Timely and Safe Removal of Backboards in a Rural Emergency Department

This study explored the need for timely and safe removal of backboards in a rural emergency department where no guidelines or protocols were currently in place for patients being brought in on backboards. Studies indicate adverse effects on patients who are allowed to have prolonged backboard time because doing so results in these individuals experiencing unnecessary pain and ineffective immobilization, as well as unnecessary use of resources. Patients were tracked over a three month period of time in order to evaluate the amount of time they remained on backboards: from the time they came through the hospital doors until the time they were removed. Patients who were included in the data collection were any trauma patients brought in by ambulance on backboards and who were eighteen years of age or older. Patients who were excluded from this measure were those in cardiac arrest and receiving CPR, dead on arrival, or under the age of eighteen. Interviews with providers were conducted to assess pre-guideline understanding of backboard use and spinal immobilization as well as apprehensions regarding patient removal from backboards. After establishing the need for a guideline, a presentation and training for providers was given including an evidence-based guideline to reduce patients' times on backboards. After implementation, patients' backboard times were tracked and times were compared from pre and post implementation for guideline effectiveness. Pre times were approximately 72 minutes as opposed to post times which were approximately 12 minutes-with a preset goal of 20 minutes or less for backboard removal. Patients' backboard times significantly decreased following provider education on current recommendations and implementation of an evidence-based guideline.

Running head: BACKBOARD REMOVAL Timely and Safe Removal of Backboards in a Rural Emergency Department Craig Garrett Project Chair: Ana Sanchez Birkhead Content Expert: Craig Cook University of Utah College of Nursing In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice 1 BACKBOARD REMOVAL 2 Abstract This study explored the need for timely and safe removal of backboards in a rural emergency department where no guidelines or protocols were currently in place for patients being brought in on backboards. Studies indicate adverse effects on patients who are allowed to have prolonged backboard time because doing so results in these individuals experiencing unnecessary pain and ineffective immobilization, as well as unnecessary use of resources. Patients were tracked over a three month period of time in order to evaluate the amount of time they remained on backboards: from the time they came through the hospital doors until the time they were removed. Patients who were included in the data collection were any trauma patients brought in by ambulance on backboards and who were eighteen years of age or older. Patients who were excluded from this measure were those in cardiac arrest and receiving CPR, dead on arrival, or under the age of eighteen. Interviews with providers were conducted to assess pre-guideline understanding of backboard use and spinal immobilization as well as apprehensions regarding patient removal from backboards. After establishing the need for a guideline, a presentation and training for providers was given including an evidence-based guideline to reduce patients' times on backboards. After implementation, patients' backboard times were tracked and times were compared from pre and post implementation for guideline effectiveness. Pre times were approximately 72 minutes as opposed to post times which were approximately 12 minutes-with a preset goal of 20 minutes or less for backboard removal. Patients' backboard times significantly decreased following provider education on current recommendations and implementation of an evidence-based guideline. Keywords: Backboards, Spinal Injuries BACKBOARD REMOVAL 3 Timely and Safe Removal of Backboards in a Rural Emergency Department Introduction Problem Description As part of a rural medical facility in Central Utah, there is an emergency department that sees its fair share of traumas due to its location and surrounding recreational attractions. This particular facility did not have a guideline or protocol when it came to patients being brought in on backboards. Since it is a rural facility, many of the traumas being brought in were coming from an extensive distance away. This was resulting in patients being left on backboards for an hour or more before even arriving at the facility. With this in mind, as well as no current guideline existing for the providers to follow, patients often ended up spending an extended period of time on backboards. Many of these providers were leaving the patients on the backboards until they had received imaging, and the results were obtained from the radiologist. It was not uncommon to see patients on backboards for two hours or more while waiting for the radiologist to clear the spine. Often times, in rural hospitals, provider views vary on the purpose of backboards and their role in immobilization. This results in no clear current guideline when patients have a potential spinal injury. Many rural healthcare providers are family medicine doctors who do not necessarily have training in trauma medicine but who cover the emergency department; they often lack education associated with trauma and/or the purpose of backboards. Without a current guideline in place and providers with varying views on backboard use, patients were experiencing prolonged backboard times--resulting in these individuals suffering unnecessary pain and ineffective immobilization, as well as unnecessary use of resources. BACKBOARD REMOVAL 4 