1. Trauma Services Backboard Removal Project

2. First off, we need a volunteer please……

3. What is a backboard? Backboards are frequently used by Pre- hospital to immobilize or extricate patients. They are hard, non- flexible devices Used to keep patients immobile when there is concern for spinal injury.

4. Assess-Are back boards necessary? Immediate Concerns with inability to properly assess the patients neck and back Skin break down, which can happen in a matter of minutes.

5. Assess-How does this effect Long term patient care? “Skin breakdown and the development of pressure ulcers in the Intensive Care Unit (ICU) effect 33% to 56% of critically ill patients and can result in a longer length of stay (LOS), morbidity, and increases costs to health care organizations.”

6. Why did we look at this process? CASE REVIEW: Jane was the unrestrained passenger involved in a single auto rollover crash. She was ejected and came to rest under the guard rail when the vehicle rolled over a single time. (At highway speed) 1320 - She was extricated and placed in full spinal immobilization by EMS. 1343 - Arrival to the ED on the back board and she was noted to have no movement of her lower extremities on exam. She was noted to be critically injured.

7. Her ED Course: full trauma resuscitation which included Full body x-rays RSI (Rapid Sequence Induction and Intubation) Unsuccessful IV attempts IO placement Central line placement Administration of blood products Her injuries included bilateral rib fractures with a right flail segment, bilateral hemothorax, T9-T10 spine fracture with neuro deficits, and an unstable pelvis fracture.

8. 1640 –Patient was transferred by helicopter to a Level I trauma center in full spinal immobilization. Emergency Department length of stay 2 hours 56 minutes. The patient had a complicated hospital stay at the receiving facility.

9. Synthesize the Process…. Review of literature for national trauma standards and best practice: Society of Trauma Nurses, EAST, ENA, and ATLS all provide evidence based information – standard is to have the patient off of the backboard < 20 minutes. Evaluate the process in the Emergency Department (ED) for the removal of patients from back boards. The information had to be assessed to know if there a problem or was the occurrence isolated. Trauma began to educate the staff regarding the need to document the removal of the patients from the backboard. Concurrent review of charts provided the opportunity for timely communication with the ED staff regarding documentation. The information was entered and tracked through the LUH trauma registry for 6 months.

10. N= 134 Collection period: January 1st – June 30, 2012 *134 charts were reviewed for length of time the patient remained on the backboard from ED arrival. * National trauma standard or goal is to remove the backboard < 20 minutes of patient arrival. 52% compliance with standard. Average time to removal - 34 minutes Minimum - on patient arrival- 0 minutes Maximum - 165 minutes

11. Design: How did we fix the problem? After the review of data from the trauma registry and literature, it was felt that we had an opportunity. The information was presented to the Emergency Department and Trauma Committee for review and discussion. It was felt that LUH should change in process from physician order for removal of backboard to nurses removing patients from the backboard on arrival to the ED. Policy drafted and approved by trauma committee. Education of the Emergency Department Physicians and staff. Ongoing concurrent follow-up and education.

12. N= 75 Collection period: October 1st - December 31, 2012 75 charts were reviewed for length of time the patient remained on the backboard from ED arrival * National trauma standard or goal is to remove the backboard < 20 minutes of patient arrival. 66% compliance with standard. Average time to removal - 22 minutes Minimum - on patient arrival - 0 min Maximum - 169 minutes Implement and Evaluate

13. N= 39 Collection period: January 1st - March 31, 2013 * 39 charts were reviewed for length of time the patient remained on the backboard from ED arrival. * National trauma standard or goal is to remove the backboard < 20 minutes of patient arrival. 82% compliance with standard. Average time to removal - 13 minutes Minimum - on patient arrival - 0 min Maximum - 65 minutes

14. Integrate and Maintain N= 55 Collection period: April 1st- June 30th, 2013 * 55 charts were reviewed for length of time the patient remained on the backboard from ED arrival. * National trauma standard or goal is to remove the backboard < 20 minutes of patient arrival. 96% compliance with standard. Average time to removal - 7.8 minutes Minimum - on patient arrival - 0 min Maximum - 62 minutes

16. What about Pre-Hospital? Decrease the use of Backboards in the Prehospital setting. June 1 st - change in transporting agencies protocols to decrease the use of backboards for transport.

17. N= 52 Collection period: July 1st- Sept 30th, 2013 * 52 charts were reviewed for length of time the patient remained on the backboard from ED arrival. * National trauma standard or goal is to remove the backboard < 20 minutes of patient arrival. 98% compliance with standard. Average time to removal - 7.2 minutes Minimum - on patient arrival - 0 min Maximum - 103 minutes

18. Why does this matter to me? If we can start reducing the chance of hospital acquired pressure ulcers as early as the Emergency Department our patients may: Have improved outcomes, and decreased length of stay Have increased patient satisfaction Have decreased chance of re-admission

19. References: STN: Society of Trauma Nurses EAST: Eastern Association for the Surgery of Trauma American College of Surgeons Committee on Trauma. Spine and Spinal Cord Trauma. Advance Trauma Life Support. 7 th ed. Chicago IL; American College of Surgeons: 2004:187 Centers for Medicare and Medicaid Services, “Hospital Acquired Conditions” dated May 23, 2012 available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HospitalAcqCond/downloads//HACFactsheet.pdf Annals of Emergency Medicine. Immobilization. 26:1 July, 1995