Nurses taking patient's off backboards without doctor clearnce?

KellyBrackett · Jun 17, 2012

I'm an EM doctor in the U.S, and I'm looking to introduce a policy much like what the OP described.

So, since this thread was written, does anybody have any more experiences with similar protocols? Informally, our nurses support such a policy, bu there are "concerns." My hope is that a written policy will address those concerns.

If ZippyGBR is reading, I would especially like to hear from him/her.

Thanks!

Brooks Walsh, M.D.

Esme12, ASN, BSN, RN · Jun 17, 2012

i'm an em doctor in the u.s, and i'm looking to introduce a policy much like what the op described.
so, since this thread was written, does anybody have any more experiences with similar protocols? informally, our nurses support such a policy, bu there are "concerns." my hope is that a written policy will address those concerns.
if zippygbr is reading, i would especially like to hear from him/her.
thanks!
brooks walsh, m.d.

welcome dr.! an is the largest online nursing community!

this post is actuallya total of 5 years old. the last post was 2010 but zippy still posts. i have worked where rn's were allowed to remove ccertain patients from the backboard.

the policy i had was similar to this that allowed for adult patients who demonstrated no evidence of agitation, combativeness, or other behaviors that would cause the registered nurse to think the patient would be unable to maintain spinal precautions on the ed stretcher to be removed from the backboard immediately upon arrival to the ed. adults only. we all know of the scenario that they walked to the lsb at the scene.

nursing center - journal article

requested pdf document

university of toledo traume service protocol

http://www.utoledo.edu/policies/utmc/trauma_service/pdfs/3364-141-02.pdf

a copy of another:

titleof policy: rn removal of patients from backboard

effectivedate: draft

supersedesdate: new

i. purpose:

to allow trauma patients at sunrise hospitaland medical center and sunrise children’s hospital to be fully assessed in asafe and comfortable manner.

ii. policy: rns in the trauma resuscitation bay,including both the adult and pediatric ed, may remove a patient transported byems from the backboard prior to physician evaluation

iii. procedure: the patient must meet all the criterialisted below for rn backboard removal; if not met; a physician order must beobtained prior backboard removal.

a. alert and oriented to person, place, time,cooperative and able to communicate fully and effectively, with age appropriatecommunication.

b. normal sensory and motor functions in allextremities; no numbness, weakness or tingling or paresthesia noted

c. no radiation of pain to the extremities

d. no neck or spinal tenderness or pain on palpation orwith movement

v if the conditions are met, using the 3-person logroll approach (seepolicy tsu1020), logroll the patient with in-line stabilization of the head andneck.

v if the patient complains of neck or back pain during movement, logrollthe patient to the supine position back onto the board.

v palpate the entire spine, if pain or tenderness is present, the patientmust remain on the backboard, until cleared by the physician caring for thepatient.

v if no pain or tenderness is present, remove the backboard while thepatient is on his/her side, and then logroll back to the supine position,maintaining c-spine precautions.

v in all cases, until the patient is evaluated by the caring physician, thecervical collar must remain in place.

v instruct the patient to maintain neutral alignment while in c-spineprecautions, until seen by the physician

v report findings both negative and positive, of pain or tenderness to thephysician in charge of the patient, so that the cervical spine clearance mayproceed in a timely manner.

references:

eastern associationof surgical trauma (e.a.s.t.) cervical spine clearance –update-2000 managementof the cervical spine-east.org

ems field spineclearance, (caldwell, crouse, fix, loving), journal of emergency nursing 200127; 286-8

the following is a sample nursing policy for c-spine immobilization.

purpose:

to outline the procedure for applying immobilizing the upper spine, including application of a cervical collar and “boarding” the patient.

policy:

application of a cervical collar and placing the patient on a backboard may be indicated for trauma patients with mechanisms of injury that place the patient at risk for spinal injury. this will not be necessary for patients with all of the following:

no posterior midline cervical tenderness
no evidence of intoxication
normal level of alertness (gcs 15)
no focal neurological deficit
no painful distracting injuries

the md or rn will maintain manual stabilization of the cervical spine until cervical collar is applied and patient is placed on backboard.
* talk to the patient and tell them what you are doing- and not to move their head and neck
place hands on both sides of patient’s head with thumbs along mandible and fingers holding back of head.
assistants will help with the rest of the application of the cervical collar and backboard.
perform a baseline cms assessment of the extremities.
remove jewelry from the neck and ears.
choose an appropriately sized collar by measuring the distance (with fingers) between the top of the shoulder where the collar will rest and the chin. this same number of fingers will fit between the fastener on the collar and the bottom edge of the rigid plastic of the collar.
cervical collar is assembled by snapping the fastener into the hole on the side of the collar
adjustable rigid cervical collars are measured from the bottom edge of the rigid plastic to the red circle denoting the size of the collar (red circle will move up or down as size of the collar is adjusted)
slide the back of the collar behind the right side of the neck until the velcro tab is visible on the left side of the neck.
slide the chin portion up the chest until the chin fits in the collar.
secure the velcro when the collar is on straight (nose, circle on chin portion of collar, and umbilicus are in alignment).
place the patient on a slide board with all team members working in a smooth fashion which moves the patient’s spine as little as possible. patients already in bed will be log rolled and slider board inserted.
* do not obtain a rectal temperature while the patient is turned unless the md specifically requests this.
recheck cms.
the md or rn can now remove hands from head.
document both cms checks and procedure in patient’s record