Available Knowledge The use of backboards as part of routine trauma care has been subject to increased scrutiny, and early backboard removal is considered best practice (Cooney, Wallus, Asaly, and Wojcik, 2013). Although no studies have defined a specific allotment of time for patients to remain on a backboard, early removal from the backboard is considered best practice (Cooney, et. al., 2013). A recent study was conducted on twenty healthy, pain free individuals, who were immobilized on backboards and all reported pain after 30 minutes (Ausband, Brown, and March, 2009). Also, studies have shown that pressure sores can begin to form over the boney prominences in as little as one hour of lying in the same position (Gefen, 2008). Patients presenting to rural emergency departments are often left on backboards until they are transferred to another facility-approximately one to three hours. These patients are at increased risk for several complications including: agitation and anxiety, altered physical examination, delay in treatment, increased cranial pressure, pain, pressure sores, respiratory compromise, and unnecessary radiographs (ENA, 2015). Due to these potential risks, a pilot quality assurance observational study was completed to determine the total and interval backboard times of patients arriving via emergency medical services to a level 1 academic trauma center (Cooney, et. al., 2013). This study demonstrated that the average time that the patient remained on the backboard once arriving to the emergency department was 21 minutes ±15 minutes (Cooney, et. al., 2013). The process of leaving patients on backboards has been administered by many providers because they felt the backboard was a form of immobilization or restriction to protect the spine from further injury. In reality, the backboard is intended as a tool of extrication with a purpose of facilitating transfer of a patient to a transport stretcher, and it is not intended or appropriate for BACKBOARD REMOVAL 5 achieving spinal motion restriction (ENA, 2015). No available evidence exists to suggest that backboards prevent worsening conditions in transport, yet there are studies that demonstrate that they may result in harm (White, Domeier and Millin, 2014). Through observing patients on backboards, it is evident that backboards do not restrict spinal movement, and if anything, patients actually move more on backboards because they are constantly shifting their weight to remove the pressure. However, it is agreed that spinal motion restrictions should be implemented on the following: blunt trauma with altered level of consciousness, spinal deformity or spinal pain and/or tenderness, focal neurological deficit, high energy mechanism of injury together where the patient is impaired with alcohol and/or drugs or has distracting, painful injury or communication barrier (White, et.al., 2014). With that being said, spinal motion restriction is not necessarily obtained through the use of backboards as mentioned above. Rationale The aforementioned rural facility lacked any current guidelines regarding backboards and it was apparent that both patients and healthcare providers could greatly benefit from developing a current guideline. This particular issue with backboards was discussed with all of the providers at this facility and there was not a consensus on what to do with patients who came in on backboards. For liability issues, many providers were concerned about taking patients off of backboards until they were cleared through radiographic evaluation. However, as mentioned above, this often prolongs patients' time on backboards resulting in more complications. One of these serious complications is that of patients developing pressure sores. A pressure ulcer can begin to develop in the first hour of direct pressure. If a pressure ulcer BACKBOARD REMOVAL 6 develops, there is a direct link to higher mortality rates, longer hospital stays, and costly treatment (Gefen, 2008). This is likely why the American College of Surgeons recommends that once patients arrive at the emergency department, every effort should be made to remove the rigid spine board as early as possible to reduce the risk of pressure ulcer formation (American College of Surgeons, 2012, p.189). The removal of backboards should ideally be done during the secondary survey when patients are logrolled for inspection and palpation of the spine, and it should not be delayed for the sole purpose of obtaining definitive spinal imaging (American College of Surgeons, 2012, p.190). Doing so will eliminate the development of pressure ulcers, unnecessary pain, ineffective immobilization, as well as unnecessary use of resources. However, once removed, these patients should remain in spinal motion restriction until definitive imaging is performed--unless the provider has clinically cleared the spine. Once medical providers were made aware of the adverse effects of prolonged backboard use and the benefits of early removal as well as had a current guideline in place, this was a positive change that was easily attainable. Specific Aims The purpose of this project was to decrease the overuse of backboards and to decrease the extensive amount of time patients were spending on backboards through the development of a current "Evidence-Based Backboard Removal Guideline" (See Appendix A). There was a definite need to update the current practice regarding backboards and patients' removal at this rural emergency department. It was anticipated that this new guideline would not only improve patients' satisfaction and comfort, but it would also be a more efficient use of resources because patients would not have to be monitored as closely as when they were strapped to a backboard. It BACKBOARD REMOVAL 7 was determined by the emergency