Portfolio Assignment: Spinal Immobilization Essay

Portfolio Assignment: Spinal Immobilization Essay
Introduction Spinal Immobilization
Nursing research is a systematic inquiry to generate evidence that is trustworthy, valid and useful in the development of evidence-based nursing practice (Polit & Beck, 2017). In the emergency department (ED), patients are regularly brought to the ED in full spinal immobilization which includes a C-collar, head blocks, and straps. Many times, these interventions can remain in place long enough to promote the development of a pressure injury, most commonly in the sacral area. Portfolio Assignment: Spinal Immobilization Essay. To change interventions and treatment practices, a thorough understanding of the issue, and the research related to spinal immobilization is imperative. Developing a question which seeks to understand the phenomenon, and guide changes towards evidence-based practice changes will set the framework for the study.
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The objective of this paper is to discuss the question “For trauma patients removed from a backboard within thirty minutes compared to current practice of over 2 hours, what percentage of patients develop pressure injuries over a three-month period?”, given insight to the literature review and examine the possibility of translating the evidence into a new clinical application and evidence-based nursing practice Portfolio Assignment: Spinal Immobilization Essay.
Portfolio Assignment: Spinal Immobilization
Emergency medicine is a specialty practice with collaborative approaches, from pre-hospital emergency services, through hospital inpatient admissions. From this perspective, each entity needs to be aware of what the others do. However, many times this is not the case. Patients may present to an emergency department, whether it is a trauma center or not, with pre-hospital treatments or interventions in progress. Many of these interventions are not used by the emergency room staff and do not have the training to manage them well. Spinal immobilization (SI) is done primarily in the prehospital setting and patients will be on a rigid backboard, a c-collar in place and the patient restrained in an immovable and uncomfortable position. These interventions are thought to prevent further spinal injury and facilitate removal and transport, but if not managed properly can create more problems than they solve. According to Oteir, Smith, Jennings, and Stoelwinder, (2014), SI has several disadvantages, including increased risk of respiratory compromise, back and neck pain, a risk of pressure sores, and raised intracranial pressure associated with cervical collar application Portfolio Assignment: Spinal Immobilization Essay. The use of extrication collars for extended periods can cause pressure injuries, nerve disorders and increase the potential for aspiration (Webber-Jones, Thomas, & Bordeaux, 2002). Spinal immobilization is also time-consuming and expensive. The significance for nursing is understanding the mechanisms of injury that SI can produce may alter their management of a patient in SI. By being proactive in advocating for the removal of the backboard within thirty minutes, and initiating pressure injury prevention strategies in the emergency department setting.
Formulating a PICOT Question
From changing established clinical practices to evidence-based practices, a thorough understanding of the practice, as it is currently, versus what new evidence tells us, is required. However, the effort to research the practice in question can be simplified by the creation of a question, which sets specific variables. The anatomy of a good clinical practice question includes the variables, population=P, intervention=I, comparison=C, outcome=O and timeframe=T (PICOT). A PICOT format will help facilitate a well-worded question (Polit & Beck, 2017). From the question of using spinal immobilization and accompanying interventions and the potential problems they create in trauma patients, many variables or questions arose. Five possible avenues for research, 1. For trauma patients, does the use of a soft spine board instead of a hard spine board, decrease the incidence of pressure injuries, in a six-month period? 2. For trauma patients, is c-collar placement necessary versus not necessary, for all fall patients over a six-month period? 3. For patients with a suspected hip fracture, does placing a patient on a rigid backboard versus scoop stretcher, create more pain over a one-year period? 4. For trauma patients, in a pre-hospital Stif-neck cervical immobilizer changed to a padded rigid c-collar in the emergency department versus no change, decrease the incidence of pressure injuries of the face, head or neck over a one-year period? 5. For trauma patients, does placing pads under the sacrum and heels, compared to no padding, reduce the incidence of pressure injuries over a one-year period? Portfolio Assignment: Spinal Immobilization Essay
According to Polit and Beck (2017), there are four considerations to remember when selecting a research problem. They are the problems significance, research ability, feasibility, and of course interest to the researcher. The feasibility of these questions, factors are time, money, ethical considerations, resource requirements, researcher experience and interest, study participants availability and the cooperation of others. When looking at these factors, all the questions have valid significance to emergency department clinical practices.
Preliminary PICOT
The PICOT that was generated for the preliminary question was “For trauma patients removed from a backboard within thirty minutes compared to the current practice of over 2 hours, what percentage of patients develop pressure injuries over a three-month period?”  The P-population variable is trauma patients, the I-intervention is removing the patient from backboard within 30 minutes, the C-comparison of current practice is not removing the patient from backboard for over 2 hours, O-outcome is the percentage of patients who develop pressure injuries, and T-timeframe is measured over a three-month period.
