Nurses taking patient's off backboards without doctor clearnce?

[the big nurse]

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 practice up.

thanks

[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.

[ZippyGBR, BSN, RN]

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 ...

[ZippyGBR, BSN, RN]

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 ...

[NativeSundance, LPN]

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!!

[ZippyGBR, BSN, RN]

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 .

[BULLYDAWGRN, RN]

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...

[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.

[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

[BULLYDAWGRN, RN]

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.

[ZippyGBR, BSN, RN]

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

[ZippyGBR, BSN, RN]

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

[CraigB-RN, MSN, RN]

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.