Backboard time for patients receiving spinal immobilization by emergency medical services

Article (PDF Available)inInternational Journal of Emergency Medicine 6(1):17 · June 2013with67 Reads
DOI: 10.1186/1865-1380-6-17 · Source: PubMed
Abstract
Use of backboards as part of routine trauma care has recently come into question because of to the lack of data to support their effectiveness. Multiple authors have noted the potential harm associated with backboard use, including iatrogenic pain, skin ulceration, increased use of radiographic studies, aspiration and respiratory compromise. An observational study was performed at a level 1 academic trauma center to determine the total and interval backboard times for patients arriving via emergency medical services (EMS). Patients were directly observed. Transport time was recorded as an estimate of initiation of backboard use; arrival time, nurse report time and time of removal from the backboard were all recorded. National Emergency Department Overcrowding Study (NEDOCS) score, Emergency Severity Index (ESI) and demographic information were recorded for each patient encounter. Forty-six patients were followed. The mean total backboard time was 54 min (SD +/-65). The mean EMS interval was 33 min (SD +/-64), and the mean ED interval was 21 min (SD +/-15). The ED backboard interval trended inversely to ESI (1 = 5 min, 2 = 10 min, 3 = 25 min, 4 = 26 min, 5 = 32 min). Patients had a mean total backboard time of around an hour. The mean EMS interval was greater than the mean ED interval. Further study with a larger sample directed to establishing associated factors and to target possible reduction strategies is warranted.
BR I E F RE S E A R C H R E P O R T Open Access
Backboard time for patients receiving spinal
immobilization by emergency medical services
Derek R Cooney
1*
, Harry Wallus
1
, Michael Asaly
2
and Susan Wojcik
1
Abstract
Background: Use of backboards as part of routine trauma care has recently come into question because of
the lack of data to support their effectiveness. Multiple authors have noted the potential harm associated
with backboard use, including iatrogenic pain, skin ulceration, increased use of radiographic studies,
aspiration and respiratory compromise. An observational study was performed at a level 1 academic trauma
center to determine the total and interval backboard times for patients arriving via emergency medical
services (EMS).
Finding s: Patients were directly observed. Transport time was recorded as an estimate of initiation of
backboard use; arrival time, nurse report time and time of removal from the backboard were all recorded.
National Emergency Department Overcrowdin g Study (NEDOCS) score, Emergency Severity Index (ESI) and
demographic information were recorded for each patient encounter. Forty-six patients were followed. The
mean total backboard time was 54 min (SD ±65). The mean EMS interval was 33 min (SD ±64), and the mean
ED interval was 21 min (SD ±15). The ED backboard interval trended inversely to ESI (1 = 5 min, 2 = 10 min,
3=25min,4=26min,5=32min).
Conclusion: Patients had a mean total backboard time of around an hour. The mean EMS interval was greater
than the mean ED interval. Further study with a larger samp le directed to establishing associated factors and
to target possible reduction stra tegies is warranted.
Keywords: Backboard, Delay, EMS, ESI score, Immobilization, NEDOCS, Prehospital, Spinal, Spine board, Triage
Background
Use of long spine boards, also known as backboards, for
spinal immobilization as part of routine trauma care has
recently come under increased scrutiny, and early re-
moval from the board is considered best practice [1]. In
addition, multiple authors have brought the utility of
backboard use into question because of a lack of data to
support their effectiveness in preventing secondary in-
jury and the potential harm associated with backboard
use, including iatrogenic pain, skin ulceration, increased
use of radiographs, aspiration and respiratory comprom-
ise [2-7]. These potential risks prompted initiation of a
pilot quality assurance observational study to determine
the total and interval backboard times of patients arriv-
ing via emergency medical services (EMS) to this level 1
academic trauma center.
Findings
Methods
A convenience sample of patients arriving via EMS in
spinal immobilization, utilizing a backboard, was in-
cluded in the study. Trained research associates directly
observed patients as they arrived and followed them
until they were removed from the backboard. Transport
time from EMS documentation was recorded as an esti-
mate of initiation of backboard use. Times of directly
observed e vents, including arrival time, nurse report
time and time of removal of the patient from the back-
board, were all recorded. At the time of arrival to the
ED, research associates also recorded the current Na-
tional Emergency Department Overcrowding Study
(NEDOCS) score for each patient. The Emergency
* Correspondence: cooneyd@upstate.edu
1
Department of Emergency Medicine, SUNY Upstate Medical University, 550
East Genesee / EMSTAT Center, Syracuse, NY 13202, USA
Full list of author information is available at the end of the article
© 2013 Cooney et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly cited.