This question has the potential for several keywords and phrases that can be used for search databases. Possible keywords used: backboard, spinal immobilization, pressure injury, pressure sores, c-collar, cervical immobilization, trauma, spinal injury, head injury, log-roll, as well as using special characters with the keywords such as *, and Boolean operators AND, OR and NOT. Portfolio Assignment: Spinal Immobilization Essay.
Summary of the PICOT Question
The ability to develop a PICOT question to research a clinical practice requires practice, knowledge and researcher interest. Today the evidence-based practice is based on the search results of systematic reviews, random controlled trials, cohort studies, filtered and unfiltered databases among others. And then critiquing the results to develop a plan for change, if needed, based on the research results Portfolio Assignment: Spinal Immobilization Essay. From the levels of evidence pyramid, we learn that the pillar of evidence are systematic reviews. A systematic review provides readers with best available evidence that has been derived from primary research articles (Houde, 2009). As a researcher, a systematic review in a filtered database should be the first level one seeks to find evidence, then the unfiltered databases.
Spinal Immobilization a Literature Review
According to Polit and Beck (2017), nurses are required to conduct research and understand it, to base their practice on evidence-based practices (EBP). Research competency requires the ability to evaluate, assess and critique the current research studies. In the hierarchy of evidence, there are multiple facets of data, in varying degrees of complexity, reliability, validity, and credibility. At the top level are filtered sources such as systematic reviews, which are studies that have evaluated multiple studies over many years and compiled data that covers a topic, and critically appraised articles or individual topics (Polit & Beck, 2017). Unfiltered sources include Random Controlled Trials (RCT), cohort studies, and case-controlled studies, series, and reports. Then there are background information or expert opinion (Polit & Beck, 2017).
A nursing researcher must develop a plan to answer a clinical practice question well before undertaking a literature review. A solid answerable question must be formulated in the form of a PICOT query. Then a strategy for searching needs to be developed (Polit & Beck, 2017). A literature search was conducted to evaluate the amount of current information available about SI and PU development, and the conclusions are drawn from among the literature to either validate or dispute the hypothesis that PI is a result of long-term exposure to SI. Portfolio Assignment: Spinal Immobilization Essay.
Literature Search Strategy
From the PICOT question “For trauma patients removed from a backboard within thirty minutes compared to current practice of over 2 hours, what percentage of patients develop pressure injuries over a three-month period?” a search strategy was utilized by generating keywords, that when plugged into multiple databases, such as Cochrane Database of Systematic Reviews, CINAHL, MEDLINE and others, produced multiple documents. Then a checklist of criteria, such as year published, country of origin and language, was developed which narrowed the results. Once a list of appropriate articles was created, the task of evaluation could be completed.
Literature Review
The literature review, related to my PICOT question resulted in multiple documents that sought to answer the questionable use of spinal immobilization (SI) and the negative outcomes associated with it. My review includes a systematic review, a prospective cohort study, a case-controlled study, random controlled trial, and a prospective study. Portfolio Assignment: Spinal Immobilization Essay.
The first study evaluated: Pressure ulcer development in trauma patients with suspected spinal injury; the influence of risk factors present in the Emergency Department, by Ham, Schoonhoven, Schuurmans, and Leenen, (2017) is a prospective cohort study. They looked at associated risk factors that may contribute to pressure injuries (PI) in patients with a spinal cord injury. The researchers followed 254 trauma patients during January through December 2013, who presented in full SI to the emergency room. The findings showed the incidence of pressure ulcer development during the period of hospital stay was 28.3%, and the incidence of pressure ulcer development within 48h after admission was 13%. PI was directly related to age, Glasgow Coma Score (GCS) and Injury Severity Score (ISS) and hemoglobin levels Portfolio Assignment: Spinal Immobilization Essay. The researchers also did a comparative literature review and felt there were not enough studies to corroborate their findings.
The second study: Managing patients with cervical spine injury, by Montgomery, and Goode (2014) is a systematic review. The goal was to determine the best practice and possible complications for SI. Through analysis of the studies, many different opinions and conclusions about best practice were apparent. However, the common thread was the finding that the incidence of long-term immobilization creates a greater risk of PI. The researchers concluded that since a tremendous variation in spinal-immobilization technique was used, more research is required to determine best practice in this area.
The third study: The Effect of a Liner on the Dispersion of Sacral Interface Pressures During Spinal Immobilization, by Nemunaitis et al., (2015) is an experimental case-controlled study. With the focus to evaluate sacral interface pressure and sensing area during prolonged spinal immobilization, on a spine board, and the effect of a gel pressure dispersion liner (PDL), using healthy volunteers. Portfolio Assignment: Spinal Immobilization Essay. There were several limitations in the study. The sample size of 37 subjects is limited, and the data from the study involved healthy young subjects, which limits the conclusion when trying to extrapolate to injured, aged, or paralyzed patients.
