page 4

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   NativeSundance
    Hell will freeze over before I de-board a fully immobilized patient without a doctors order to do so. I work in a trauma center and it would be completely inappropriate for any nurse to randomly decide to deboard someone. Depending on mechanism of injury, the patient will not be de-boarded until the c-spine is cleared. In any case, the patient will not be de-boarded until the doctor states or writes the order to do so.

    In our ER, all immobilized patients are seen quickly by the MD to assess for board removal, so it really has never been an issue.

    Certainly, no-one would argue that there are problems assosiated with prolonged boarding, but I think it could also be said that early board removal to avoid these problems takes the back seat to c-spine protection.

    Given the choice between a pressure ulcer and paralysis from my fractured c-spine...I'll take the pressure ulcer every day of the week!

    Given the option of retaining my license or risk losing it over early board removal, I'll opt to retain my license every day of the week!

    In my ER, the trauma team is all experienced, TNCC certified, ACLS, PALS and NALS certified, and most are CEN certified. I personally have 24 years of ER experience and would not consider for one moment de-boarding a patient prior to MD eval. Policy or no policy, in the end it is MY license...and the patients future!

    BTW: our policy clearly states that board removal is done ONLY after MD eval and either verbal or written order for removal. Some of the new "hot shot" "I'm so smart" "I'm just as competent as any doctor" "I want total autonomy" nurses will never understand this approach. We see them in our ER all the time. They don't last long.

    Please God...If I am EVER in a situation where I find myself boarded and collared, PLEASE PLEASE PLEASE let me awake to find myself in a trauma center where nurses are not making the "educated" decision to deboard me!! They don't have xray vision or the training to make that decision. I have a very busy life God, and I need to be able to walk and move my body freely in order to perform my job and care for my family and farm. Please God, if I develop a pressure ulcer or experience any discomfort associated with the "big bad nasty uncomfortable board" I will ignore it and not hold you or anyone else responsible for it. My life and the free movement and perfect functioning of my body is significantly more important to me. So PLEASE GOD...let me arrive at a facility that will care for me appropriately and prioritize my presenting problems from a trauma perspective to ensure the BEST POSSIBLE long term outcome for me and my family! Thank you God!!
  2. by   ZippyGBR
    Quote from NativeSundance
    Hell will freeze over before I de-board a fully immobilized patient without a doctors order to do so. I work in a trauma center and it would be completely inappropriate for any nurse to randomly decide to deboard someone. Depending on mechanism of injury, the patient will not be de-boarded until the c-spine is cleared. In any case, the patient will not be de-boarded until the doctor states or writes the order to do so.
    is there something magical that happens to a doctor's hands during the course of their professional education which makes it less risky for them to undertake a clinical examination than oany other suitabley educated, competent Health professional ...

    no -one who has been immobilised should be un-immobilised until their neck is cleared whether that be clinically or radiologically where clinical clearance is inappropriate... the question which some respondents seem to be unable to see beyond is

    1. what is the most appropriate Spinal immobilisation methodology for the ED vs pre hospital - specifically what the rationale behind keeping someone on a longboard once they have been transferred to the stable environment of a Emergency Department trolley and are in a clinical area of the ED.

    2. are the definite risks for the average patient to remain boarded for potentially several hours commensurate with the very small additional potnetial risk that one additional handling procedure poses - given the majority of patients immobilised by EMS have no bony spinal injury and fewer still have lasting , or any cord symptoms.

    In our ER, all immobilized patients are seen quickly by the MD to assess for board removal, so it really has never been an issue.

    define quickly as the suggestio nfrom some sources i nthe uk is that patients should not remain on a long board for more than 20 -30 minutes - hence the reason some providers routinely carry vacumm mattresses and /or use split spine boards such as combicarrier so they immobilised directly to a conforming surface rather than a slipperly rigid 'spatula'

    Certainly, no-one would argue that there are problems assosiated with prolonged boarding, but I think it could also be said that early board removal to avoid these problems takes the back seat to c-spine protection.
    there is an element of throwing the baby out with the bathwater here, adequate C spine immobilisation does not depend on the presence or absence of a long board - as after all some peopel would support the statement that the best spinal immobilisation is manual control ... look at the phtls methodology of the 3 person rapid extrication and the emphasis this places on effective manual spinal control ...

    look at theorthodoxy of none time critical extrication from RTCs again a lot of emphasis on manual inline immobilisation and the long board is used as a 'spatula'