protocol for spinal clearance
============================
*pt cannot be less than 6 yrs old.
*pt cannot have etoh/drug imparment.
*no decreased loc or have had any loc
*gcs of 15.
*no spinal pain or point tenderness.
*no neuro deficit or neuro complaints.
*no destracting injuries, such as long bone fx etc.
*signficant moi, (mva w/entrapment or death of an occupant in the same vehicle etc)
*no language barrier.

trauma guidelines - table of contents

i hope this helps.

Esme12, ASN, BSN, RN · Jun 17, 2012

i'm an em doctor in the u.s, and i'm looking to introduce a policy much like what the op described.
so, since this thread was written, does anybody have any more experiences with similar protocols? informally, our nurses support such a policy, bu there are "concerns." my hope is that a written policy will address those concerns.
if zippy gbr is reading, i would especially like to hear from him/her.
thanks!
brooks walsh, m.d.

welcome dr.! an is the largest online nursing community!

zippy still posts. i have worked where rn's were allowed to remove certain patients from the backboard. the policy i had was similar to this that allowed for adult patients who demonstrated no evidence of agitation, combativeness, or other behaviors that would cause the registered nurse to think the patient would be unable to maintain spinal precautions on the ed stretcher to be removed from the backboard immediately upon arrival to the ed. adults only. we all know of the scenario that they walked to the lsb.

nursing center - journal article

requested pdf document

university of toledo trauma service protocol

http://www.utoledo.edu/policies/utmc/trauma_service/pdfs/3364-141-02.pdf

a copy of another:

title of policy: rn removal of patients from backboard

effective date: draft

supersedes date: new

i. purpose:

to allow trauma patients at ..........be fully assessed in a safe and comfortable manner.

ii. policy: rns in the trauma resuscitation bay,including both the adult and pediatric ed, may remove a patient transported by ems from the backboard prior to physician evaluation

iii. procedure: the patient must meet all the criteria listed below for rn backboard removal; if not met; a physician order must be obtained prior backboard removal.

a. alert and oriented to person, place, time,cooperative and able to communicate fully and effectively, with age appropriate communication.

b. normal sensory and motor functions in all extremities; no numbness, weakness or tingling or paresthesia noted

c. no radiation of pain to the extremities

d. no neck or spinal tenderness or pain on palpation or with movement

v if the conditions are met, using the 3-person log roll approach (see policy xyz), log roll the patient with in-line stabilization of the head and neck.

v if the patient complains of neck or back pain during movement, log roll the patient to the supine position back onto the board.

v palpate the entire spine, if pain or tenderness is present, the patient must remain on the backboard, until cleared by the physician caring for the patient.

v if no pain or tenderness is present, remove the backboard while the patient is on his/her side, and then log rollback to the supine position,maintaining c-spine precautions.

v in all cases, until the patient is evaluated by the caring physician, the cervical collar must remain in place.

v instruct the patient to maintain neutral alignment while in c-spine precautions, until seen by the physician

v report findings both negative and positive, of pain or tenderness to the physician in charge of the patient, so that the cervical spine clearance may proceed in a timely manner.

references:

eastern association of surgical trauma (e.a.s.t.) cervical spine clearance –update-2000 management of the cervical spine-east.org

ems field spine clearance, (caldwell, crouse, fix, loving), journal of emergency nursing 200127; 286-8

protocol for spinal clearance
============================
*pt cannot be less than 6 yrs old.
*pt cannot have etoh/drug impairment.
*no decreased loc or have had any loc
*gcs of 15.
*no spinal pain or point tenderness.
*no neuro deficit or neuro complaints.
*no distracting injuries, such as long bone fx etc.
*significant moi, (mva w/entrapment or death of an occupant in the same vehicle etc)
*no language barrier.

trauma guidelines - table of contents deconess medical center

i hope this helps.

ROLO · Jun 17, 2012

Beautiful policy/procedure/guideline!

I am just "tuning in" and have not seen all of the other posts, but I might remind us of the Emergency Nurses Association (ENA) (check out their web site). The ENA has position statements on various topics and concerns (advanced practice nurses in the ED...difficult IV access...violent patients...etc.). Also, the National Guideline Clearinghouse is a great source of information regarding standards of care (see their web site). I am an ED nurse, and when I was working on the management of the adult psychiatric patient in the ED, the Clearinghouse had already addressed it, and so I was able to find some good information.