department in conjunction with the Regional Trauma Director that the emergency department would develop a guideline that would establish the necessary steps to be taken to get patients cleared and removed as quickly as possible from backboards upon arrival to the facility. It was determined that the projected goal would be to get patients off of backboards within 20 minutes from the time of arrival. The goal of 20 minutes was selected after reviewing a study completed by a level 1 trauma center where they documented an average time of 21 minutes for backboard removal (Cooney, et. al., 2013). Therefore, being a rural facility with fewer patients, this seemed like an attainable goal. Methods Context The facility at which this quality improvement project took place was at a rural critical access hospital in Central Utah that sees its fair share of traumas. A major freeway and highway run through this rural community; with increased amounts of traffic, more motor vehicle accidents occur in this area and are then transferred to this facility. In addition, this facility is the primary emergency department for several popular recreational destinations. Some of these recreational locations include: Little Sahara Sand Dunes, Cherry Creek Motor Cross Track, Yuba Reservoir, and Mt. Nebo--just to name a few. In this rural hospital setting, the emergency department would generally see around 14-20 patients daily, with a typical increased number of traumas on weekends and holidays. The staffing for this emergency department consisted of one physician, one-two nurses (depending on the time of day), and a unit clerk. This probably does not seem like a very large staff when it comes to caring for traumas, but due to the low overall census, the facility was not able to staff more than that. BACKBOARD REMOVAL 8 As previously mentioned, when traumas were brought into this facility, they were generally brought in on backboards. Many of these patients spent an hour or more on their backboards--just in transfer time to the rural facility. When they reached the facility, they were often left on their backboards for another hour or more until they received imaging and had their spine cleared by a board certified radiologist, which resulted in a total backboard time of two hours or more. Interventions The desired outcome of this quality improvement project was to decrease patients' time on backboards once they arrived at the emergency department. The first step was to assess current practice in the rural emergency department in Central Utah. There were not any current guidelines in place at the facility, so each physician was individually interviewed on what he/she considered to be appropriate backboard use and when to remove patients from backboards. In addition, each physician was questioned about his/her apprehensions for removing patients from backboards. These interviews with providers were essential in determining what was taking place with backboard use within the facility as well as what obstacles needed to be overcome to develop a successful guideline that could be utilized by the facility. Many of the physicians' apprehensions came down to liability as well as a concern of upsetting the trauma surgeon if these patients ended up needing to be transferred to a trauma center. These providers were also asked what it would take for them to change their current approach on backboard use, and the general consensus was that they needed to receive the information from the trauma center where the majority of the facility's traumas were being transported. BACKBOARD REMOVAL 9 After addressing the concerns with the physicians regarding prolonged backboard time and the lack of any policy on the matter, it was determined that an evidence-based guideline would be created with the help of the trauma team from the definitive facility. The trauma physicians helped to validate the research for the guideline that was formed. Once the current "Evidence-Based Backboard Removal Guideline" (See Appendix A) was developed, it was time to put it into place. This current guideline has helped standardize care and remove previous misconceptions concerning the role of backboards in traumas. In order to help all the providers get on the same page concerning the backboard matter, a meeting was held with the Chief Medical Physician from the trauma team where this facility sends most of their trauma patients. He concurred that removing patients from backboards as swiftly as possible is best practice and indicated that patients should not remain on the board for much more than 20 minutes after arrival at this rural facility if at all possible. This meeting helped reduce concerns of providers at the facility and validated the need for the implementation of a current guideline, which would encourage early backboard removal times. Studies and research conducted by multiple medical professionals was shared with the physicians at the rural facility. It was explained that current studies and research indicate that spinal immobilization does not decrease rates of spinal cord injury; immobilization with devices increases the risk of pressure ulcer development; increased time on backboards results in increased false-positives for exams due to pain and discomfort created by the board itself (Rezaie, 2017). With the potential harm caused by the use of backboards for immobilization, every effort should be made to ensure that the time is minimized (Cooney, et. al., 2013). It is considered best practice that when the patient arrives to the emergency department, every effort should be made to remove the patient from the rigid spine board as early as possible to prevent BACKBOARD REMOVAL 10 secondary injury and potential harm associated with backboards (American College of Surgeons, 