scholarly journals Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial

10.2196/16966 ◽  
2020 ◽  
Vol 9 (6) ◽  
pp. e16966
Author(s):  
Christian Vaillancourt ◽  
Manya Charette ◽  
Monica Taljaard ◽  
Kednapa Thavorn ◽  
Elizabeth Hall ◽  
...  
Keyword(s):  
Health Economic Evaluation ◽  
Total Duration ◽  
Improve Patient Care ◽  
Low Risk ◽  
Spine Injury ◽  
Trauma Patients ◽  
X Rays ◽  
Stepped Wedge ◽  
Cord Injury ◽  
Cluster Randomized

Background Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. Objective This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. Methods We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. Results Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. Conclusions We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). Trial Registration ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. International Registered Report Identifier (IRRID) DERR1-10.2196/16966

scholarly journals Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial (Preprint)

2019 ◽  
Author(s):  
Christian Vaillancourt ◽  
Manya Charette ◽  
Monica Taljaard ◽  
Kednapa Thavorn ◽  
Elizabeth Hall ◽  
...  
Keyword(s):  
Health Economic Evaluation ◽  
Total Duration ◽  
Improve Patient Care ◽  
Low Risk ◽  
Spine Injury ◽  
Trauma Patients ◽  
X Rays ◽  
Stepped Wedge ◽  
Cord Injury ◽  
Cluster Randomized

BACKGROUND Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. OBJECTIVE This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. METHODS We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. RESULTS Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. CONCLUSIONS We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). CLINICALTRIAL ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/16966

scholarly journals PL03: Implementation of the Canadian C-Spine Rule by paramedics: a safety evaluation

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S26-S27 ◽  
Author(s):  
C. Vaillancourt ◽  
M. Charette ◽  
J.E. Sinclair ◽  
J. Maloney ◽  
R. Dionne ◽  
...  
Keyword(s):  
Motor Vehicle ◽  
Eligible Patient ◽  
Vital Signs ◽  
Low Risk ◽  
Spine Injury ◽  
Trauma Patients ◽  
Risk Criteria ◽  
Radiologic Evaluation ◽  
Kappa Agreement ◽  
The Impact

Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.

scholarly journals Impact of Electronic Versus Paper Vital Sign Observations on Length of Stay in Trauma Patients: Stepped-Wedge, Cluster Randomized Controlled Trial (Preprint)

2018 ◽  
Author(s):  
David CW Wong ◽  
Julia Knight ◽  
Jacqueline Birks ◽  
Lionel Tarassenko ◽  
Peter J Watkinson
Keyword(s):  
Length Of Stay ◽  
Vital Sign ◽  
Controlled Trial ◽  
Early Warning Score ◽  
Trauma Patients ◽  
Stepped Wedge ◽  
Documentation System ◽  
Stay Time ◽  
Paper Documentation ◽  
Cluster Randomized

BACKGROUND Electronic recording of vital sign observations (e-Obs) has become increasingly prevalent in hospital care. The evidence of clinical impact for these systems is mixed. OBJECTIVE The objective of our study was to assess the effect of e-Obs versus paper documentation (paper) on length of stay (time between trauma unit admission and “fit to discharge”) for trauma patients. METHODS A single-center, randomized stepped-wedge study of e-Obs against paper was conducted in two 26-bed trauma wards at a medium-sized UK teaching hospital. Randomization of the phased intervention order to 12 study areas was computer generated. The primary outcome was length of stay. RESULTS A total of 1232 patient episodes were randomized (paper: 628, e-Obs: 604). There were 37 deaths in hospital: 21 in the paper arm and 16 in the e-Obs arm. For discharged patients, the median length of stay was 5.4 (range: 0.2-79.0) days on the paper arm and 5.6 (range: 0.1-236.7) days on the e-Obs arm. Competing risks regression analysis for time to discharge showed no difference between the treatment arms (subhazard ratio: 1.05; 95% CI 0.82-1.35; P=.68). A greater proportion of patient episodes contained an Early Warning Score (EWS) ≥3 using the e-Obs system than using paper (subhazard ratio: 1.63; 95% CI 1.28-2.09; P<.001). However, there was no difference in the time to the subsequent observation, “escalation time” (hazard ratio 1.05; 95% CI 0.80-1.38; P=.70). CONCLUSIONS The phased introduction of an e-Obs documentation system was not associated with a change in length of stay. A greater proportion of patient episodes contained an EWS≥3 using the e-Obs system, but this was not associated with a change in “escalation time.” CLINICALTRIAL ISRCTN Registry ISRCTN91040762; http://www.isrctn.com/ISRCTN91040762 (Archived by WebCite at http://www.webcitation.org/72prakGTU)

