Cervical Collar Clearance: Using EBP to Decrease Pressure Injuries

Purpose: The purpose of this evidence-based practice (EBP) project was to decrease medical device pressure injury (MDPI) related to Cervical Collar (C-collar) clearance in adult blunt trauma patients. PICO: In the adult obtunded blunt trauma patient, should a c-collar be cleared with a negative CT, compared to a negative CT with adjunct imaging to reduce adverse events such as MDRPI? Background: Our unit observed an incidence in C-collar MDRPI of 3 in 2019 and 3 in 2020 based on the date of the survey. C-collar clearance in the blunt trauma patient is a crucial step to avoid MDRPI. There are two validated and widely accepted guidelines for the stable and alert trauma patient, NEXUS and Canadian C-spine rule. Many trauma critical care patients fail to meet these criteria and therefore may have prolonged periods of C-collar use and increased risk for MDRPI. Therefore, our goal was to evaluate current evidence related to C-collar clearance. Methods: A literature search was conducted to identify best practices of C-Collar clearance in the obtunded adult blunt trauma patient. Databases searched include Pubmed, Embase, and CINAHL. The search strategy included “Adult” AND “Blunt Trauma” AND Cervical Collar” AND “Clearance” within the last 5 years. English Language only. 20 articles resulted and 8 were included for content and reliability to the clinical question and evaluated based on Johns Hopkins Nursing EBP guidelines. Results/Findings: A review of the findings was presented to the trauma performance improvement and patient safety (PIPS) committee. Based on current evidence, the Trauma PIPS committee revised the existing guideline to include C-Collar clearance 24 hours or less based on initial CT scan and clinical findings. Since implementation, our unit observed zero C-collar MDRPIs with a significant reduction in MRIs ordered for purpose of C-collar clearance. Which resulted in a significant reduction in cost, increased safety, and decreased risk of pressure injury development. Conclusions and Implications for Practice: Translation of EBP to the bedside is the most critical step in promoting positive patient outcomes. Protocols and guidelines should be updated regularly with the most up-to-date evidence-based practices. In this EBP project, a modification to a practice guideline led to a decrease in MDRPIs. References: Badhiwala, J. H., Lai, C. K., Alhazzani, W., Farrokhyar, F., Nassiri, F., Meade, M., Mansouri, A., Sne, N., Aref, M., Murty, N., Witiw, C., Singh, S., Yarascavitch, B., Reddy, K., & Almenawer, S. A. (2015). Cervical spine clearance in obtunded patients after blunt traumatic injury. Annals of Internal Medicine 162, 429-437. http://doi.org/10.7326/M14-2351 Bush, L., Brookshire, R., Roche, B., Johnson, A., Cole, F., Karmy-Jones, R., Long, W., & Martin, M. (2016). Evaluation of cervical spine clearance by computed tomographic scan alone in intoxicated patients with blunt trauma. JAMA Surgery 151(9), 807-813. http://doi.org/10.1001/jamasurg.2016.1248 Duane, T. M., Young, A. J., Vanguri, P., Wolfe, L. G., Katzen, J., Han, J., Mayglothling, J., Whelan, J. F., Aboutanos, M. B., Ivatury, R. R., and Malhotra, A. K. (2016). Defining the cervical spine clearance algorithm: A single-institution prospective study of more than 9,000 patients. The Journal of Trauma and Acute Care Surgery 81(3), 541-547. http://doi.org/10.1097/TA.0000000000001151 Inaba, K., Byerly, S., Bush, L. D., Martin, M. J., Matin, D. T., Peck, K. A., Barmpars, G., Bradley, M. J., Hazelton, J. P., Coimbra, R., Choudry, A. J., Brown, C. V., Ball, C. G., Cherry-Bukowiec, J. R., Burlew, C. C., Joseph, B., Dunn, J., Minshall, C. T., Carrick, M. M., Berg, G. M., ... & the WTA C-Spine Study Group. (2016). Cervical spinal clearance: A prospective Western Trauma Association multi-institutional trial. The Journal of Trauma and Acute Care Surgery 81(6), 1122-1130. http://doi.org/10.1097/TA.0000000000001194 Martin, M. J., Bush, L. D., Inaba, K., Byerly, S., Schreiber, M., Peck, K. A., Barmparas, G., Menaker, J., Hazelton, J. P., Coimbra, R., Zielinski, M. D., Brown, C. V., Ball, C. G., Cherry-Bukowiec, J. R., Burlew, C. C., Dunn, J., Minshall, C. T., Carrick, M. M., Berg, G. M., Demetriades, D., ... & the WTA C-Spine Study Group. Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association multi-institutional trial and survey. The Journal of Trauma and Acute Care Surg 83(6), 1032-1040. http://doi.org/10.1097/TA.0000000000001650 McCallum, J., McLaughlin, P., Hameed, M., & Kanji, H.D. (2018). 64-Slice CT compared to MRI to clear cervical spine injury in high-risk GCS < 14 blunt trauma patients admitted to the ICU. Trauma 20(1), 38-45. http://doi.org/10.1177/1460408617698512 Patel, M. B., Humble, S. S., Cullinane, D. C., Day, M. A., Jawa, R. S., Devin, C. J., Delozier, M. S., Smith, L. M., Smith, M. A., Capella, J. M., Long, A. M., Cheng, J. S., Leath, T. C., Falck-Ytter, Y., Haut, E. R., & Como, J. J. (2015). Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. The Journal of Trauma and Acute Care Surgery 78(2), 430-41. http://doi.org/10.1097/TA.0000000000000503 Viega, J. R., & Mitchell, K. (2019). Cervical spine clearance in the adult obtunded blunt trauma patient: A systematic review. Intensive and Critical Care Nursing 51, 57-63. http://doi.org/10.1016/j.iccn.2018.11.001

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