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Evaluation of the safety of C-spine clearance by paramedics: design and methodology.

Vaillancourt C, Charette M, Kasaboski A, Maloney J, Wells GA, Stiell IG - BMC Emerg Med (2011)

Bottom Line: Less than 1% of those patients have a c-spine fracture and even less (0.5%) have a spinal cord injury.Paramedics with this service participated in an earlier validation study of the Canadian C-Spine Rule.Once safety and potential impact are established, we intend to implement a multi-centre study to study actual impact.

View Article: PubMed Central - HTML - PubMed

Affiliation: Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital - Civic Campus, 1053 Carling Avenue, Room F-658, Ottawa, ON, K1Y 4E9, Canada. cvaillancourt@ohri.ca

ABSTRACT

Background: Canadian Emergency Medical Services annually transport 1.3 million patients with potential neck injuries to local emergency departments. Less than 1% of those patients have a c-spine fracture and even less (0.5%) have a spinal cord injury. Most injuries occur before the arrival of paramedics, not during transport to the hospital, yet most patients are transported in ambulances immobilized. They stay fully immobilized until a bed is available, or until physician assessment and/or X-rays are complete. The prolonged immobilization is often unnecessary and adds to the burden of already overtaxed emergency medical services systems and crowded emergency departments.

Methods/design: The goal of this study is to evaluate the safety and potential impact of an active strategy that allows paramedics to assess very low-risk trauma patients using a validated clinical decision rule, the Canadian C-Spine Rule, in order to determine the need for immobilization during transport to the emergency department.This cohort study will be conducted in Ottawa, Canada with one emergency medical service. Paramedics with this service participated in an earlier validation study of the Canadian C-Spine Rule. Three thousand consecutive, alert, stable adult trauma patients with a potential c-spine injury will be enrolled in the study and evaluated using the Canadian C-Spine Rule to determine the need for immobilization. The outcomes that will be assessed include measures of safety (numbers of missed fractures and serious adverse outcomes), measures of clinical impact (proportion of patients transported without immobilization, key time intervals) and performance of the Rule.

Discussion: Approximately 40% of all very low-risk trauma patients could be transported safely, without c-spine immobilization, if paramedics were empowered to make clinical decisions using the Canadian C-Spine Rule. This safety study is an essential step before allowing all paramedics across Canada to selectively immobilize trauma victims before transport. Once safety and potential impact are established, we intend to implement a multi-centre study to study actual impact.

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The Canadian C-Spine Rule. The Canadian C-Spine Rule for alert (Glasgow Coma Scale score 15) and stable trauma patients for whom cervical spine injury is a concern, including patients with either posterior neck pain with any blunt mechanism of injury or no neck pain but some visible injury above the clavicles. MVC, Motor vehicle crash.
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Figure 1: The Canadian C-Spine Rule. The Canadian C-Spine Rule for alert (Glasgow Coma Scale score 15) and stable trauma patients for whom cervical spine injury is a concern, including patients with either posterior neck pain with any blunt mechanism of injury or no neck pain but some visible injury above the clavicles. MVC, Motor vehicle crash.

Mentions: The results of phase I, the derivation of the CCR, were published in JAMA in October 2001 [75]. This prospective cohort study involving 8, 924 stable, alert adult trauma patients was conducted in 10 large Canadian community and teaching hospitals (1996-1999). The ED physicians evaluated each patient for 20 standardized clinical findings and recorded these on a data sheet prior to radiography. Where feasible, a second physician conducted an independent interobserver assessment. Those variables found to be both reliable (kappa > 0.6) and strongly associated with the outcome measure (p < .05) were combined using recursive partitioning statistical techniques. The final model was formulated into a clinician-friendly algorithm, the Canadian C-Spine Rule (Figure 1). The rule stratifies patients into high-, medium-, and low-risk groups and requires evaluation of active range of motion for those in the low-risk group. This rule was cross-validated on the derivation sample and was found to identify all 151 cases of clinically important cervical spine injuries with a sensitivity of 100% (95% CI 98-100). The rule also performed with a specificity of 42.5% and would have required radiography for only 58.2% of patients, a 23.9% relative reduction from the current ordering rate of 76.5%.


