Background
Canadian emergency departments (EDs) annually treat 1.3 million patients who have suffered blunt trauma from falls or motor vehicle collisions and who are at risk for cervical spine injury. Most such cases are alert and stable adults and less than 1% has a c-spine fracture. Most trauma victims transported in ambulances are protected by a backboard, collar, and sandbags and, on arrival at the ED, are sent to high acuity resuscitation rooms, where they remain fully immobilized for hours until physician assessment and radiography are complete. This prolonged immobilization is often unnecessary and adds considerably to patient discomfort and also adds to the burden of our overcrowded Canadian EDs in an era when they are under unprecedented pressures. These patients use valuable ED resuscitation room space.

Nurses usually do not evaluate the c-spine of trauma patients but we believe that they should be able to safely assess alert and stable ambulance patients and "clear" the c-spine of low-risk cases on arrival at the triage station. Patients could then be much more rapidly, comfortably, and efficiently managed in other areas of the ED. An expanded role for nurse decision-making has the potential to improve trauma care efficiency in all Canadian hospitals. Very little research has been done in this area of nurses' clearing patient c-spines.

This renewal application builds on previous CIHR funded grants by the applicants to develop a decision rule for c-spine evaluation. This Canadian C-Spine Rule (CCR) is comprised of simple clinical variables and was designed to allow clinicians to "clear" the c-spine without radiography and to decrease immobilization times (Phase I - JAMA 2001). We also validated the accuracy of the rule when used by physicians (Phase IIa - New Engl J Med 2003). We have now finished a CHSRF/CIHR funded study to validate the accuracy and reliability of the CCR when used by ED triage nurses at 6 hospitals. Recently, we completed the implementation trial at 12 Canadian hospitals to evaluate the impact on patients of the CCR when used by physicians on 11,824 patients.

Objectives
The goal of phase IV of the Canadian C-Spine Rule project is to evaluate the safety and potential impact of an active strategy to empower ED triage nurses to evaluate and clear the c-spine of very low-risk trauma patients. Specific objectives are to: 1) Determine safety by screening for: a) Missed fractures and b) Serious adverse outcomes; 2) Determine clinical impact by measuring: a) C-spine clearance rates by nurses, b) Length of time until c-spine clearance; 3) Evaluate performance of the Canadian C-Spine Rule for: a) Accuracy, b) Nurse accuracy in interpretation, and c) Nurse comfort and compliance.

Methods
We propose a cohort study which evaluates outcomes during a 12-month period at 5 hospital EDs, including 3 community and 2 teaching hospital sites. Enrolled will be consecutive, alert and stable adult trauma patients presenting to the ED with neck pain or with c-spine immobilization on an ambulance stretcher. Participating will be ED triage nurses who previously underwent a structured educational strategy to learn the CCR and who successfully participated in the validation study at the same sites. These nurses will be empowered by medical directive to "clear" the c-spine of patients according to the CCR, thus allowing them to remove c-spine immobilization and to triage patients to a less acute area of the ED. These outcomes will be assessed: 1) Measures of safety: a) Number of missed fractures, b) Number of serious adverse outcomes; 2) Measures of clinical impact: a) C-spine clearance rates by nurses, b) Length of stay in ED, and c) Patient satisfaction; 3) Performance of the Canadian C-Spine Rule: a) Accuracy, b) Nurse accuracy of interpretation, and c) Nurse comfort. We estimate a sample size of 1,500 patients will be accrued.

Importance
This evaluation/implementation study (phase IV) is an essential step in the process of developing a new clinical decision rule / guideline for nurses to clear the c-spine. Once we have established safety and potential impact in phase IV, we can move to the final step (phase V), a multi-center implementation across Canada to study actual impact. We believe that teaching ED triage nurses to clear the c-spine of very low-risk trauma patients has the potential to significantly improve the efficiency and comfort of patient care in our busy Canadian EDs. Ultimately, we expect the results of this study to be used by ED triage nurses throughout Canada and the world.

• Phase I: Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8.
  
  
• Phase IIa: Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510-8.

OHRI Team members:

Cathy Clement, Program Manager
Pam Sheehan, RN, Research Assistant
Gabi Varga, RN, Research Assistant
Tami Clavet, RN, Research Assistant
Connor Sheehan, Research Assistant
Jennifer Brinkhurst, Research Assistant
My Linh Tran, Database Coordinator
Sheryl Domingo, Database Clerk

Study Site Team Members:

Ottawa Hospital - Civic Campus
Tami Clavet, Wendy Fortier, Cheryl Geymonat, Cari Poulin, Taryn MacKenzie, Gabi Varga
Ottawa Hospital - General Campus
Anne Marie Dimillo, Christine Beland, Jennifer Payne, Pamela Sheehan, Christine Beaudoin