SPINAL MOTION RESTRICTION:AN EDUCATIONAL AND IMPLEMENTATION PROGRAM TO REDEFINE PREHOSPITAL SPINAL ASSESSMENT AND CARE James F. Morrissey, EMT P, MA, Elsie R. Kusel, EMT-P, Karl A. Sporer, MD, FACEP, FACP ABSTRACT have experienced a mechanism of injury forceful enough to possibly damage the spinal column. Emer- Introduction. Prehospital spine immobilization has long gency medical services (EMS) textbooks commonly been applied to victims of trauma in the United States and up to 5 million patients per year are immobilized mostly with a stress that any significant mechanism of injury requires cervical collar and a backboard. Objective. The training of full body immobilization, which is typically defined as paramedics and emergency medical technicians on the prin- the patient being secured to a backboard and a cervical 1,2 cipals of spine motion restriction (SMR) will decrease the use collar being applied. It is estimated that up to 5 mil- of backboards. Methods. The training for SMR emphasized lion patients receive spine immobilization each year in the need to immobilize those patients with a significant po- the United States, most of who have no evidence of tential for an unstable cervical spine fracture and to use alter- spine injuries.3,4 native methods of maintaining spine precautions for those The rate of cervical spine fractures among severely with lower risk. The training addressed the potential com- traumatized patients is 2–5% and the rate of unsta- plications of the use of the unpadded backboard and edu- ble cervical fracture is 1–2%.5−7 Among patients with cation was provided about the mechanics of spine injuries. lesser mechanisms, such as a motor vehicle crash with- Emergency medical services (EMS} personnel were taught out multisystem trauma or a fall from standing and as- to differentiate between the critical multisystem trauma pa- 3,8−11 tients from the more common moderate, low kinetic energy sault, the cervical fracture rate (1.2–3.3%) and the trauma patients. A comprehensive education and outreach cervical spine cord injury rate (0.4–0.7%) are substan- 12,13 program that included all of the EMS providers (fire and tially lower. private), hospitals, and EMS educational institutions was Recent research among patients with penetrating developed. Results. Within 4 months of the policy imple- trauma demonstrated a doubling of mortality among mentation, prehospital care practitioners reduced the use those who received spine immobilization.7,14−20 Are- of the backboard by 58%. This was accomplished by a de- cent systematic review of this literature pointed out the crease in the number of patients considered for SMR with relatively rare appearance of patients with an unstable For personal use only. low kinetic energy and the use of other methods, such as spine fracture and no neurologic deficits.21 They con- the cervical collar only. Conclusion. The implementation of cluded that there are no data to support routine spine a SMR training program significantly decreases the use of backboards and allows alternative methods of maintaining immobilization in patients with penetrating injury to spine precautions. Keywords: Emergency Medical Services; the neck, head, or torso. humans; spinal injuries/therapy; transportation of patients; There are clinical complications with cervical spine cervical vertebrae/injuries; emergency medical services/ immobilization as it is currently practiced. Pain is al- − methods; emergency medical technicians; immobilization/ most universal with the use of a backboard.22 25 There methods; spinal motion restriction are other potential problems, such as mild respiratory 26 27,28 PREHOSPITAL EMERGENCY CARE 2014;18:429–432 compromise , increased intracranial pressure, or the rare cases of distracting an unstable fracture.29,30 A Prehosp Emerg Care Downloaded from informahealthcare.com by 166.107.108.236 on 07/29/14 recent pediatric study demonstrated that immobilized INTRODUCTION children with a similar level of trauma had higher rates of pain and were more likely to undergo radiographic Prehospital spine immobilization has long been ap- evaluation and admission to the hospital.31,32 Are- plied to victims of blunt or penetrating trauma who cent position statement by NAEMSP and the American College of Surgeons on the use of backboards states that they are largely unproven and their use should be Received July 18, 2013 from the Alameda County EMS Agency, San judicious, so that the potential benefits outweigh the 33 Leandro, California. Revision received November 5, 2013; accepted risks. for publication November 5, 2013. The Alameda County Emergency Medical Services The authors report no conflicts of interest. The authors alone are re- Agency developed a unique training program to sponsible for the content and writing of the paper. continue to immobilize those patients with a high risk of an unstable cervical spine injury, and to avoid Address correspondence to Karl A. Sporer, MD, Alameda County the use of the backboard in our patients with lesser EMS Agency, 1000 San Leandro Blvd, Suite 200, San Leandro, CA mechanisms of injury. Our hypothesis is that the 94577, USA. e-mail: [email protected] implementation of this program will result in fewer doi: 10.3109/10903127.2013.869643 patients receiving immobilization with backboards. 