Evaluation of the safety of C-spine clearance by paramedics: design and methodology.

Vaillancourt C, Charette M, Kasaboski A, Maloney J, Wells GA, Stiell IG - BMC Emerg Med (2011)

The Canadian C-Spine Rule. The Canadian C-Spine Rule for alert (Glasgow Coma Scale score 15) and stable trauma patients for whom cervical spine injury is a concern, including patients with either posterior neck pain with any blunt mechanism of injury or no neck pain but some visible injury above the clavicles. MVC, Motor vehicle crash.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3040719&req=5

Figure 1: The Canadian C-Spine Rule. The Canadian C-Spine Rule for alert (Glasgow Coma Scale score 15) and stable trauma patients for whom cervical spine injury is a concern, including patients with either posterior neck pain with any blunt mechanism of injury or no neck pain but some visible injury above the clavicles. MVC, Motor vehicle crash.
Mentions: The results of phase I, the derivation of the CCR, were published in JAMA in October 2001 [75]. This prospective cohort study involving 8, 924 stable, alert adult trauma patients was conducted in 10 large Canadian community and teaching hospitals (1996-1999). The ED physicians evaluated each patient for 20 standardized clinical findings and recorded these on a data sheet prior to radiography. Where feasible, a second physician conducted an independent interobserver assessment. Those variables found to be both reliable (kappa > 0.6) and strongly associated with the outcome measure (p < .05) were combined using recursive partitioning statistical techniques. The final model was formulated into a clinician-friendly algorithm, the Canadian C-Spine Rule (Figure 1). The rule stratifies patients into high-, medium-, and low-risk groups and requires evaluation of active range of motion for those in the low-risk group. This rule was cross-validated on the derivation sample and was found to identify all 151 cases of clinically important cervical spine injuries with a sensitivity of 100% (95% CI 98-100). The rule also performed with a specificity of 42.5% and would have required radiography for only 58.2% of patients, a 23.9% relative reduction from the current ordering rate of 76.5%.

Bottom Line: Less than 1% of those patients have a c-spine fracture and even less (0.5%) have a spinal cord injury.Paramedics with this service participated in an earlier validation study of the Canadian C-Spine Rule.Once safety and potential impact are established, we intend to implement a multi-centre study to study actual impact.

View Article: PubMed Central - HTML - PubMed

Affiliation: Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital - Civic Campus, 1053 Carling Avenue, Room F-658, Ottawa, ON, K1Y 4E9, Canada. cvaillancourt@ohri.ca

ABSTRACT

Background: Canadian Emergency Medical Services annually transport 1.3 million patients with potential neck injuries to local emergency departments. Less than 1% of those patients have a c-spine fracture and even less (0.5%) have a spinal cord injury. Most injuries occur before the arrival of paramedics, not during transport to the hospital, yet most patients are transported in ambulances immobilized. They stay fully immobilized until a bed is available, or until physician assessment and/or X-rays are complete. The prolonged immobilization is often unnecessary and adds to the burden of already overtaxed emergency medical services systems and crowded emergency departments.

Methods/design: The goal of this study is to evaluate the safety and potential impact of an active strategy that allows paramedics to assess very low-risk trauma patients using a validated clinical decision rule, the Canadian C-Spine Rule, in order to determine the need for immobilization during transport to the emergency department.This cohort study will be conducted in Ottawa, Canada with one emergency medical service. Paramedics with this service participated in an earlier validation study of the Canadian C-Spine Rule. Three thousand consecutive, alert, stable adult trauma patients with a potential c-spine injury will be enrolled in the study and evaluated using the Canadian C-Spine Rule to determine the need for immobilization. The outcomes that will be assessed include measures of safety (numbers of missed fractures and serious adverse outcomes), measures of clinical impact (proportion of patients transported without immobilization, key time intervals) and performance of the Rule.

Discussion: Approximately 40% of all very low-risk trauma patients could be transported safely, without c-spine immobilization, if paramedics were empowered to make clinical decisions using the Canadian C-Spine Rule. This safety study is an essential step before allowing all paramedics across Canada to selectively immobilize trauma victims before transport. Once safety and potential impact are established, we intend to implement a multi-centre study to study actual impact.

Show MeSH
Related in: MedlinePlus