Background: A new selective preventive spinal immobilization (PSI) protocol was introduced in the Netherlands. This may have led to an increase in non-immobilized spinal fractures (NISFs) and consequently adverse patient outcomes. Aim: A pilot study was conducted to describe the adverse patient outcomes in NISF of the PSI protocol change and assess the feasibility of a larger effect study. Methods: Retrospective comparative cohort pilot study including records of trauma patients with a presumed spinal injury who were presented at the emergency department of a level 2 trauma center by the emergency medical service (EMS). The pre-period 2013-2014 (strict PSI protocol), was compared to the post-period 2017-2018 (selective PSI protocol). Primary outcomes were the percentage of records with a NISF who had an adverse patient outcome such as neurological injuries and mortality before and after the protocol change. Secondary outcomes were the sample size calculation for a larger study and the feasibility of data collection. Results: 1,147 records were included; 442 pre-period, and 705 post-period. The NISF-prevalence was 10% (95% CI 7-16, n = 19) and 8% (95% CI 6-11, n = 33), respectively. In both periods, no neurological injuries or mortality due to NISF were found, by which calculating a sample size is impossible. Data collection showed to be feasible. Conclusions: No neurological injuries or mortality due to NISF were found in a strict and a selective PSI protocol. Therefore, a larger study is discouraged. Future studies should focus on which patients really profit from PSI and which patients do not.
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In 2016, a selective preventive spinal immobilization protocol for emergency medical service (EMS) nurses was introduced in the Netherlands. This protocol leaves more room for autonomous decision-making in the pre-hospital phase regarding preventive spinal immobilization (PSI), compared to the previous strict protocol. In this study, we explored the experiences and perspectives of EMS nurses on decision making about PSI after the change from a strict to a selective PSI protocol. Methods: We used a qualitative design with semi structured face-to-face interviews. Thematic analysis was applied. The capability-opportunity-motivation behavior-model was used to interpret the experiences and perspectives. Results: Thirteen EMS nurses from three emergency medical services were interviewed. Respondents appreciated autonomous decision-making as there was more room for patient-centered informed decision-making. However, autonomous decision-making required optimized knowledge and skills and elicited the need to receive feedback on their decision not to apply PSI. When nurses anticipated resistance to selective PSI from receiving hospitals, they were doubtful to apply it. Conclusion: Nurses appreciate the increased autonomy in decision-making, encouraging them to focus on patient-centered care. Increased autonomy also places higher demands on knowledge and skills, calling for training and feedback. Anticipated resistance to receiving hospitals based on mutual protocol discrepancies could lead to PSI application by EMS nurses while not deemed necessary. Recommendations: To enhance PSI procedures, optimizing the knowledge and skills of EMS nurses that facilitate on-scene decision-making may be indicated. A learning loop for feedback between the EMS nurses and the involved hospitals may add to their professional performance. More efforts are needed to create support for the changed Emergency Medical Services strategy in PSI to prevent unnecessary PSI and practice variation.
MULTIFILE
Of all patients in a hospital environment, trauma patients may be particularly at risk for developing (device-related) pressure ulcers (PUs), because of their traumatic injuries, immobility, and exposure to immobilizing and medical devices. Studies on device-related PUs are scarce. With this study, the incidence and characteristics of PUs and the proportion of PUs that are related to devices in adult trauma patients with suspected spinal injury were described. From January–December 2013, 254 trauma patients were visited every 2 days for skin assessment. The overall incidence of PUs was 28⋅3% (n = 72/254 patients). The incidence of device-related PUs was 20⋅1% (n = 51), and 13% (n = 33) developed solely device-related PUs. We observed 145 PUs in total of which 60⋅7% were related to devices (88/145). Device-related PUs were detected 16 different locations on the front and back of the body. These results show that the incidence of PUs and the proportion of device-related PUs is very high in trauma patients
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