    Given the choice between a pressure ulcer and paralysis from my fractured c-spine...I'll take the pressure ulcer every day of the week!
    chance of skin integrity damage from poor spinal management - approaches 1 even if you are completely uninjured

    application of Spinal immobilisation by EMS or triage and actually bony or cord injury considerably less

    Given the option of retaining my license or risk losing it over early board removal, I'll opt to retain my license every day of the week!
    given that you risk losing your licence over your gross negligence in causing an iatrogenic wound ....

    how do you justify not removing a device which is not longer required and is actively causing harm to your patient

    In my ER, the trauma team is all experienced, TNCC certified, ACLS, PALS and NALS certified, and most are CEN certified. I personally have 24 years of ER experience and would not consider for one moment de-boarding a patient prior to MD eval. Policy or no policy, in the end it is
    do you collar and board everyone who presents to triage with 'neck pain' and a possible MoI or do you undertake a clinicla examination and selelctively immobilise?

    does your 'supplying' EMS provider(s) have a selective immobilisation guideline / protocol ?

    MY license...and the patients future!


    BTW: our policy clearly states that board removal is done ONLY after MD eval and either verbal or written order for removal. Some of the new "hot shot" "I'm so smart" "I'm just as competent as any doctor" "I want total autonomy" nurses will never understand this approach. We see them in our ER all the time. They don't last long.
    and your evidence base for this ?

    Please God...If I am EVER in a situation where I find myself boarded and collared, PLEASE PLEASE PLEASE let me awake to find myself in a trauma center where nurses are not making the "educated" decision to deboard me!! They don't have xray vision or the training to make that decision.
    you don't need x ray vision to decide to remove a long board

    you don't need x ray vision to decide to remove immobilisation

    you do need appropriate physicial examination skills to justify your decision to irradiate someone

    I have a very busy life God, and I need to be able to walk and move my body freely in order to perform my job and care for my family and farm. Please God, if I develop a pressure ulcer or experience any discomfort associated with the "big bad nasty uncomfortable board" I will ignore it and not hold you or anyone else responsible for it.
    however a painful and time lost iatrogenic injury especially if you didn't have any bony , nevermind cord injury / symptoms is a big deal ... a triumph of pointless dogma with no evidence base over critical thinking and sensible analysis of the risks.

    a signficant and /or infected pressure sore could result in some one being off work for siginficant amounts of time as it is healed / surgically repaired , those with existign cord injuries are a special case but it can involve hospitalisation and total bed rest for several months
    - this could also be the delay in rehabilitation of an 'acute' patient with a cord injury who has been mismanaged in the early stages following their injury .
  3. by   BULLYDAWGRN
    man thats way to long of a damn post to basically say that you consider yourself the supreme authority on spine board removal. I can see you in the near future just taking upon your self to remove a board in triage just because you did some type of rinky-dink phtls/tncc assessemnt and the pt ruptures a disk or a nerve. and as you are being bent over the table getting assaulted by a lawyer I'm sure you'll be thinking "hmm maybe I should've waited on that docs order" but at least the patient wont have a pressure ulcer...
  4. by   ukstudent
    ZippyGBR I don't doubt what you are saying. It is quiet likely that the backboard does not provide any extra spine support than being taped/strapped to a stretcher and that nurses (correctly trained) are capable of clearing then. However none of that counts here in America. As long as Dr's are the only legal ones allowed to order changes in treatment and lawyers with no medical knowledge can go before juries with no medical knowledge, you had better get a Dr's order. Do you know how many unneeded tests are performed, operations done just so in a court room the medical team can say that everything was done. The OP is in America and the advice to follow policy and get an order is based on that.
  5. by   Joe B1
    I've worked at one facility, a level 2 trauma center, where there was a backboard protocol in which we were allowed to remove the pt from the board in the case that there was no back pain with no spinal tenderness or deformity on palpation, in alert and oriented pt's without distracting injuries or any intoxicating substances on board. It worked exceedingly well. We left the cervical collar in place until the physician saw the pt and cleared the c-spine per his/her exam. I was actually glad to see it implemented.

    I can see that some nurses would be uncomfortable with such a practice, especially if they lacked in experience doing trauma exams. I can also see that these interventions are best left to experienced trauma nurses.