429 430 PREHOSPITAL EMERGENCY CARE JULY/SEPTEMBER 2014 VOLUME 18 / NUMBER 3 METHODS 3) Hands-on practice of spine injury assessment and SMR (including vacuum mattress use and alter- Alameda County is an urban/suburban/rural county native methods maintaining spine precautions). in Northern California that is 737 square miles with a 4) Post-test and evaluation. population of 1.5 million. Our paramedic-staffed first response engines and paramedic/EMT-staffed trans- A similar mandatory training was also delivered to port ambulances respond to 125,000 EMS calls each new accreditation candidates at our orientation. Ref- year and transport 90,000 patients each year. This erence articles and research papers, as well as spine county was one of the early adopters of the State of injury and SMR policies from other areas are made Maine and later NEXUS criteria to allow paramedics available electronically (www.acphd.org/emtpara/ to omit spine immobilization on selected trauma edutrain/spineinjuryresources.aspx). More condensed 11,12,34−39 patients. The past practice was to place minor versions of training (brief lecture with demonstra- and major trauma patients who could not be cleared tion of techniques and no practicum) were presented by the NEXUS criteria on an unpadded hardboard and to various stakeholders, including receiving hospi- cervical collar. The UCSF Committee on Human Re- tals, trauma audit committee, and local EMS ed- search decided that approval was not required for this ucational institutions. The lesson plan emphasized study because the data was extracted from a perfor- physically assessing patients prior to performing pro- mance improvement data set with no identifiable per- cedures, avoiding placing patients with suspected sonal information. spine injury directly on a backboard and supporting The initial training of over 800 paramedics (approx- alternative methods of maintaining spine precautions imately 90% of practicing paramedics) for modifying with other methods that are more comfortable and our spine injury assessment and treatment procedures with fewer complications. was delivered to EMS providers as a component of The curriculum differentiated the critical multisys- the County’s mandatory annual policy update training tem, multitrauma victim from more common moder- (see Table 1). This training consisted of ate, low kinetic energy trauma correlating that infor- mation to stable vs. potentially unstable spinal column 1) Video lecture – 11 minutes of the 41-minute policy injuries. The concept that stable spine injuries need update video was devoted to spine injury assess- very little in terms of field stabilization was empha- ment and treatment. sized. Many patients require only a cervical collar and 2) “Train the trainer” session to the leaders of to be secured just like any other nontrauma patient. We the County’s various agencies’ clinical educa- For personal use only. also demonstrated alternative methods of maintaining tion departments. Discussion period of varied spine precautions, including the vacuum mattress that duration for providers to address questions and allows patients to be comfortably secured in a myriad concerns regarding pathophysiology, assessment, of positions such a sitting, reclined, or on their side. We spine motion restriction (SMR) techniques, and li- stressed that any SMR method should conform to the ability. patient, not the other way around. Our electronic patient care records were queried for the number of patients who received cervical spine immobilization from April 2012 through April 2013. TABLE 1. Spinal motion restriction (SMR) teaching points During the period of April 1 through November 31, Prehosp Emerg Care Downloaded from informahealthcare.com by 166.107.108.236 on 07/29/14 • No longer use mechanism of injury as the sole criteria for 2012, the only option was no immobilization or full spinal immobilization immobilization with a hard collar and a backboard. • Education about the mechanics of spinal injuries and stable Specific data elements on cervical spine management versus unstable cervical column injuries in the electronic patient care record were expanded to • Differentiated the critical multisystem, multitrauma victim from