Cooney et al. International Journal of Emergency Medicine 2013, 6:17
http://www.intjem.com/content/6/1/17
Severity Index (ESI), determined by the nurse, was also
added to the data set. Demographic information, includ-
ing age, race and sex, was also recorded. Data were en-
tered into SPSS® Statistics 19 (IBM®) and analyzed to
determine the mean total backboard time, as well as in-
tervals for backboard time associated with EMS trans-
port and the time spent on the backboard in the ED all
reported in minutes (min). Data were also analyzed to
evaluate for the presence of an association between the
NEDOCS score and backboard times. The varia bles of
age and E SI level were also analyzed for associations
with backboard times. This manuscript reports the re-
sults of quality assurance investigation and was reviewed
by the IRB Chief Compliance Officer in reference to the
OHRP guidelines. No reference number was assigned as
this was considered QA.
Results
Forty-six patients were followed and times recorded a s
part of the convenience sample. All data for each patient
were complete prior to analy sis with SPSS® Statistics 19
(IBM®). The mean total backboard time was 54 min
(SD ±65) with a minimum of 11 min and a maximum
of 7 h 49 min (in a patient who stayed on the backboard at
an outside hospital and was transferred). The mean EMS
backboard time interval was 33 min (SD ±64), and the
mean ED backboard ti me interval was 21 min (SD ±15) as
summarized in Table 1. Patients varied in age from 9 to
greater th an 89 years old and were 37% female and 63%
male. NEDOCS scores at the time of patient arrival ranged
from 36 (busy) to 200 (dangerously overcrowded). The ESI
level of patients was predominantly 3 (69.6%), with
only two each at levels 4 5 (less emergent) and five
each at lev els 12 (very emergent). There was no sta-
tistically significant diff erence in total time when com-
pared by NEDOCS score g rouping (0 100, 1 0114 0,
141180 , 181), age group (pediatric = 0 to17 years
old and adult = 18 to 89 years old) and ESI level.
However, the ED backboard interval did show mean
increases in time with decreasing severity of triage level
by ESI (1 = 5 min, 2 = 10 min, 3 = 25 min, 4 = 26 min,
5 = 32 min) with a statistically significant difference be-
tween patients triaged as ESI level 1 and 3 (p =0.035).
Study limitations
This represents a small pilot observational quality assur-
ance study. The small sample size in this study limits
data analysis. A larger sample size study may reveal asso-
ciations with the NEDOCS score and ESI, as well as
other factors relating to delays in removing patient s
from backboards in the ED.
Discussion
In light of the potential harm caused by the use of back-
boards for immobilization, every effort should be made
to ensure that the time is minimized [1]. A study on
backboard use by Lerner et al. showed that the mean
total ED backboard time was as high as 165.3 min (SD
±49.7) [ 8]. Other studies have shown successful use of
prehosptial algorithms designed to allow EMS providers
to avoid spinal immobilization in patients with little to
no risk of spinal injury [9-13]. More study in this area is
needed to determine causes of delay in removal of pa-
tients from the backboard after EMS arrival to the
hospital.
Conclusion
Patients presenting via EMS to this level 1 academic
trauma center had a mean total backboard time of nearly
an hour. Although the mean EMS interval was greater
than the mean ED inte rval, the ED interval was still sig-
nificant, with a mean of greater than 20 min. Patients
perceived to be in lesser need of emergency care may
have had a longer wait until removal from the backboard
than those with an obvious need for immediate atten-
tion. Further study is needed to elucidate factors associ-
ated with delays and to evaluate strategies to reduce
total backboard time.
Abbreviations
ED: Emergency department; EMS: Emergency medicinal services;
ESI: Emergency severity index; NEDOCS: National emergency department
overcrowding study.
Competing interests
The authors declare that they have no competing interests. No funds were
received in the support of this study.
Authors contributions
DRC designed the study and, along with HW, reviewed the results and
prepared the manuscript. MA assisted in data collection and data entry. SW
provided design support, statistical analysis and editorial support services to
the project. All authors read and approved the final manuscript.
Authors information
DRC is an Associate Professor of Emergency Medicine and the Program
Director for the EMS Medicine Fellowship. HW is a Clinical Instructor of
Emergency Medicine and was a Fellow in EMS Medicine at the time of study
completion. MA was a medical student at the time of the study. SW is an
Associate Professor (PhD) and a member of the research faculty.
