Can nurses, working in the emergency department, independently clear cervical spines?: a review of the literature

doi:10.1016/j.aaen.2003.08.003

Accident and Emergency Nursing

Volume 12, Issue 1, January 2004, Pages 19-23

https://doi.org/10.1016/j.aaen.2003.08.003 Get rights and content

Abstract

The prompt clearance of a patient’s cervical spine is extremely beneficial both to the patients and the department however correct guidelines and education must be estabilished before this can be undertaken safely. This paper examines whether nurses given the appropriate training and education using appropriate diagnostic and clinical criteria can safely, effectively clear cervical spines without consulting a medical practitioner. The paper explores the use of the Nexus Guidelines [J.R. Hoffman, W.R. Mower, A.B. Wolfson, New England Journal of Medicine 343 (2) (2000) 94–99] as a clinical prediction tool and presents evidence for its use.

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Cited by (8)

A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses
2018, Annals of Emergency Medicine
Citation Excerpt :
Removal of immobilization by nurses was associated with a reduction in ED length of stay, an important issue in this era of crowded EDs. Although there has been little research completed to date, there is strong support for the concept of nurses clearing the cervical spine of alert and stable trauma patients.14-16 Previous studies have been relatively small, with only one involving actual cervical spine clearance by nurses.
The Canadian C-Spine Rule has been widely applied by emergency physicians to safely reduce use of cervical spine imaging. Our objective is to evaluate the clinical effect and safety of real-time Canadian C-Spine Rule implementation by emergency department (ED) triage nurses to remove cervical spine immobilization.
We conducted this multicenter, 2-phase, prospective cohort program at 9 hospital EDs and included alert trauma patients presenting with neck pain or with cervical spine immobilization. During phase 1, ED nurses were trained and then had to demonstrate competence before being certified. During phase 2, certified nurses were empowered by a medical directive to “clear” the cervical spine of patients, allowing them to remove cervical spine immobilization and to triage to a less acute area. The primary outcomes were clinical effect (cervical spine clearance by nurses) and safety (missed clinically important cervical spine injuries).
In phase 1, 312 nurses evaluated 3,098 patients. In phase 2, 180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%, collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806 immobilized ambulance patients, the primary outcome of immobilization removal by nurses was 41.1% compared with 0% before the program. The primary safety outcome of cervical spine injuries missed by nurses was 0. Time to discharge was reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization removed. In only 1.3% of cases did nurses indicate their discomfort with applying the Canadian C-Spine Rule.
We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.
Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: An integrative review
2016, Australasian Emergency Nursing Journal
Citation Excerpt :
Definitions of terms to refine the search were needed to narrow the search. The term ‘collar’ was defined as a temporarily applied c-spine immobilisation device.25 The term ‘safely’ was defined as the prevention of harm to patients, free from hurt, injury involving little or no risk of error.26
Well validated clinical decision rules exist to facilitate the safe removal of collars in the alert, orientated, low risk adult trauma patient, however this practice is traditionally conducted by medical staff. The aim of this review is to synthesise current evidence to determine the efficacy of emergency nurses in safely and accurately removing cervical spine collars using cervical spine rules, in alert, orientated, low risk trauma adult patients.
A multi-method search strategy was used to find primary research studies followed by a rigorous screening and quality appraisal process. Data from included articles were extracted, grouped and synthesised.
Nine quantitative research articles resulted in four key findings: the inter-rater reliability between nurses and doctors clearing the cervical spine was high (kappa range (0.61–0.80)); nurses can safely implement the cervical spine clinical decision rule; use of a cervical spine clinical decision rule decreases the time patients are immobilised and; nurses felt confident applying a cervical spine clinical decision rule.
Appropriately trained emergency nurses can safely apply cervical spine rules to alert, orientated, low risk adult trauma patients. Implementation of nurses clearing cervical spines should include training and ongoing monitoring.
Perceived facilitators and barriers to clinical clearance of the cervical spine by emergency department nurses: A major step towards changing practice in the emergency department
2011, International Emergency Nursing
Citation Excerpt :
More commonly, investigators have studied nursing evaluation of ankle and knee injuries (Szucs et al., 2001; Kec et al., 2003; Fiesseler et al., 2004; Derksen et al., 2005). Recent review articles strongly support the concept of ED nurses clinically clearing the c-spine (Charters, 2004; Danis, 2005; Zimmerman, 2006). We have been able to identify only five original research papers that assessed the potential for nurses to evaluate the c-spine.
