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

[CraigB-RN, MSN, RN]

I don't think he's failed at all, just like I don't think "the other side" made their case at all. It looks like an area that needs more study and probably more inmportatantly more education for all involved. The catastrophic results of spinal injuries can sometimes give us what I think is an unhealthy fear of these pateints.

We all come from different backgrounds and experience and work in different places that lead us to different practices. That is one of the diffuculties of nursing. Way to much is dependent on experience and the location you work. I've been fortunate enough to have participated in some of the research that identified that the majority of patients don't need the backboards at all.

Out of all this, my biggest fear isn't that some take patients off backboards or not, it's the mechanics of taking patients of backboards. With this discusion, I looked at people taking patients off backboards and the technigue is terrible. And the documentation worse.

Open discusion is a good think, it's hard to keep it proffesional and not let it get personal when both sides feel so strongly about things.

[ZippyGBR, BSN, RN]

as craig and ERbunny have stated there need be no issue with the decision to remove a patient from a longboard ( an extrication device) once they are in the Emergency department, even if theiry are not 'cleared' as long as all the other precautions remain in place and the removal is done in a safe and appropriate manner with respect to patient handling.

there is no reason for CYA immobilisation when there is the evidence base from the international use of the canadian C-spine rule by a variety of providers physician and none -physician , incidentially the Canadain C-spine ruleis held in sufficient regard in the Uk for it to be incorporated in out National Pre-hospital care guidelines

removing someoen fro mthe long board and reducing their risk of iatrogenic injury does not equal clearance of the spine - which the anecdotal report mmtuk posted is about - where inadequate care by physician providers lead to a disocntinuation of pinal precautiosn without the proper physicla ( and if indicated ) radiological examination.

[mmutk, BSN, RN, EMT-I]

I don't think he's failed at all, just like I don't think "the other side" made their case at all.

I am not trying to argue "the other side" here, as I said before I am not going to argue with you all, someone asked for a reference to my point and I went on google for 5 min and posted the first thing I came across. I'm not trying to argue a case and point here. I am just stating my OPINION (as I said before).

Which is ...if I was a patient and I rolled in to your ER with a broken neck, and you went through the process of rolling me off the backboard before xrays were performed, i would tend to sue you because you can't prove my neck wasn't broken before you MOVED me off the backboard. However xrays and subsequent CTs would show my neck was broken after you took me off the backboard.

And if I was on a jury I would find for the defendant also.

[CritterLover, BSN, RN]

i've been watching this thread for a while now, interested to see what kind of practices the rest of the country has.

i spent the past few years working in a fairly small er. our docs had to clear pts from the spine boards, but it didn't seem as though there was much to the exam -- rarely, if ever, did i see the pt xray'd prior to removal of the board. usually just a pe; palpation/inspection/"does this hurt?"

before that, however, i worked for a few years in the icu of a level-1 trauma center. sometimes, a patient came to me from the er with the spine board still in place, usually when the xrays hadn't been done yet. when this happened, we usually used it to move them to the bed, and then removed it (via log-roll).

(we did, though, take the spine board to xray with us when the ctls were done -- better pictures, we were told.)

however, there was one noteable exception:

i came in one night to find i had been assigned a new admission. the patient had an unstable cspine fracture. neurosurgery hadn't been able to operate yet -- i don't remeber the reason, maybe they needed some equipment; maybe they needed staff, maybe the patient needed something by way of stabelization.

at any rate, the patient was going to the or first thing in the morning to have his spine fused.

he was still intact, and the fracture was unstable enough that neurosurgery was very worried about what could happen during the night. so, this is what they did: he was still on the spine board, ccollar in place. the clothes they had cut off him were still under him on the board. he was taped securly to the board -- close to a roll of silk tape had been used, with "do not remove" written in sharpie all over the tape (by the neurosurgeon). he was intubated, and on continuous infusions of versed, morphine, and norcuron.