Author details
1
Department of Emergency Medicine, SUNY Upstate Medical University, 550
East Genesee / EMSTAT Center, Syracuse, NY 13202, USA.
2
SUNY Upstate
Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
Received: 6 February 2013 Accepted: 1 June 2013
Published: 20 June 2013
Table 1 Backboard time with breakdown
Mean SD
Total 54 min ±65
EMS interval 33 min ±64
Hospital interval 21 min ±15
Cooney et al. International Journal of Emergency Medicine 2013, 6:17 Page 2 of 3
http://www.intjem.com/content/6/1/17
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doi:10.1186/1865-1380-6-17
Cite this article as: Cooney et al. : Backboard time for patients receiving
spinal immobilization by emergency medical services. International
Journal of Emergency Medicine 2013 6:17.
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    • "In this study we therefore looked at anaesthetized patients as a proxy for these patient categories. The average duration of the surgical procedure was about one hour, which is in practice equal to the average time a trauma patient is immobilized on a spineboard [2,3].3. Example of clearly defined redness on the sacrum after lying on the rigid spineboard during surgery. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Immobilization of the spine of patients with trauma at risk of spinal damage is usually performed using a rigid long spineboard or vacuum mattress, both during prehospital and in-hospital care. However, disadvantages of these immobilization devices in terms of discomfort and tissue-interface pressures have guided the development of soft-layered long spineboards. We compared tissue-interface pressures between awake and anaesthetized (unconscious) patients during immobilization on a rigid spineboard and a soft-layered long spineboard. Methods: In this comparative study, 30 anaesthetized patients were randomized to immobilization on either the rigid spineboard or the soft-layered spineboard for the duration of their elective surgery. Tissue-interface pressures measured using an Xsensor pressure-mapping device were compared with those of 30 healthy volunteers who were immobilized sequentially on the rigid spineboard and the soft-layered spineboard. Redness of the sacrum was also recorded for the anaesthetized patients immediately after the surgery. Results: For both anaesthetized patients and awake volunteers, tissue-interface pressures were significantly lower on the soft-layered spineboard than on the rigid spineboard, both at start and after 15min. On the soft-layered spineboard, tissue interface pressure and peak pressure index (PPI) for the sacrum were significantly lower for anaesthetized patients than for awake volunteers. Peak pressures and PPI on the rigid spineboard were equal for both groups. Tissue-interface pressures did not change significantly over time. Redness of the sacrum was significantly more pronounced on the rigid spineboard than on the soft-layered spineboard. Conclusions: This prospective randomized controlled trial shows that using a soft-layered spineboard compared to a rigid spineboard for spinal immobilization resulted in lower tissue-interface pressures in both awake volunteers and anaesthetized patients. Moreover, tissue-interface pressures on the soft-layered spineboard were lower in anaesthetized patients than in awake volunteers. These findings show the importance of using a soft-layered spineboard to reduce tissue-interface pressure, especially for patients who cannot relieve pressure themselves by changing position.
    Full-text · Article · Nov 2014
  • Article · Apr 2014
  • [Show abstract] [Hide abstract] ABSTRACT: Aim: To assess the effect of trauma backboards on the radiation dose at computed tomography (CT) when using automatic tube current modulation (ATCM). Materials and methods: An anthropomorphic phantom was scanned with two commercially available CT systems (GE LightSpeed16 Pro and Siemens Definition AS+) without and with backboards. Tube current-time product (mAs), and CTDIvol (mGy) were recorded for each examination. Thermoluminescent dosimeters were used to measure skin entrance dose in the pelvis and breast. Statistical significance was determined using a two-sample t-test. In addition, an institutional review board-approved retrospective image review was performed to quantify the frequency of backboard use during CT in the emergency department. Results: There was a statistically significant increase in maximum tube current-time product (p<0.05) and CTDIvol (p<0.05) with the presence of a backboard; tube current-time product increased up to 31% and CTDIvol increased up to 27%. There was a significant increase in skin entrance dose in the anterior and posterior pelvis (p<0.05) with the presence of a backboard; skin entrance dose increased up to 25% in the anterior pelvis. Skin entrance dose to the breast increased with a backboard, although this was not statistically significant. The frequency of backboard use during CT markedly decreased (from 77% to 3%) after instituting a multidisciplinary policy to promptly remove patients from backboards upon arrival to the emergency department after a primary clinical survey. Conclusions: Using backboards during CT with ATCM can significantly increase the radiation dose. Although the decision to maintain patients on backboards is multifactorial, attempts should be made to minimise backboard use during CT when possible.
    Article · Feb 2016