Background
Each year, Canadian emergency departments (EDs) treat 185,000 adults who are alert, stable trauma victims and who are at risk for cervical spine injury. Only 0.9% of these patients have, however, suffered a cervical spine fracture or dislocation. Use of radiography is not efficient with more than 98% of cervical spine radiographs ordered in Canadian centres being negative for fracture or dislocation. In addition, these patients invariably are triaged to high acuity resuscitation rooms in the ED, where they remain fully immobilized on a backboard with a rigid collar and sandbags for many hours. This leads to considerable patient discomfort and unnecessary use of valuable time and space in our crowded EDs. Typically, cervical spine immobilization is removed only after complete physician assessment and radiography.

This proposal builds on previous our previous studies in which we developed a decision rule for physician c-spine evaluation (phase I, 1996-99, N=8,924), and prospectively validated this Canadian C-Spine Rule (phase II, 1999-2002, N=8,283). The Canadian C-Spine Rule is comprised of simple clinical variables (Figure 1) and was designed to allow physicians to be much more selective in ordering radiography and to decrease the period of immobilization (JAMA 2001). In the recently completed prospective validation (phase II), we confirmed the accuracy and reliability of the rule in 8,283 additional patients, when used by physicians.

Generally, ED nurses do not evaluate the c-spine of trauma patients and automatically triage all immobilized patients to the resuscitation room. We believe that nurses should be able to safely evaluate alert and stable patients. If they could "clear" the c-spine at the triage station, patients could be much more rapidly and efficiently managed in areas other than the resuscitation room. This study proposes to address this issue of nursing organization and standards of practice in Canadian EDs and to explore the role for expanding nurse decision making.

Objectives
The goal is to prospectively assess the potential impact of ED triage nurses' use of the Canadian C-Spine Rule in alert and stable trauma patients. Specific objectives are to: 1) develop an effective but efficient educational/training program for nurses; 2) embed the Canadian C-Spine Rule protocol in the process of routine ED triage care; 3) assess the accuracy of nurses' use of the Canadian C-Spine Rule, 4) determine the reliability of their interpretation, 5) determine the potential of the rule to reduce the duration of cervical spine immobilization, and 6) determine the potential efficiencies and benefits to patients of being evaluated earlier by triage nurses.

Methods
This prospective cohort study will be conducted in the emergency departments of three teaching and three community hospitals and will represent collaborative and interdisciplinary research among nurses and physicians. The study will enroll consecutive alert, stable adults with acute blunt trauma to the head and neck. In this validation study, patients will be managed according to standard clinical practice and not according to the decision rule in order to evaluate the safety of nurse assessment. Nurses will, however, fully assess each patient for high-risk factors, neck tenderness, and range of motion. First, ED triage nurses at the nine hospitals will be taught to use the Canadian C-Spine rule by means of a specific workplace educational/training package. Second, the nurses will assess and classify each eligible study patient, at the ambulance entrance, according to the Canadian C-Spine Rule and with mentoring from an experienced clinician. The nurses will then send the patients to the resuscitation room for standard physician management and radiography. A subset of patients will be examined independently by two nurses. Accuracy will be assessed by classification performance with 95% confidence intervals. Reliability will be assessed by the kappa coefficient. Potential impact will be evaluated by estimating the total period of immobilization that could be avoided by nurse assessment. The estimated sample size is 4,000 patients (including 60 "clinically important" cervical spine injury cases) to be enrolled over 3 years.

Importance
Triage nurses' use of the Canadian C-Spine Rule may lead to improved efficiencies and patient comfort when treating alert stable trauma patients. This study is an essential step extending the responsibility of effective triage of trauma patients to Canadian nurses. To our knowledge, nowhere in Canada do nurses evaluate patients for potential c-spine injury, a task that is exclusively the domain of physicians. Our previous studies have determined the safety and effectiveness of the rule when used by physicians but what remains unknown is safety and efficiency of patient care that would follow evaluation of the c-spine by ED triage nurses. We believe that use of the Canadian C-Spine Rule has the potential to improve the efficiency of patient flow in busy Canadian EDs and to increase the autonomy of the nursing profession in managing stable trauma patients.

• The Canadian C-Spine Rule
• Nursing NDF Form
• Performance Checklist
• Clinical Presentation Scenarios
• Links

OHRI members:

Cathy Clement, Manager
Pam Sheehan, Research Assistant
My-Linh Tran, Database Manager

Participating Sites:

Dr. Ian Stiell, Kathy Slattery, MJ Jacobsen – Civic Campus, TOH
Dr. Ian Stiell, Christine Beland, Christine Beaudoin – General Campus, TOH
Dr. Brian Devin, Dr. Chuck Su, Anne Elliott, Krista O'Donohue – Winchester District Memorial
Dr. Alan Drummond, Pat Corrigan, Sue McCaig, Martha Moore, Nancy Rattle – Perth Campus
Dr. Michael Horsey, Linda Bisonette, Pat Corrigan, Mary Ann Scollan – Smiths Falls Campus
Lori Lazette, Janice Heattie – Hawkesbury General Hospital