    That's my 2 cents,
    Joe
  6. by   BULLYDAWGRN
    hospital protocols are'nt worth the paper they are typed on in a liable suit. plenty of rns/doctors and hospitals as a whole has been taken to the cleaners by following a hospital protocol. any reputable trial attorney worth their salt can easily manipulate any protocol to show negligence or malpractice. for that reason i'm simply not going to take the chance.
  7. by   ZippyGBR
    Quote from BULLYDAWGRN
    hospital protocols are'nt worth the paper they are typed on in a liable suit. plenty of rns/doctors and hospitals as a whole has been taken to the cleaners by following a hospital protocol. any reputable trial attorney worth their salt can easily manipulate any protocol to show negligence or malpractice. for that reason i'm simply not going to take the chance.

    in 'English' UK civil law / tort law there are 2 principles which have become known as the 'Bolam test ' and the 'Bolitho test' after the cases where the case law was established ,

    "
    The Tests of Liability - Bolam and Bolitho
    The Bolam Test

    This was recognised in the classic direction of McNair J to a jury in Bolam-v-Friern Hospital Management Committee
    • A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper and responsible by a responsible body of medical men skilled in that particular art - Putting it the other way round, a doctor is not negligent if he is acting in accordance with such a practice merely because there is a body of opinion which takes the contrary view.
    • The implications of this for those in primary care is that the standard against which one is judged is that of ones own peers - not that of the wisest and most prudent doctor who exists and not that of a hospital consultant who may carelessly venture opinion as to the management in general practice. By the same principal the persons who give evidence to the Court about the standards in general practice can only be general practitioners who were practising at the time of the case.
    • The standard to be applied is not that of a most astute doctor or necessarily that of a Professor of General Practice, but that of an ordinary and competent GP acting responsibly.

    The Bolitho Test

    In the case of Bolitho, the House of Lords decided in effect that if the management by a body of responsible doctors was not demonstrably reasonable it would not necessarily constitute a defence. If professional opinion called in support of a defence case was not capable of withstanding logical analysis, then the court would be entitled to hold that the body of opinion was not reasonable or responsible. More simply put- you cannot defend a case on the basis of a current practice that is not reasonable or logical." (http://www.patient.co.uk/showdoc/40024929/)


    there is also the following principle to take account of

    "Loss of a Chance In the case of Gregg-v-Scott brought to the House of Lords in 2002 it was established that a patient must prove that a doctors action or lack of it caused him to suffer injury and not just the chance of avoiding an injury. In practical terms this means that a doctor failing to diagnose a case of cancer in which a patient has only a 25% chance of survival would not be found negligent. Only if the chance of survival was over 50% ie a probabilitiy of a cure rather than a chance of a cure, would negligence be found." ((http://www.patient.co.uk/showdoc/40024929/


    there's a interesting run down ofthe applications of Bolam on the wikipedia site under
    http://en.wikipedia.org/wiki/Bolam_Test


    is vicarious liability an alien concept for the US as well - as people are suggestiing that hospital guidelines offer no defence... if they are reasonable , evidence based and staff act in accordance with them surely the employer is vicariously liable - unless the guideline failes to meet and 'pass' Bolam / Bolitho type tests
  8. by   ZippyGBR
    A further issue to consider is the implication by some that 'clearance' of the C sipine can only be achieved radiologically , selective immobilisation guidelines suggest other wise as does UK practice , perhaps in part driven by POPUMET and currently the Ionising Radiation (medical exposure ) Regs 2000 which requires clinicla justification of any imaging request by the referrer ( who is generally a Health Professional, but there is no specific professiona specified , as well as Doctors, dentists, Podiatrists it is quite common to find Nurses , Paramedics and Physios with Referrer rights - although none Physician /Surgeon referrers usually have restrictions on where they can request imaging - e.g. the logical restrictions for the Dentist or podiatrist and for other none medicla referrers depending o ntheir area of practice, e.g. when i was working in the Emergency Dept rather than the assessment units i was a referrer and we could refr for knees and distally , shoulders and distally and any where except face for foreign bodies that could be imaged , the Nurse practitioners and ECPs had a wider range of requests including Hip , facial bones etc... reflecting their advanced practice
  9. by   CraigB-RN
    Quote from BULLYDAWGRN
    hospital protocols are'nt worth the paper they are typed on in a liable suit. plenty of rns/doctors and hospitals as a whole has been taken to the cleaners by following a hospital protocol. any reputable trial attorney worth their salt can easily manipulate any protocol to show negligence or malpractice. for that reason i'm simply not going to take the chance.
    Actualy the large majority of lawsuits are from people staying from the protocols. I don't practice in fear, and taking someone off the backboard isn't "clearing" the C-Spine. Again go up to the neuro ICU/Trauma ICU and look at the patients with known back injuries. They aren't laying on a long board, and a large proportion don't have HALO either. I've taken care of patients or days, who don't have their C-pine cleared, because they weren't able to tell me if it hurt, all laying on a hosp bed with a c-collar, they were turned, washed, and all that nursing care stuff, all withouth a back board and all without having their c-spine cleared.