You may have already talked about these things, but I just wanted to throw them out there:)

Esme12, ASN, BSN, RN · Jun 17, 2012

The ENA is an excellent resource.! http://www.ena.org/about/position/Pages/Default.aspx

So is the AHRQ Clearinghouse.

http://guideline.gov/

ZippyGBR, BSN, RN · Jun 17, 2012

I saw the topic pop up as an email notification and my first thoughts were ' holy thread resuscitation , batman ! '

Esme thanks for helping the Doc out with your protocol

as for the individuals complaining that their X-ray techs wont image unless the patient is on the X ray table ... are your ED trolleys not X ray compatible with a film holder ?

because i'm aware of the converse situation being posited that despite the assertions of the manufacturer over x ray translucently / transparency , x raying on a long extrication board produces poor images in the opinion of the radiographer and radiologist,plus of course all the artefact from handles, speed pin clips etc ...

as for staffing issues it's interesting that the immediate assumption is that it will deplete the ED of staff, despite ATLS methodolgy over doing initial imaging in the ED resus room and it seems to assume that there will be no patient transport porters etc ... to assist ... as for ct well yes they do need to be moved onto the CT scanner table but this is where the scoop hoist previously mentioned comes into it;s own ...

http://www.flickr.com/photos/backmanmal/5430726840/

http://www.flickr.com/photos/backmanmal/5430125729/in/photostream/

the scoop used in 'backmanmal's' pictures above is a ferno 65 exl which is UK ferno's standard scoop stretcher

Product: Scoop 65 EXL (010795900) | Ferno

KellyBrackett · Jun 18, 2012

Thanks Esme, ZippyGBR, I appreciate the examples. It's been very helpful to review the links, along with the whole thread, despite how old it is.

Just in case it is of interest to any other folks, I want to describe the policy we're proposing for the ED. We often just have too many boarded patients coming into the ED for a physician (or PA/APRN) to examine them all prior to removing the board. So, we want to have the EMTs, along with the RN, perform a logroll to remove the back board as part of the handover from EMS.

It's important to emphasize that this will not constitute clearing the spine, but simply maintaining spinal precautions. While there is a policy for spinal clearance in place, it is rarely used by the RNs. Too much of a culture shift, I'm not sure.

By making the policy very simple (all ages, all injuries come off the board) we hope to facilitate acceptance, and improve patient comfort. I think most of the staff is receptive, but a policy is needed (understandably) to allay legal/medical concerns.

Thanks again for allowing me to dredge up this long-dormant thread. If the policy passes I'll add a note later on!

Esme12, ASN, BSN, RN · Jun 18, 2012

Thanks Esme, Zippy GBR, I appreciate the examples. It's been very helpful to review the links, along with the whole thread, despite how old it is.
Just in case it is of interest to any other folks, I want to describe the policy we're proposing for the ED. We often just have too many boarded patients coming into the ED for a physician (or PA/APRN) to examine them all prior to removing the board. So, we want to have the EMTs, along with the RN, perform a log roll to remove the back board as part of the handover from EMS.
It's important to emphasize that this will not constitute clearing the spine, but simply maintaining spinal precautions. While there is a policy for spinal clearance in place, it is rarely used by the RENTs. Too much of a culture shift, I'm not sure.
By making the policy very simple (all ages, all injuries come off the board) we hope to facilitate acceptance, and improve patient comfort. I think most of the staff is receptive, but a policy is needed (understandably) to allay legal/medical concerns.
Thanks again for allowing me to dredge up this long-dormant thread. If the policy passes I'll add a note later on!

That's why essentially didn't move it as the thread itself had some great points.

As long as the patient is cooperative it should be fine. Thanks for coming and asking a bunch of nurses.. I found x-ray/diagnostics were the most resistant to move the patient without the LSB. The nurses were happy to ge those poor patients OFF of those terrible boards.

We were glad to help.

CrashED · Jun 19, 2012

We are working on that at my trauma center, more so because our medics have rediculous protocols. Anyone with fall or mvc below the age of 5 or above the age of 65 automatically comes in boarded and collared, even without neck or back pain! So due to impaired skin integrity issues, we can take them off if there is no complaint of neck or back pain on initial exam. We can also remove back boards that were just placed for transferring. (#hips sometimes come in boarded). They are currently working on a protocol for us to be able to take all patients off the board without MD at bedside.

MassED, BSN, RN · Jun 22, 2012

I have to disagree. There is plenty of information out there that shows the majority of patient placed on backboard don't need to be on them. If your taking them off the backboard, you need to have witten policies covering you. You ned to cover things like documentation, distracting injuries, ETOH and such. It can be safe, if your doing it right.

as long as you are maintaining C-spine and log roll your patients, while a nurse who knows how to run a back is palpating, then there isn't a problem. I will run a back. I'm TNCC trained and this is also a part of that. If there's tenderness, step-off, etc., then we keep the person supine, as would a doctor. If it's crazy and there are traumas and a doctor can't get to a person for a while, we certainly will run the back and let the doc know our assessment.

MassED, BSN, RN · Jun 22, 2012

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..

Would you mind not to write in code and text, please? It's difficult to read and interpret. I realize this is an old post, but still....

MassED, BSN, RN · Jun 22, 2012

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...

Us ER nurses can be held liable for many things, least of which is on how to maintain C-spine/log roll. If you're trained in an intervention, you practice accordingly.