2012, p. 189). As previously mentioned, we discussed that a level 1 academic trauma center was able to remove patients from the backboard at an average time of 21 minutes (Cooney, et. al., 2013). With this in mind, and level 1 trauma centers being much busier than this rural facility, it was determined in an emergency department committee meeting for this facility that the goal would be to have patients removed from backboards within 20 minutes of arriving at the emergency department. Lewin's Change Theory provided a framework for accomplishing the change; the framework has three phases: unfreeze, change, and refreeze (Mind Tools, 2017). For this to be successful the unfreeze step needed to happen first; this ensured that the providers were ready to change. During this phase it was important to assess the current practice and knowledge of providers concerning backboard removal in trauma patients and clarify why a change was necessary. The next phase was the change phase where the intended changes were executed; during this phase a current evidence-based guideline addressing the appropriate use of backboards was developed and agreed upon by all the providers. Once this was developed, an implementation period was needed. The last phase was to refreeze or to make sure that the changes made became permanent. During this phase it was important to evaluate the effectiveness of the implemented guideline in terms of its usefulness as well as provider-reported satisfaction, and make minor changes as needed. Measures As previously mentioned, this is a rural facility where the quality improvement project took place and the number of traumas greatly fluctuates depending on the time of the year or day BACKBOARD REMOVAL 11 of the week. Patients who were included in the data collection were any trauma patients brought in by ambulance on backboards and who were eighteen years of age or older. The measure that was evaluated in this project was the time each patient spent on the backboard: from the time they came through the hospital doors until the time they were taken off the backboard or the time they left on the backboard to be transferred to another facility. Patients who were excluded from this measure were those in cardiac arrest and receiving CPR, dead on arrival, or under the age of eighteen. Backboard removal times were collected and reviewed for three months pre and post implementation of the guideline. During pre-guideline implementation, data was collected through chart reviews for 21 patients who presented to the emergency department on backboards. During post-guideline implementation, data was collected via live data for 17 patients as they were presented to the emergency department on backboards and were removed as promptly as possible-in conjunction with the new protocol requirements. The mean pre-guideline implementation backboard removal times were 72 minutes with a standard deviation of ±39.2 minutes, which was compared to a mean post-guideline backboard removal time of 12.8 minutes with a standard deviation of ±7.1 minutes. Patients' times on backboards greatly decreased from pre guideline implementation to post guideline implementation. (See Appendix B). Analysis The analysis for this quality improvement project was straight forward. By comparing the average time patients spent on backboards before implementation of guideline compared to after implementation of the guideline. The time on backboards was measured from the time patients BACKBOARD REMOVAL 12 were brought through the emergency department doors and does not account for patients' time on the backboard in transit. Ethical Consideration The biggest ethical consideration brought up by the providers at this facility through interviews was the fear of worsening patients' spinal injuries by taking them off their backboards. However, as previously mentioned, backboards are intended as tools of extrication with a purpose of facilitating transfer of patients to a transport stretcher, and are not intended or appropriate for achieving spinal motion restriction (ENA, 2015). There is no scientific evidence that backboards effectively immobilize the spine or improve outcomes (Bledsoe, 2013). Yet there are studies that demonstrate prolonged backboard times may result in harm (White, Domeier and Millin, 2014). This is definitely an ethical consideration because as providers, we do not want patients leaving in worse condition than how they arrived, and we want them to achieve the best possible outcome. As research has shown, removing patients from backboards to stretchers does not worsen patients' outcomes, and in fact decreases complications that result from prolonged backboard times. It has been found in several studies that there is no high-level evidence that prolonged spinal immobilization-greater than 30 minutes-positively impacts patient oriented outcomes (Rezaie, 2017). Results Results BACKBOARD REMOVAL 13 During this backboard quality improvement project, backboard removal times were collected and reviewed for three months pre and post implementation of the guideline. The results are demonstrated below in mean backboard removal times for both pre and post implementation with standard deviations. It should be noted that some of the patients in the preimplementation category were never taken off the backboards at this facility, and were transferred for definitive care to the nearest trauma center without having the backboards ever being removed. For these patients who were never removed from the backboards, the backboard removal times are stopped when the patients were discharged from this facility for transfer. This quality improvement project was straight forward in regard to pre and post implementation data analysis. The mean pre-guideline implementation backboard removal