he went to surgery the next morning -- i sent him before i left. when i came in that night, he was gone. to the floor. surgery was successful, he no longer needed icu care (so the above precautions were due to his spinal instability; the rest of his injuries wern't that serious).

it has been so long that i don't remember what the specific injury was., but i want to say it was an odontoid fracture.

i'm relaying this instance to reinforce that the spine board is not just for transport.

and i'm sure that his neck was very painful when he came in to the er, and i'm sure that no nurse posting here would have removed his ccollar. however, he was never even log-rolled in the er to have his back inspected. he had a portable cspine done in the trauma room that revealed the fracture, and the spine exam stopped there (except for further xrays).

who knows -- maybe neurosurgery was being ultra-conservative (they were pretty aggressive in treating spines, much more so than ortho), and he would have been fine sitting up in bed with the ccollar in place waiting for surgery. they obviously felt it wasn't worth the gamble.

[CraigB-RN, MSN, RN]

ANd that sounded like the best care this patient could have gotten! Sounds like the patient got great care.

The point that this thread still brings to bear is how much of our practice isn't based on a scientific fact. Dogma tends to bring out very emotional responses.

I do remember many times cussing at the ER staff for the condition of trauma patients when they made it to my SICU. Now I am one. :)

I remeber at one point in my career were I was sure I knew everything there was to know and that I was the right one. Now I've discovered that in many cases I"m wrong. I learned to not take it personally and learn, and get pass the fear and the "you'll get sued" mentality, and the we've always done it this way mentality.

I know they have been done, but I'd like to see a flouro study or something like that to establish the best form of imobilization, short of HALO for these patients.

But like it was said before, we've definitly reached the point of well passed diminished returns. I've enjoyed the discusion, it met the purpose of havign to think about what I do on a day to day basis and evaluate my and my co workers practice.

[Donna RN]

I am not trying to argue "the other side" here, as I said before I am not going to argue with you all, someone asked for a reference to my point and I went on google for 5 min and posted the first thing I came across. I'm not trying to argue a case and point here. I am just stating my OPINION (as I said before).

Which is ...if I was a patient and I rolled in to your ER with a broken neck, and you went through the process of rolling me off the backboard before xrays were performed, i would tend to sue you because you can't prove my neck wasn't broken before you MOVED me off the backboard. However xrays and subsequent CTs would show my neck was broken after you took me off the backboard.

And if I was on a jury I would find for the defendant also.

Taking a patient off a back board without the consent of a MD is NEVER a good idea. One - if you obtain a verbal from the MD and something happens it falls on the MD - Document well please!!! and Two - (removing a patient off a back board w/o MD orders) if you remove the patient from a back board and something happens it is on your shoulders. Patients tend to think that once the back board is off they can sit up, turn on their side, etc as long as their neck is protected. Not good. Pt. runs the risk of a broken back. Further injury, to the patient, can be avoided by leaving the patient tied to the back board and turning (log roll) patient Q30min - 1 hour, to relieve pressure point(s) pain. CYA (cover your a__) at all times and document, document, document.

[Jennifer, RN]

Taking a patient off a back board without the consent of a MD is NEVER a good idea. One - if you obtain a verbal from the MD and something happens it falls on the MD - Document well please!!! and Two - (removing a patient off a back board w/o MD orders) if you remove the patient from a back board and something happens it is on your shoulders. Patients tend to think that once the back board is off they can sit up, turn on their side, etc as long as their neck is protected. Not good. Pt. runs the risk of a broken back. Further injury, to the patient, can be avoided by leaving the patient tied to the back board and turning (log roll) patient Q30min - 1 hour, to relieve pressure point(s) pain. CYA (cover your a__) at all times and document, document, document.

I agree with this also. I never take a patient off a backboard without verbal consent. That way, I can document that a physician was aware of the patient's complaint and gave me a verbal order to remove the backboard.

Some docs get a little perturbed, but so what? Those same docs get p.o.'d over many, many things.