The fourth study: Effects of unconsciousness during spinal immobilization on tissue-interface pressures: A randomized controlled trial comparing a standard rigid spine board with a newly developed soft-layered long spine board, by Hemmes, Brink, and Poeze, (2014). Patients about to undergo a surgical procedure were randomly assigned to one of two a spine board device. The control group was the awake volunteers. This study measured bony prominence pressures on awake versus anesthetized patients on either a rigid spine board or a new soft layered spine board. The conclusions were the soft layered spine board produced a significant decrease in patients in either state. The limitations again are due to the use of healthy individuals and a small sample size. Portfolio Assignment: Spinal Immobilization Essay.
The fifth study: Spinal immobilization in pre-hospital and emergency care: A systematic review of the literature, by Hood, and Considine, (2015). This systematic review evaluated the PICOT question: ‘‘In victims with suspected spinal injury, does the use of spinal immobilization during prehospital or emergency care (in-line manual immobilization, head blocks, spinal boards, cervical collars), compared with no immobilization, effect neurological outcome or other outcomes (prevention of movement, spinal positioning/alignment, comfort or pain, and complications)?’’ (Hood, & Considine, (2015). As a systematic review, the amount of data extrapolated was excellent quality, reliable and valid. There were 47 studies reviewed which were either supportive, neutral or opposed spinal immobilization. Portfolio Assignment: Spinal Immobilization Essay. However, there was no clear answer to the PICOT question. The conclusion, however, does provide compelling data validating the hypothesis for the PICOT question related to spinal immobilization and pressure injury occurrences.
Synthesis of Current Studies
From analyzing the studies and reviews, there seems to be compelling evidence that prolonged use of standard spinal immobilization techniques poses a greater risk for pressure injuries. There is not a great deal of data or research related to the use of spine boards. However, there are multiple resources for pressure injuries related to trauma, immobility, and age among other risk factors. The studies did not seem to have contradictions or inconsistencies; however, the systematic reviews show there are multiple studies that may have a bias. The studies were either supportive, neutral or opposed the use of SI. Potential gaps in the studies are the lack of other studies to compare their findings with the current data collected.
A synthesis of studies chosen for a literature review requires an unbiased attitude. According to Polit and Beck (2017), studies that do not agree with the researchers’ hypothesis should not be omitted from the review process. Conflicting studies allow the researcher to see the issue from multiple angles. The studies evaluated are in the table appendix A at the end of the Portfolio Assignment: Spinal Immobilization Essay paper.
Change in Practice
A preliminary conclusion, the data suggests a validity for designing a change in practice, and, at the same time suggesting further research for the use of standard SI. The data shows prolonged time of SI was a risk factor in pressure injuries. The use of SI should be based on clinical presentation, instead of the mechanism of injury. The possible negative aspects related to the use of SI interventions must be taken into consideration and practices should be changed to address the time spent on a rigid spine board.
An evidence-based practice change would be to document the arrival time, amount of time a patient has been in SI, advocate for the removal of SI as soon as possible and identify the associated risk factors for PI is directly related to age, GCS, ISS and hemoglobin levels. Then initiate preventive measures such as padding susceptible areas, repositioning as able, and assessing skin for circulation compromise frequently. Portfolio Assignment: Spinal Immobilization Essay.
Summary
The amount of time a trauma patient remains on a rigid spine board coupled with other factors is directly corroborated to the development of PI. Over the years prehospital care has improved and advanced with care and treatment of the sick and injured. However, not many studies have been undertaken to address best practices for spinal immobilization after the patient arrives at the ED and subsequent admittance to a trauma center. According to Hamm, et al., (2017) there are few studies related to risk factors for PU development in trauma patients. However, there are multiple studies related to risk factors for pressure ulcer development within other patient populations.
To obtain current, valid and accurate information to synthesize a change in clinical practices a research plan needs to be implemented. A study design based around the PICOT question is developed. It could either be a systematic review, RCT or case study to test the hypothesis. Portfolio Assignment: Spinal Immobilization Essay. A search for previous literature and either quantitative, qualitative or mixed method studies needs to be undertaken to give a knowledge base from which to work. And then using applied research a focus to define solutions to the PICOT question is undertaken (Polit & Beck, 2017).
The PICOT question, subsequent literature reviews, and applied research analysis of the studies chosen indicate a clear change in practice through the evidence is warranted. On admission to the ED, PU risk should be assessed in all trauma patients who present in full SI. Awareness that PU risk is greatest in patients with older age, lower GCS and higher ISS score in the ED. To be proactive in the prevention of PU development preventive interventions should be initiated in the ED (Hamm et al., 2017). Portfolio Assignment: Spinal Immobilization Essay.
 