scholarly journals A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Sara Malone ◽  
Virginia R. McKay ◽  
Christina Krucylak ◽  
Byron J. Powell ◽  
Jingxia Liu ◽  
...  
Keyword(s):  
Public Health ◽  
Clinical Outcomes ◽  
Antibiotic Stewardship ◽  
Implementation Strategies ◽  
Antibiotic Use ◽  
Low Risk ◽  
Stepped Wedge ◽  
Cluster Randomized ◽  
The Impact ◽  
Order Set

Abstract Background Antibiotic-resistant infections have become a public health crisis that is driven by the inappropriate use of antibiotics. In the USA, antibiotic stewardship programs (ASP) have been established and are required by regulatory agencies to help combat the problem of antibiotic resistance. Post-operative antibiotic use in surgical cases deemed low-risk for infection is an area with significant overuse of antibiotics in children. Consensus among leading public health organizations has led to guidelines eliminating post-operative antibiotics in low-risk surgeries. However, the best strategies to de-implement these inappropriate antibiotics in this setting are unknown. Methods/design A 3-year stepped wedge cluster randomized trial will be conducted at nine US Children’s Hospitals to assess the impact of two de-implementation strategies, order set change and facilitation training, on inappropriate post-operative antibiotic prescribing in low risk (i.e., clean and clean-contaminated) surgical cases. The facilitation training will amplify order set changes and will involve a 2-day workshop with antibiotic stewardship teams. This training will be led by an implementation scientist expert (VRM) and a pediatric infectious diseases physician with antibiotic stewardship expertise (JGN). The primary clinical outcome will be the percentage of surgical cases receiving unnecessary post-operative antibiotics. Secondary clinical outcomes will include the rate of surgical site infections and the rate of Clostridioides difficile infections, a common negative consequence of antibiotic use. Monthly semi-structured interviews at each hospital will assess the implementation process of the two strategies. The primary implementation outcome is penetration, which will be defined as the number of order sets changed or developed by each hospital during the study. Additional implementation outcomes will include the ASP team members’ assessment of the acceptability, appropriateness, and feasibility of each strategy while they are being implemented. Discussion This study will provide important information on the impact of two potential strategies to de-implement unnecessary post-operative antibiotic use in children while assessing important clinical outcomes. As more unnecessary medical practices are identified, de-implementation strategies, including facilitation, need to be rigorously evaluated. Along with this study, other rigorously designed studies evaluating additional strategies are needed to further advance the burgeoning field of de-implementation. Trial registration NCT04366440. Registered April 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04366440.

scholarly journals Detection and Analysis of Perfusion Pressure through Measuring Oxygen Saturation and Requirement of Dural Incision Decompression after Laminectomy

2021 ◽  
Vol 2021 ◽  
pp. 1-6
Author(s):  
Jamal Alshorman ◽  
Yulong Wang ◽  
Guixiong Huang ◽  
Tracy Boakye Serebour ◽  
Xiaodong Guo
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Blood Flow ◽  
Oxygen Saturation ◽  
Spine Injury ◽  
Secondary Injury ◽  
Traumatic Spinal Cord Injury ◽  
Trauma Patients ◽  
Injury Site ◽  
Cord Injury

Background. Traumatic spinal cord injury (SCI) can continue and transform long after the time of initial injury. Preventing secondary injury after SCI is one of the most significant challenges, and early intervention to return the blood flow at the injury site can minimize the likelihood of secondary injury. Objective. The purpose of this study is to investigate whether laminectomy can achieve the spinal cord blood flow by measuring the spinal blood oxygen saturation intraoperatively without the presence of light. Methods. Between June and August 2021, eight patients were admitted after traumatic spinal cord injury for surgical treatment. We explored the effectiveness of laminectomy and whether the patients required further procedures or not. We used a brain oxygen saturation monitor at the spine injury site under dark conditions. Results. Eight cervical trauma patients, six males and two females, underwent laminectomy decompression. Three patients’ ASIA grade improved by one level, and one patient showed slight motor-sensory improvement. Oxygen saturation was in the normal range. Conclusion. Performing bony decompression can show good results. Therefore, finding an examination method to confirm the improvement of blood perfusion by measuring oxygen saturation at the injury site after laminectomy is essential to avoid other complications.

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