We conducted a validation study on use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients (N = 3633). This survey sought to identify potential facilitators and barriers to an implementation policy that would allow nurses to clinically clear the c-spine of minor trauma patients.
We conducted a prospective quantitative survey of ED nurses in six hospitals. Questions were developed from a previous qualitative survey at the same validation study EDs.
158 ED nurses were surveyed and 137 (86.7%) responded. Nurses strongly endorsed potential facilitators for nursing clearance of the c-spine, including ‘Like to try new things at work’ (96.4%) and ‘Easy for me to take on new responsibilities’ (96.4%). Most respondents were comfortable applying the rule (89.1%). Nurses endorsed potential barriers but at much lower rates, with the most common being ‘Heavy workload makes it difficult to use the rule’ (37.2%). Variation existed among hospitals for the facilitator ‘Use of the rule would be useful to my practice’, ranging from 81.8% to 100% endorsement (P = 0.004).
This survey was an important step towards the goal of empowering ED nurses to clinically clear the c-spine of alert and stable trauma patients. There was a high rate of endorsement of facilitators and a low rate of endorsement of barriers. We found variation between hospitals, emphasizing the importance of understanding local beliefs when seeking to change clinical practice. We are conducting an implementation trial based on this feedback.
Can emergency nurses use the Canadian cervical spine rule to reduce unnecessary patient immobilisation?
2006, Accident and Emergency Nursing
The Canadian c-spine rule (CCR) allows safe, reproducible use of radiography in alert, stable patients with potential c-spine injury in the emergency setting [Stiell, I., Clement, C., McKnight, R., Brison, R., Schull, M., Lowe, B., Worthington, J., Eisenhauer, M., Cass, D., Greenberg, G., MacPhail, I., Dreyer, J., Lee, J., Bandiera, G., Reardon, M., Holroyd, B., Lesiuk, H., G. Wells, 2003. The Canadian c-spine rule versus the nexus low-risk criteria in patients with trauma. The New England journal of medicine 349 (26), 2510–2518; Stiell, I., Wells, G., Vandemheen, K., Clement, C., 2001. The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA 286 (15), 1841]. This paper reports on a study of emergency nurses’ ability to identify patients requiring immobilisation using the CCR.
Emergency department triage nurses (N = 112) were trained in the use of the CCR and then asked to use the tool over the following 14 months in the assessment of 460 patients who presented with potential c-spine injury. Trained medical staff repeated 55% of the clinical assessments independently using the rule. The level of agreement between nurse and medical judgement was calculated. The inter-rater reliability using the κ statistic was 0.6 (95% CI 0.50–0.62 N = 254) indicating a ‘good’ level of agreement. The majority of nurses indicated they were comfortable using the rule.
The results suggest that UK emergency department nurses were able to use the Canadian c-spine rule to successfully guide selective immobilisation. A 25% reduction in immobilisation rates would have been achieved if the rule had been followed. Further studies are needed to test the reduction in levels of immobilisation that could be achieved in clinical practice.
Trauma today and tomorrow: Recent clinical literature
2005, Journal of Emergency Nursing
Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department
2010, CMAJ. Canadian Medical Association Journal
The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospect -ively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses.
We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form.
Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%-100.0%) and specificity of 43.4% (95% CI 42.0%-15.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%-95.0%) and a specificity of 43.9% (95% CI 42.0%-16.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases.
Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.

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Can nurses, working in the emergency department, independently clear cervical spines?: a review of the literature

Abstract

Pre-Hospital Emergency Care

American Journal of Emergency Medicine

Annals of Emergency Medicine

A new cervical spine clearance protocol using computed tomography

Journal of Trauma

Evaluation of the Oxford protocol for total spine clearance in the unconscious trauma patient

Journal of Trauma

Current practice in clinical cervical spinal clearance: implications for EMS

Pre-Hospital Emergency Care

My neck hurts: an audit of self presenting patients with neck injury

Emergency Nurse

Clearing the cervical spine in victims of blunt trauma

Military Medicine

Best practices of emergency care for alcohol-impaired patients

Journal of Emergency Nursing

The efficacy of magnetic imaging in paediatric cervical spine clearance

Spine

Trauma Care Manual

Requesting and interpreting X-ray in A&E

Emergency Nurse

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilisation Study Group

New England Journal of Medicine

Clinical clearance of cervical spinal injuries by emergency nurse

Academic Emergency Medicine