Spinal clearance guideline for out-of hospital providers

Abstract

Unnecessary spinal cord immobilisation is a common problem in South Africa, even though out-of hospital spinal clearance is becoming standard of care in international emergency medical care (EMC) communities. Large numbers of unnecessary spinal immobilisations, in low risk trauma patients, result in an increased health and economic burden in both the in-hospital and out-of hospital settings. Currently, informal spinal clearance is being practiced in South Africa creating large practice variation, potential patient safety compromise and probable economic burden. An evidence-based out-of hospital spinal clearance algorithm would minimise the unnecessary hospitalisation of low risk spinal patients. Our objectives included: (i) To provide an accurate and reproducible algorithm to identify and correctly refer clinically relevant spinal injury in the out-of hospital setting and (ii) To inform policy makers of best practice for spinal cord clearance through evidence informed decision making and provide implementation and evaluation recommendations. This document provides recommendations for a spinal clearance guideline for South Africa and includes implementation strategies and evaluation criteria. Methods: A Population, Intervention, Professionals, Outcomes and Health Context (PIPOH) research question was designed to answer the guideline topic. The literature was systematically searched for spinal clearance guidelines or recommendations. These were screened, appraised and adapted by a specialist emergency care review group using the Appraisal of Guidelines Research and Evaluation (AGREE II) and ADAPTE tools recommended for guideline adaptation and development. The results were filtered by the primary author using pre-defined selection criteria. Results: A total of 8 guidelines met the inclusion criteria. Each guideline was independently assessed by two emergency care specialists using the AGREE II tool. A forum discussion was held to adapt the included guidelines to the local out-of hospital needs. Emergency care policy stakeholders and operational and student paramedics were asked to review and comment on the adapted algorithm. Conclusion: An out-of hospital spinal clearance guideline was developed with evaluation and implementation strategies for the out-of hospital context. The author would like to acknowledge the South African Cochrane Centre and Dr Tamara Kredo for their support.