[traumarns]

our trauma protocol-level 1, must be taken off the backboard within 15 mins of arrival.

there are situations when the pt cant come off board wihin that time, ie- 6 alerts and 1 activation all rolling in at the same time.

we MUST document when they come off the board, that is to maintain our trauma designation. (when the trauma surveyors come in we can get dinging for it)

we DONT take them off unless the doc is in the room, to palpate back.

it takes a couple of minutes to remind the doc-"hey this guy is still on the board"

we dont take off c-collars. the doc does that.

my fav is when the pt chews his collar off- thats always fun.

our ems are mostly using scoops.

the back board does nothing to maintain spine precautions, all it does is cause skin breakdown.

remember you are a pt advocate-get em off the board as quickly as poss.

if somebody has cord compression, use a slide board for transfers.

like other people have said, always check your policies.

[ROLO]

our trauma protocol-level 1, must be taken off the backboard within 15 mins of arrival.

there are situations when the pt cant come off board wihin that time, ie- 6 alerts and 1 activation all rolling in at the same time.

we MUST document when they come off the board, that is to maintain our trauma designation. (when the trauma surveyors come in we can get dinging for it)

we DONT take them off unless the doc is in the room, to palpate back.

it takes a couple of minutes to remind the doc-"hey this guy is still on the board"

we dont take off c-collars. the doc does that.

my fav is when the pt chews his collar off- thats always fun.

our ems are mostly using scoops.

the back board does nothing to maintain spine precautions, all it does is cause skin breakdown.

remember you are a pt advocate-get em off the board as quickly as poss.

if somebody has cord compression, use a slide board for transfers.

like other people have said, always check your policies.

(If this appears twice, it is because I hit something and it was accidently sent).

I could not have said it better! Doesn't TNCC address this? Seems my last couple of courses did. Also, we talked about this at my last state ENA symposium.

Basically: keep collars on...docs remove them...ETOH may complicate matters...backboards should be removed ASAP (hopefully within 15mins)...MDs should be present, but not so much an issue as with collar and someone's neck...backboards can be injurious...skin breakdown, potential for aspiration, in "patient vs. the backboard" game, the backboard usually wins (combative pt who will not hold still & flips himself off stretcher)...

[mamamerlee, LPN]

A few years ago, my husband fell at work, and broke some ribs. He has Cerebral palsy, which made him have tremendous muscle spasms, and he could hardly move. Due the the acute angles in our apartment, he was put on a backboard for transportation purposes only. But he arrived at the ER on a backboard, and they refused to take it off until he was cleared. He screamed and cried for OVER AN HOUR, his body was wracked with visible spasms, and still no MD. I had to stand at the nurses' station and cry and beg for an MD to come just to get the backboard off. He has often said it was the worst pain he has ever had, and he doesn't ever want to be on a backboard for ANY reason, ever again. His initial injury was 3 days prior to this, but nobody seemed to be able to get past the fact that he was brought in on the backboard.

[ROLO]

A few years ago, my husband fell at work, and broke some ribs. He has Cerebral palsy, which made him have tremendous muscle spasms, and he could hardly move. Due the the acute angles in our apartment, he was put on a backboard for transportation purposes only. But he arrived at the ER on a backboard, and they refused to take it off until he was cleared. He screamed and cried for OVER AN HOUR, his body was wracked with visible spasms, and still no MD. I had to stand at the nurses' station and cry and beg for an MD to come just to get the backboard off. He has often said it was the worst pain he has ever had, and he doesn't ever want to be on a backboard for ANY reason, ever again. His initial injury was 3 days prior to this, but nobody seemed to be able to get past the fact that he was brought in on the backboard.

Awesome point! That is a reminder that the ED nurse must commit to the nursing process: assessment (subjective and objective), planning, intervention, & evaluation. Why would we leave this man on a backboard... and then for over an hour?! I will use this example (I assume it is OK, as it was posted) when I talk about spinal immobilization and trauma care. I thank you!:heartbeat

[mamamerlee, LPN]

Rolo - you have my permission to use our story. I wish that the EMTs had been more specific when they gave report, or had taken him off of it when they got there. I never understood why they left him on it.