Caring - Dartmouth-Hitchcock

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Caring for patients with spinal injuries is a
high-risk endeavor. Injuries to the spine
can be difficult to rule out, and they
carry the risk of potentially devastating
neurological complications.
“That means we have to prove nothing
is wrong with patients before removing
devices that immobilize their neck
and spine,” says JoElla McCarragher,
RN, MSN, a clinical nurse specialist in
DHMC’s Level 1 Trauma Center.
Prolonged cervical immobilization
has its own set of complications. “For
starters, it’s uncomfortable for those
patients who are conscious,” says
McCarragher. “It affects how we can
position patients—if we can’t sit them up
in a natural position for breathing or
coughing, they may have to be intubated
longer which leaves them more at
risk for respiratory difficulties and potential
pneumonias.”
Other complications include delayed
mobilization and its associated risks. “The
longer they are bedridden, the higher the
chance they may develop complications
such as blood clots in their legs,” she
explains. “It also delays our ability to get
them into physical or occupational therapy,
and they become more susceptible
to skin breakdowns and pressure ulcers.”
Identifying Areas for Improvement
To better manage this dilemma, McCarragher
and her colleague Ingrid Mroz,
RN, MSN, a clinical nurse specialist in the
Intensive Care Unit (ICU), spearheaded a
collaborative effort—utilizing an evidence-based
nursing model—to improve
the care of patients with spinal injuries.
“We recognized early on that we
couldn’t just focus on the ICU—we
needed to look at the whole spectrum of
care for these patients,” says McCarragher.
“So we pulled together a diverse
group of clinicians from the emergency
department (ED), neuroscience, pediatrics,
the ICU, the surgical floor, the
trauma program, orthopedics, physical
therapy, and discharge planning.”
The multidisciplinary task force began
meeting monthly in February 2002.
Evidence-Based Practices Improve Trauma Care
The next steps for the task
force will be measuring
post-implementation
outcomes which will
include tracking the time
patients spend on
backboards, examining
the thoroughness of
orders, and measuring
the timeframe for
replacing extrication
collars with in-house
collars.
Several areas were targeted for improvement.
“One of our biggest challenges
was we had multiple services managing
patients,” she says. “This led to problems
like inconsistent precautions, prolonged
backboard time for patients, and care
issues associated with cervical collars.”
A Standardized Approach
To address the inconsistencies, the task
force developed a standardized order set
for spine injury management. “We
agreed that the orders should be written
the same way, whether the patient was in
general surgery, trauma, neurology, or
orthopedics,” McCarragher says. “We
implemented it in December 2002,
revised it after six months, and continue to
monitor it monthly—it’s been very helpful.”
In conjunction with the group’s efforts,
the ED initiated a project to reduce the
time some patients were spending immobilized
on backboards. “They developed
a policy and procedure that allows nurses
to make the assessments—the result is lowrisk
patients are now removed from backboards
more quickly.”
McCarragher also felt that an assessment
of cervical collars needed to be
done. “We looked at the literature and
had the two leading companies come in
and present their products,” she says.