Nurses taking patient's off backboards without doctor clearnce?

ZippyGBR, BSN, RN · Dec 29, 2009

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.

as you've seen across the whole thread, unfortunately Nurses in some settings in some geographical locations cannot or will not exercise their professional skills , instead hoping that deferring decisions to a Doctor somehow protects them, hoping that 'only following orders' with insulate them from action - at the risk of bringing down the wrath of Godwin's law it didn't work in Nuremburg what makes you think it will work in any other courtroom

a long extrication Board is a device for extrication and initial transfer it offers no additional benefit on arrival to a recieving facility - anyone who suggests differently really does not understand the evidence base or the risks of iatrogenic harm prolonged use of the long extrication board causes and choses to ignore a number of reputable clinical practice guidelines such as JRCALC.

without resuscitating all the arguments in the thread i do wonder how some of the posters would defend themselves before their registration board or a civil court in a negligence compensation suit if a patient developed a pressure sore which prolonged their hospital stay or in the worse case scenario required invasive procedures to repair ( even if the 'invasive' procedure was only VAC dressings rather than debride and close / graft) ?

i currently work in a regional spinal injuries unit and there's no long extrication board there ... there is however a 'scoop stretcher' and a straight lift patient hoist to assist with the transfer of patients with unstable bony spinal injuries...

MassED, BSN, RN · Dec 29, 2009

not unless told by MD to remove backboard, and I would clearly document that MD such and such cleared pt from backboard and authorized RN to remove pt.

ZippyGBR, BSN, RN · Dec 29, 2009

not unless told by MD to remove backboard, and I would clearly document that MD such and such cleared pt from backboard and authorized RN to remove pt.

have you read the thread ?

and all the discussion about

1. over use of the long extrication board by 'cookbook' and 'mother may I' ems - when like so many parts of the USA your EMS are 110 hour glorified first aiders (the DoT minimum duration for an EMT-B course) and/ or doing it to get promotion points to Engineer or Crew Commander in the fire brigade ...

2. Nexus , Canadian C-spine Rule and the JRCALC selective immobilisation rules and the implications this has for clinical practice of Health professionals , regardless of whether they are Doctor, Nurse or ( none USAn ) Paramedic.

2a. is there something magical about the hands of physicians that means that a patient's spine won't be damaged if they make the decision to remove the long extrication board after assessing the patient vs. the same pshysical examination undertaken by any other Provider?

3. the documented iatrogenic harm that comes to patients who are inappropriately immobilised for over long periods of time

4. the fact that this iatrogenic harm will result in prolonged hospital stays , increased bills and potentially further disablement or death regardless of t whether the patient has or does not have a bony or cord injury to the spine.

5. the fact that people with unstable spinal columns are routinely nursed in critical care and spinal injuries settings with only a collar and sandbags and are routinely turned side to side for pressure relief

MassED, BSN, RN · Dec 29, 2009

have you read the thread ?
and all the discussion about
1. over use of the long extrication board by 'cookbook' and 'mother may I' ems - when like so many parts of the USA your EMS are 110 hour glorified first aiders (the DoT minimum duration for an EMT-B course) and/ or doing it to get promotion points to Engineer or Crew Commander in the fire brigade ...
2. Nexus , Canadian C-spine Rule and the JRCALC selective immobilisation rules and the implications this has for clinical practice of Health professionals , regardless of whether they are Doctor, Nurse or ( none USAn ) Paramedic.
2a. is there something magical about the hands of physicians that means that a patient's spine won't be damaged if they make the decision to remove the long extrication board after assessing the patient vs. the same pshysical examination undertaken by any other Provider?
3. the documented iatrogenic harm that comes to patients who are inappropriately immobilised for over long periods of time
4. the fact that this iatrogenic harm will result in prolonged hospital stays , increased bills and potentially further disablement or death regardless of t whether the patient has or does not have a bony or cord injury to the spine.
5. the fact that people with unstable spinal columns are routinely nursed in critical care and spinal injuries settings with only a collar and sandbags and are routinely turned side to side for pressure relief

Zippy,

as to #2a, of course that's a ridiculous statement - but legally, we cannot remove a patient from a backboard, regardless of how ludicrous the EMT's decision was to place the patient on the board.