times were 72 minutes with a standard deviation of ±39.2 minutes, which was compared to a mean post-guideline backboard removal time of 12.8 minutes with a standard deviation of ±7.1 minutes. That is not only a significant improvement in backboard removal times, but it exceeded the facility's predetermined goal of having patients off backboards in 20 minutes or less. (See Appendix B). Once the providers were educated on best practices for backboard use and removal, there was a realization for the needed change. The providers were onboard and could see the patients' benefits of early backboard removal, the results then speak for themselves with a drastic improvement in backboard removal times. Discussion Summary BACKBOARD REMOVAL 14 This quality improvement project was done at a rural facility as an effort to decrease the amount of time trauma patients spend on backboards. As previously mentioned, there are several complications that can arise from prolonged backboard times. Therefore, this project was created at this facility in an effort to help improve backboard times, with a goal of having patients taken off of backboards in 20 minutes or less from the time they arrive at the facility. To achieve this goal, providers were interviewed at the beginning of the project, so that the unseen barriers to removing patients from backboards could be identified. Next, providers were educated on the need of early backboard removal times with the help of the Regional Trauma Physician to help break down the barriers keeping patients on backboards for prolonged periods of time. A guideline was then created for the providers at this facility to follow. Data was collected for three months prior to guideline implementation and for three months post implementation to determine the effectiveness of the new guideline. The desired outcome of having patients off of backboards within 20 minutes or less was achieved and even succeeded- deeming this project a success for all involved. Interpretation Prior to the guideline implementation, there were several misconceptions and barriers that needed to be overcome. Patients were remaining on backboards for extended periods of time and even being transferred out of the facility without ever being taken off of their backboards. This was done because many of the providers were using the backboards as a tool of immobilization of the spine until the patient could be cleared from the backboard by imaging, or transferred to definitive care. This was resulting in prolonged backboard times at this facility, and potentially creating adverse outcomes for patients who could develop pressure sores from being on BACKBOARD REMOVAL 15 backboards for such extended periods of time. Once providers were educated on the need for early removal, and that there were no benefits from keeping patients on backboards, they were all on board for making an effort to get patients off backboards as early as possible. Because of the education and guideline implementation there has been a drastic improvement in backboard removal times from an average of 72 minutes to 12.8 minutes, which has exceeded the goal of 20 minutes. This goal was determined from an observational study that was conducted at a level 1 trauma center, which was able to have patients removed from backboards in 21 minutes on average (Cooney, et. al., 2013). With this rural facility being a smaller facility with fewer traumas and patients in general, it was discussed and determined in an emergency department committee meeting that the facility's goal for backboard removal time would be 20 minutes or less in conjunction with following the guideline. Study Limitations A major limitation to this study is the period of time for which data was collected. Obviously, with the demonstrated results, there has been a significant improvement in backboard removal time at this facility. However, to truly analyze the full effectiveness of the guideline implementation, backboard times should be tracked for a year at this facility; therefore, data could be evaluated during the busy summer trauma season. The higher number of patients brought in on backboards will make for a more accurate mean, to evaluate how all the providers are following the new guideline. Conclusions BACKBOARD REMOVAL 16 Thus far this quality improvement project has shown to be very beneficial to this facility in improving backboard removal time, and in turn, hopefully improving patients' satisfaction and long term outcomes. As the data clearly shows, there has been a substantial improvement in backboard removal times at this facility. With that being said, there is still a need to continue to track this and consider making it a quality measure that can be evaluated for all trauma patients who are brought to this facility. Due to how receptive the medical team of this facility was to this backboard project, I have no doubts or concerns about future implementation and early backboard removal times. BACKBOARD REMOVAL 17 References American College of Surgeons (2012). Advanced trauma life support: ATLS student course manual. Ausband, S., Brown, L., March, J. (2009). Changes in physical examination caused by use of spinal immobilization. Retrieved from http://www.tandfonline.com/doi/abs/10.1080/10903120290938067. Bledsoe, B. (2013). The evidence against backboards. EMS World. Retrieved from http://www.emsworld.com/article/10964204/prehospital-spinal immobilization. Cooney, D. R., Wallus, H., Asaly, M., & Wojcik, S. (2013). Backboard time for patients receiving spinal immobilization by emergency medical services. International Journal of Emergency Medicine, 6, 17. http://doi.org/10.1186/1865-1380-6-17. Emergency Nurses Association (ENA). (2015). Long backboard use for spinal motion restriction. Retrieved from https://www.ena.org/practice research/Practice/Documents/LongBackboardUse.pdf. Gefen, A. (2008). How Much Time Does it Take to Get a Pressure Ulcer? Integrated Evidence from Human, Animal, and In Vitro Studies. 