References
Ham, H., Schoonhoven, L., Schuurmans, M. J., & Leenen, L. P. (2017). Pressure ulcer development in trauma patients with suspected spinal injury; the influence of risk factors present in the Emergency Department. International Emergency Nursing, 3013-19. doi:10.1016/j.ienj.2016.05.005
Hemmes, B., Brink, P. R., & Poeze, M. (2014). Effects of unconsciousness during spinal immobilization on tissue-interface pressures: A randomized controlled trial comparing a standard rigid spineboard with a newly developed soft-layered long spineboard. Injury, 451741-1746. doi:10.1016/j.injury.2014.06.006
Hood, N., & Considine, J. (2015). Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature. Australasian Emergency Nursing Journal: AENJ, 18(3), 118-137. doi:10.1016/j.aenj.2015.03.003
Houde, S. C. (2009). The systematic review of the literature: a tool for evidence-based
policy. Journal Of Gerontological Nursing, 35(9), 9-12. Portfolio Assignment: Spinal Immobilization Essay.
doi:10.3928/00989134-20090731-05
Nemunaitis, G., Roach, M. J., Boulet, M., Nagy, J. A., Kaufman, B., Mejia, M., & Hefzy, M. S. (2015). The Effect of a Liner on the Dispersion of Sacral Interface Pressures During Spinal Immobilization. Assistive Technology, 27(1), 9-17. doi:10.1080/10400435.2014.
Montgomery, N., & Goode, D. (2014). MANAGING PATIENTS WITH CERVICAL SPINE INJURY. Emergency Nurse, 22(2), 18-22. doi:10.7748/en2014.04.22.2.18.e1216
Oteir, A. O., Smith, K., Jennings, P. A., & Stoelwinder, J. U. (2014). The prehospital
management of suspected spinal cord injury: an update. Prehospital & Disaster
          Medicine, 29(4), 399-402. doi:10.1017/S1049023X14000752
Polit, D. F., & Beck, C. T. (2017).  Nursing research:  Generating and assessing evidence for
          nursing practice (10th ed.).  Philadelphia, PA:  Wolters Kluwer. Portfolio Assignment: Spinal Immobilization Essay.
Webber-Jones, J., Thomas, C., & Bordeaux RE, J. (2002). The management and prevention of
rigid cervical collar complications. Orthopaedic Nursing, 21(4), 19-27. Portfolio Assignment: Spinal Immobilization Essay
 