As to #5, I work in an ER, not on a floor where the patient has been stabilized - so your argument there is moot. A patient goes to the floor with most injuries known, in an ER, that is yet to be determined. Err on the side of caution by not removing a patient from a backboard. Since when, do you think, nurses should make that clinical judgment? And where might that stand up in court?

I don't know what #2 means - what are you trying to state?

None of your points would sway me - I'm going to protect my license and the patient. You cannot, within the scope of your nursing license, make that decision to remove a patient from a backboard, essentially clearing that patient.

I don't know where you work, but hey, follow what you internal compass you have, and I'll follow the legal one.

MassED, BSN, RN · Dec 29, 2009

as you've seen across the whole thread, unfortunately Nurses in some settings in some geographical locations cannot or will not exercise their professional skills , instead hoping that deferring decisions to a Doctor somehow protects them, hoping that 'only following orders' with insulate them from action - at the risk of bringing down the wrath of Godwin's law it didn't work in Nuremburg what makes you think it will work in any other courtroom
a long extrication Board is a device for extrication and initial transfer it offers no additional benefit on arrival to a recieving facility - anyone who suggests differently really does not understand the evidence base or the risks of iatrogenic harm prolonged use of the long extrication board causes and choses to ignore a number of reputable clinical practice guidelines such as JRCALC.
without resuscitating all the arguments in the thread i do wonder how some of the posters would defend themselves before their registration board or a civil court in a negligence compensation suit if a patient developed a pressure sore which prolonged their hospital stay or in the worse case scenario required invasive procedures to repair ( even if the 'invasive' procedure was only VAC dressings rather than debride and close / graft) ?
i currently work in a regional spinal injuries unit and there's no long extrication board there ... there is however a 'scoop stretcher' and a straight lift patient hoist to assist with the transfer of patients with unstable bony spinal injuries...

Unsure of how other ER's operate, but when a patient arrives on a backboard, a physician is usually grabbed to at least assess and remove a patient from the board. Even if they can't see the patient, they do provide that courtesy. That's pretty common - a nurse can then order all of the xrays/necessary labs and proceed. As far as pressure sores, etc., are you speaking of being in an ER setting??

ZippyGBR, BSN, RN · Dec 29, 2009

Zippy,
as to #2a, of course that's a ridiculous statement - but legally, we cannot remove a patient from a backboard, regardless of how ludicrous the EMT's decision was to place the patient on the board.

rthis statement has been made a number of times by a number of people in such threads but is never referenced with statue law or professional regualtions to back this assertion up

As to #5, I work in an ER, not on a floor where the patient has been stabilized - so your argument there is moot. A patient goes to the floor with most injuries known, in an ER, that is yet to be determined.

and your point there is ?

Err on the side of caution by not removing a patient from a backboard.

so you are advocating causing harm to patients? U'll ask the question again what is so magical about a physician's hands when s/he applies the Canadian C-Spine Rule or inspects and palpates the rest of the back?

vs this being undertaken by any other suitable educated, trained and experienced Healthcare professional , regardless of the title on the diploma hung on the downstairs loo wall

Since when, do you think, nurses should make that clinical judgment? And where might that stand up in court?

are Nurses as Professionals incapable of making a clinical judgement ? especially when the way in which the judgement is reached is with a validated and internationally respected decision support tool ?

" the level of skill of the ordinary man professing to hold that skill "

I don't know what #2 means - what are you trying to state?

there are a significant number of validated and approved selective immobilisation guidelines in existence they are used by all kinds of health professionals in many places around the world to make decisions on whether there are clinical indications for immobilisation,

None of your points would sway me - I'm going to protect my license and the patient.

by causing harm and assaulting a patient ?

You cannot, within the scope of your nursing license, make that decision to remove a patient from a backboard, essentially clearing that patient.

can you prove this assertion ? once again i return to the point made previously about the absence of proof of the assertion that a it is 'illegal' for a Nurse to remove a patient from a device known to cause iatrogenic harm when inappropriately or injudiciously used without an 'order' from a Doctor...

removing the backboard does not 'clear' the patient, however 'clearing' the patient is within the scope of Nurses and health Professional paramedics as can be seen by those places who use nexus/CCR or the JRCALC selective immobilisation guideline to make the assessment as to whether 'precautionary' immobilsation is justified without good clinical evidence of need.