54(10), 26-35. Retrieved from http://www.o wm.com/content/how-much-time-does-it-take-get-a-pressure-ulcer-integrated-evidence human-animal-and-in-vitr. Mind Tools (2017). Lewin's Change Management Model: Understanding the Three Stages of Change. Retrieved from https://www.mindtools.com/pages/article/newPPM_94.htm Rezaie, S. (2017). Spinal Immobilization in Trauma Patients. Retrieved from http://rebelem.com/spinal-immobilization-in-trauma-patients/ BACKBOARD REMOVAL 18 White, C. C., Domeier, R. M., & Millin, M. G. (2014). EMS spinal precautions and the use of the long backboard - resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 18(2), 306-314. doi:10.3109/10903127.2014.884197. BACKBOARD REMOVAL 19 Appendix A Guideline ED Backboard Removal Guideline 1. All patients presenting to the Emergency Department on a backboard should immediately have a primary survey preformed on them (Airway, Breathing, Circulation, Disability, and Exposure). If unable to move past the primary survey then the patient should remain on the backboard. 2. During the secondary survey the patient should be logrolled (while maintaining C-spine precautions with a cervical collar in place) for inspection and palpation of the thoracic and lumbar spine. At that time the backboard should be removed from under the patient. Once the backboard is removed the patient should be returned to a neutral supine position onto a transfer device (slider board, transfer sheet, hovermatt) which will already be placed on the trauma bed prior to patient arrival. 3. Once the patient is taken off the backboard they need to maintain spinal motion restriction (which means the patient lie flat in a supine position and limit any movement) if there is a suspected spinal injury and imaging is required. The patient needs to maintain this spinal motion restriction until the images are read by a radiologist. However, the patient's spine may be cleared clinically by the attending provider without imaging if there are no signs or symptoms of spinal injury, and there are no distracting injuries. 4. If a slider board is used to take the patient to radiology, once the patient returns to the trauma bay from radiology, the slider board should then be removed from under the patient. In turn, leaving the patient lying flat on the trauma stretcher with a sheet left underneath the patient for future transferring or repositioning of the patient. Again, patient is to remain in spinal motion restriction until images are read by a radiologist. 5. If imaging reveals a spinal fracture and the patient needs to be transferred to another facility, the patient should be transferred from the trauma stretcher to the ambulance stretcher by the aid of the sheet that has been left under the patient. A slider board may also be beneficial for this transfer to help maintain spinal alignment and improve the ease of transfer. Patient does not need to be placed back on a backboard for transfer to the receiving facility. However, there must be a transfer sheet left under the patient for the receiving facility to be able to safely transfer the patient on arrival. Patient should also be left in a cervical collar for transfer if there is any concern of any spinal injury. BACKBOARD REMOVAL Flow Chart •Immediately preform a primary survey (ABCDE) •If unable to move past the primary survey, then the patient should remain on the backboard Primary Survey Secondary Survey •Patient should be logrolled for inspection and palpation of the thoracic and lumbar spine •Maintain C-spine precautions with a cervical collar in place •Backboard should be removed from the under the patient •Patient should be returned to a neutral supine position onto a transfer device •Maintain spinal motion restriction if there is a suspected spinal injury and imaging is required •Spine may be cleared clinically by the attending physician, and imaging may not be required Spinal Precautions •If spine needs to be cleared radiologically patient needs to remain in spinal motion restrictions •Spinal motion restrictions means that the patient remain in a neutral, flat, supine position, without movement •Patient in spinal motion restrictions need to be transferred via sliderboard or transfer device such as hovermatt to ensure there is minimal to no spinal motion •If there is a potential spinal injury the patient needs to remain in spinal motional restriction until the spine is cleared by CT imaging and read by a board certified radiologist Potential Spinal Injury Transfer •If slider board was used: board should be removed once patient returns to the trauma bay from radiology •Patient should be left lying flat on the trauma stretcher with a sheet left underneath the patient for future transferring/repositioning •If imaging reveals a spinal fracture & patient needs to be transferred to another facility: patient should be transferred from the trauma stretcher to the ambulance stretcher by the sheet •A slider board may also be beneficial for this transfer to help maintain spinal alignment and improve the ease of transfer Transferring to another facility •Patient DOES NOT need to be placed back on a backboard for transfer to the receiving facility •There must be a transfer sheet left under the patient for the receiving facility to be able to safely transfer the patient on arrival •Patient should also be left in a cervical collar for transfer if there is any concern of any spinal injury 20 BACKBOARD REMOVAL 21 Appendix B Table Backboard Removal Average Time Standard Deviation Pre-guideline Implementation 72 min ±39.2 Post-guideline Implementation 12.8 min ±7.1