    I've heard tons of anectdotal responses, but none based on fact. I've and open mind, if someone can point me to actual case law, I'll look at changing my practice.
  10. by   BULLYDAWGRN
    Quote from CraigB-RN
    Actualy the large majority of lawsuits are from people staying from the protocols. I don't practice in fear, and taking someone off the backboard isn't "clearing" the C-Spine. Again go up to the neuro ICU/Trauma ICU and look at the patients with known back injuries. They aren't laying on a long board, and a large proportion don't have HALO either. I've taken care of patients or days, who don't have their C-pine cleared, because they weren't able to tell me if it hurt, all laying on a hosp bed with a c-collar, they were turned, washed, and all that nursing care stuff, all withouth a back board and all without having their c-spine cleared.

    I've heard tons of anectdotal responses, but none based on fact. I've and open mind, if someone can point me to actual case law, I'll look at changing my practice.
    hey you or anyone can nurse anyway they feel like they need to. and again i'm not making the issue out of "you can't take care of someone who is off the board, of course they have to get off the board eventually" hell even in this war zone we get them off boards but again the er doc is the one who decides when to remove the board, if he is unsure he'll consult neuro/ortho..that is the only point i'm trying to make...that to keep yourself from getting slammed by some slick law dog. again i'm sure everyone takin care of officially uncleared spines that the patient is off the board, hell i've done many myself, but i do not and will not take a patient off a board without the doc looking at them or getting an ordr first.. not in mississippi or here in iraq..
  11. by   RN1980
    holy crap this thread is still going on this subject...yep people will nurse the way they want to, but one good litigation will defenitly change the way a person nurses..as my old drill sgt. always said "stay alert stay alive"..
  12. by   ZippyGBR
    Quote from CraigB-RN
    Actualy the large majority of lawsuits are from people staying from the protocols. I don't practice in fear, and taking someone off the backboard isn't "clearing" the C-Spine.
    exactly , especially if the person remains in a collar and head restraint pending clinical or radiological clearnace.

    Again go up to the neuro ICU/Trauma ICU and look at the patients with known back injuries. They aren't laying on a long board, and a large proportion don't have HALO either. I've taken care of patients or days, who don't have their C-pine cleared, because they weren't able to tell me if it hurt, all laying on a hosp bed with a c-collar, they were turned, washed, and all that nursing care stuff, all withouth a back board and all without having their c-spine cleared.
    exactly

    also for those who rely on radiological clearance consider the phenomena / syndrome / fact that is SCIWORA

    I've heard tons of anectdotal responses, but none based on fact. I've and open mind, if someone can point me to actual case law, I'll look at changing my practice.
    that's being generous i've heard a lot of dogma and protocol monkey arse coverage and very little patient advocacy ...

    "they stay on the board becasue EMS put them there" - disregarding that fact that for many in the US EMS providers may have as little training as 110 hours ( the USDOT EMT_B core curriculum) and even if cared for by paramedics, the paramedic is not an autonomous accountable health professional.

    " you can't clear the spine without X rays / CT " odd then that elswhere i nthe civilised world C spines are routinely cleared by clinical means by a variety of practitioners including RNs and EMS providers

    " only doctors can make 'diagnoses " - this is one of the biggest things that makes non USAn nurses laugh the constant and seemingly irrational fear of 'practising medicine without a licence ' - yet we are told how wonderfully autonmous and highly skilled RNs i nthe US are ...
  13. by   mmutk
    Most nurses here are TNCC certified also, but that doesn't give us any special xray vision. So NO all patients on backboards are only cleared by the Doc. We turn a light on our tracking board to let the MD know if a patient is boarded.

    As to the above post, I see no problem if you take a pt off the backboard after xrays are performed, but if you do it before xrays, you are liable for the patient suing you saying when you took them off the backboard you may have caused an injury to the neck.
    Last edit by mmutk on Dec 9, '07

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