ZippyGBR, BSN, RN · Dec 29, 2009

Unsure of how other ER's operate, but when a patient arrives on a backboard, a physician is usually grabbed to at least assess and remove a patient from the board.

as someone with plenty of experiencein the ED, if only, we didn't achieve this even if n the big city teaching hospital Ed with multiple middle grades and seniors present around the clock

As far as pressure sores, etc., are you speaking of being in an ER setting??

a pressure sore can be caused in under 30 minutes - you've eaten up most of that 30 minutes in the pre-hospital phase, even with a 15 minute or less scene time...

mcknis · Dec 30, 2009

Setting yourself up for a huge liability issue! I hear the word "SUE" really come into play here!!!!!!! Like others have mentioned, the results of a fall, or other injury can be easily seen witht he naked eye, or much more minute. For instance, today we had a very seasoned ER doc tell a pt that the CT brain looked ok after a fall, however, after we received the official radiologist read result, a subarachnoid bleed was noted!

So NO, we will not de-board someone before an MD sees them. We will board someone who needs to be without a doc becuase that is part of our responsibility.

ZippyGBR, BSN, RN · Dec 30, 2009

Setting yourself up for a huge liability issue! I hear the word "SUE" really come into play here!!!!!!!

immobilisation which is not clinically justified and consequently inappropriate is

1. assault and may well be interpreted in those regressive teritories who consider tying people to beds legitimate, restraint without the appropriate assessments, care plan and MDT consent

2. something which will cause harm ... pther posters throughout the thread have mentioned what happens when patients are left immobilised on a long EXTRICATION board and becoming increasingly uncomfortable by virtue of this when they manage to flip themselves over the side rails of the hospital trolley.

Like others have mentioned, the results of a fall, or other injury can be easily seen witht he naked eye, or much more minute. For instance, today we had a very seasoned ER doc tell a pt that the CT brain looked ok after a fall, however, after we received the official radiologist read result, a subarachnoid bleed was noted!

again what exactly does this point have to do with therapeutic removal of a long EXCTRICATION board and the re institution of appropriate immobilisation if the neck and back cannot be clinically cleared ?

So NO, we will not de-board someone before an MD sees them. We will board someone who needs to be without a doc becuase that is part of our responsibility.

despite the fact

1. you are causing harm to your patient - both the actual harm of pressure damage - the probability of which approaches 1 the longer the patient remains on the long EXTRICATION board and the progression of such increases with the more debris from scene trapped between the patient and board. Secondly the potential harm from the patient flipping themselves off the trolley while still restrained and 'faceplanting' while unable to save themselves ...

2. there is no valid kinematic reason to maintain the spine out of it's natural alignment - unlike during transport where the kinematic envelope is a lot wider and more unpredictable... ( where's the accelerations, shock loads and potential for evasive manouveres on an ED trolley in a cubicle? vs on the back of transport whether that's a road ambulance or helimed ?)

3. There are internationally respected and clinically validated selective immobilisation and /or clinical clearance decision support tools - a concern which is especially valid in those areas where EMS is predominatly 110 hours of glorified first aider - the minimum spec for EMT-B and/or disinterested firemonkeys

creaturesmom · Dec 30, 2009

Worked at one facility where nurses were expected to remove pts within 10 min regardless the reason for immobilization per "policy" I refused to help once because of mechanism-bad mvc pt was removed only to develop "strange funny feeling in my fingers" Pt had c2-3 fracture. Was told oh that's really rare that would happen,rare or not , policy or not it's still my license. No patient should be on a board long enough to cause pressure problems.

ZippyGBR, BSN, RN · Dec 30, 2009

. No patient should be on a board long enough to cause pressure problems.

which means they should be off it within 30 minutes of being placed on it ... oh dear my karma just ran your dogma down

Tonjia · Dec 31, 2009

We don't do it at the hospital I work at because we can pull a resident pretty easily to atleast palpate the spine.
Honestly though,a backboard is used primarily to maintain spinal stabilization in the back of a bumpy ambulance.Think about it? Even when patient's do have spinal injuries (fractures etc.) you don't keep them on a backboard during their entire hospital stay. As long as you keep the cervical collar on and maintain good cervical stabilization then you should be all set.

we work towards rapid removal of spine board at our hospital. That doesnt mean the RN's yank people off of the board without a docs quick assessment, but studies show that prolonged periods of time on the board, is more harmful to the patient than leaving them on..