Many of us in the nursing profession often wonder if we really make a difference in our patients' care and outcomes. We have found at Gwinnett Medical Center emergency department (ED) that we really do! A recent situation involving a friend of mine reminded me how a relatively simple process change can have a positive effect on a patient outcome.
D.B. was a restrained driver involved in a minor motor vehicle crash. Upon the arrival of paramedics, a cervical collar was placed on him, and D.B was secured onto a backboard for transport to the local ED. Following the department's protocol, D.B. was triaged to a treatment area where he remained immobilized on the backboard while awaiting examination by the ED physician. The wait was approximately 4 hours-a long time for someone to be immobilized on a backboard. During this time, D.B. became angry and frustrated. This ultimately led to a very negative ED experience. When D.B. was telling me about his experience, he verbalized that he felt his experience would have been much more positive had he been removed from the backboard more expediently.
Many EDs struggle with large patient volumes and prolonged wait times. My discussions with colleagues at other EDs proved that many facilities continue to struggle with the issue of prolonged waits for patients on backboards. Fortunately, in our ED, we have developed a protocol that allows us to avoid the problem that D.B. experienced.
In 2001, the trauma clinical nurse specialist/program manager and members of the ED and intensive care unit nursing staff identified the problems of patient discomfort and skin breakdown related to the prolonged period of time that patients were lying on backboards. Knowing that backboards were designed for transport only and not prolonged hospital usage, this group set out to change the policy of patients having to be evaluated by a physician before backboard removal.1
The first step toward improving the process was to collect data and perform a literature search. Our 2-week data collection period validated our beliefs. Patients averaged 6 to 12 hours lying on backboards waiting for physician evaluation and radiological workup. A literature search resulted in minimal information. Discussions with colleagues in surrounding EDs proved that policies and practices related to backboard removal varied greatly.
Armed with our data, we then collaborated with our emergency medicine physicians, trauma surgeons, and neurosurgeons to develop a protocol that would allow ED nurses to remove certain patients from backboards before the ED physician's evaluation. A data collection form (Figure 1) was developed, staff was educated on the pilot program, and the "Backboard Project" was soon underway in the adult ED! The project allowed for adult patients who demonstrated no evidence of agitation, combativeness, or other behaviors that would cause the registered nurse to think the patient would be unable to maintain spinal precautions on the ED stretcher to be removed from the backboard immediately upon arrival to the ED.
Three months of data showed positive results (Table 1). Average backboard time for patients meeting the criteria for the study project decreased from several hours to 8 to 14 minutes when nursing staff followed the protocol. No skin breakdown was noted, and although not formally collected, patients related positive comments about not having to lie on boards. There were also no negative neurological sequelae experienced by patients removed from backboards before physician's evaluation.
Results of the pilot project were taken to the ED Process Improvement Committee, Department of Emergency Medicine Committee, and Trauma Committee. Each committee approved the development of a policy directed toward expeditious removal of backboards.
It has now been more than 3 years and the policy continues to be a success. Periodic data collection shows that most patients meeting the criteria are removed from backboards almost immediately upon arrival to the ED. Our biggest hurdle continues to be educating staff, not only ED nursing staff but also new ED physicians, radiology staff, and transport personnel. Without the backboard as a visual cue for staff to remember to maintain spinal precautions, we have to work harder to communicate to each other that these patients still have to have spinal precautions maintained until medical and radiological evaluations are completed.
Hearing stories from patients, like the one described in the beginning of this article, makes us realize that nurses can and do make a difference in patient outcomes.
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