 
 

Citation
Type of Study
 
Design Type
 
Framework/Theory
Setting
Key Concepts/Variables
Findings
Hierarchy of Evidence Level

Ham, H.,
 Schoonhoven, L., Schuurmans, M. J., & Leenen, L. P. (2017). Pressure ulcer development in trauma patients with suspected spinal injury; the influence of risk factors present in the Emergency Department. International Emergency Nursing, 3013-19. doi:10.1016/j.ienj.2016.05.005
 
Quantitative
 
Prospective Cohort Study
 
 
Explorative Study
Portfolio Assignment: Spinal Immobilization Essay
 
ER and admitted trauma patients that presented in spinal immobilization
 
Between January and December 2013, 254 trauma patients were included.
 
Concepts:
 
To explore the influence of risk factors, present at Emergency Department admission on pressure ulcer development in trauma patients with suspected spinal injury,
 
Independent Variable:
Spine board, Age, GCS, ISS
 
Dependent Variable:
Pressure Ulcer Development
 
 
 
The incidence of pressure ulcer development during the period of hospital stay was 28.3%.  The incidence of pressure ulcer development within 48 h after admission was 13%
 
Pressure ulcer development within the first 48 h of admission was positive with increased age, lower Glasgow Coma Scale, and higher Injury Severity Score
 
Level V

Montgomery, N., & Goode, D. (2014). MANAGING PATIENTS WITH CERVICAL SPINE INJURY. Emergency Nurse, 22(2), 18-22. doi:10.7748/en2014.04.22.2.18.e1216
Systematic Review
 
Framework
To determine best practice and the complications that can arise from the immobilization of patients with c-spine injuries.
Emergency settings
Portfolio Assignment: Spinal Immobilization Essay
Concepts:
 
The search yielded 35 articles, concerning one systematic review, nine literature reviews, one clinical review, two meta-analyses, two randomized crossover studies, two audits and one cohort study
One of the main complications arising from prolonged spinal immobilization is pressure necrosis, which can occur within between 48 and 72 hours
 
Found that the effects of spinal immobilization on mortality, neurological injury and spinal stability are uncertain.
 
Level 1
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Citation
Study
Design Type
Framework/Theory
Setting
Key Concepts/Variables
Findings
Hierarchy of Evidence Level

 
 
 
 
 
 
 

Nemunaitis, G., Roach, M. J., Boulet, M., Nagy, J. A., Kaufman, B., Mejia, M., & Hefzy, M. S. (2015). The Effect of a Liner on the Dispersion of Sacral Interface Pressures During Spinal Immobilization. Assistive Technology, 27(1), 9-17. doi:10.1080/10400435.2014.940473
Case-Controlled Study
 
Quantitative
 
Evaluate sacral interface pressure and sensing area in healthy volunteers during prolonged standard spinal immobilization on a spine board and the effect of a gel pressure dispersion liner (PDL).
Healthy volunteers put in spinal immobilization for prolonged periods. With and without gel pads, to measure sacral interface pressure.
Concepts:
Gel pads reduce the amount of sacral interface pressure during prolonged immobilization on a spine board.
 
Independent Variable:
No Gel-pad
 
Dependent Variable:
Mean peak sacral pressure
 
Controlled Variable:
Spinal board
Significant mean peak interface pressures are generated when an individual is strapped to a spine board in the supine position.
 
Adding a gel-pad to the spine board decreased overall mean peak sacral pressures by 27% and increased mean sensing area by 21%.
Level VI

Hemmes, B., Brink, P. R., & Poeze, M. (2014). Effects of unconsciousness during spinal immobilization on tissue-interface pressures: A randomized controlled trial comparing a standard rigid spineboard with a newly developed soft-layered long spineboard. Injury, 451741-1746. doi:10.1016/j.injury.2014.06.006
Randomized Controlled trial
 
Quantitative experimental
 
The hypothesis that when lying on a rigid spine board, unconsciousness results in higher tissue-interface pressure than when awake
 
 
30 anesthetized patients were randomized to immobilization on either the rigid spine board or the soft-layered spine board sequentially on the rigid spine board and the soft layered spine board
 
Concepts:
Lying on a rigid spine board during unconsciousness results in higher tissue-interface pressure compared to the awake status.
 
Independent Variable:
Rigid spin board or soft layered spine board
Portfolio Assignment: Spinal Immobilization Essay
 
 
 
Dependent Variable:
Increased tissue interface pressure
 
Controlled Variable:
Awake volunteers
Or anesthetized volunteers
 
For both anesthetized patients and awake volunteers, tissue-interface pressures were significantly lower on the soft-layered spine board than on the rigid spine board.
 
On the soft-layered spine board, tissue interface pressure and peak pressure index significantly lower for anesthetized patients than for awake volunteers.
 
Peak pressures and PPI on the rigid spine board were equal for both groups. Tissue-interface pressures did not change significantly over time.
 
Redness of the sacrum was significantly more apparent on the rigid spine board than on the soft-layered spine board.
Level IIIV

Hood, N., & Considine, J. (2015). Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature. Australasian Emergency Nursing Journal: AENJ, 18(3), 118-137. doi:10.1016/j.aenj.2015.03.003
Systematic Review
 
 
To examine the evidence related to spinal immobilization in pre-hospital and emergency care settings
Studies with data extrapolated from healthy volunteers, cadavers and multiple trauma patients
Concepts:
Portfolio Assignment: Spinal Immobilization Essay
 

Level I

Appendix A

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