Ten months ago I wrote about getting patients off backboards as soon as possible. The question has arisen again, so I did a little digging to find some good science behind this. And I found it.
This problem has been looked at three ways. From best to worst they are: studies on OR patients who developed pressure ulcers postop, studies on animals, and studies on tissues. I’ll focus on the first because a real person who is chemically and physically restrained to an OR table is very similar to one who has been fastened to a backboard.
The most cited study (retrospective, of course) showed that patients who had tissue pressure over bony prominences that exceeded their diastolic pressure developed pressure ulcers within 6 hours, and even faster with higher tissue pressures. But even better prospective OR studies have been done, and these showed that ulcers could occur in as little as three hours.
Keep in mind that these studies involved patients in whom real efforts were made to pad bony prominences and actively avoid tissue injuries. Yet they still occurred. Contrast this with a patient who is strapped to a hard backboard in your ED, with little ability to adjust their position to improve circulation.
Related work has shown that:
- Tissue injury is more likely in the elderly, probably because they have less adipose padding
- Obesity is not protective! The increased weight increases tissue pressure out of proportion to the padding effect
- A harder surface shortens the time to tissue damage
- Hypotension is bad, both for the patient’s well-being and for the skin over their bony prominences
Bottom line: Get your patients off that backboard ASAP! I recommend sliding it out when they are logrolled to examine the back. The board is of little or no benefit to spine stability in a cooperative patient. And we have ways of encouraging cooperation if they are not.
Reference: How Much Time Does it Take to Get a Pressure Ulcer? Integrated Evidence from Human, Animal, and In Vitro Studies. Ostomy Wound Management. 54(10):26-8, 30-5, 2008.
Backboard usage by EMS is an important part of patient safety. It keeps the patient from injuring themselves or others within the confines of the ambulance or helicopter. But too much of anything is bad, and this is true of backboards as well. As little as 2 hours on a board can lead to skin breakdown. The most common reason that patients are not taken off boards sooner is concern for spine fractures. But the reality is that the board is not necessary once the patient arrives in the ED. If the spine is broken and they are admitted as an inpatient, they will be on log roll precautions on a regular hospital bed and mattress! I recommend that hospitals develop a policy for getting all patients off backboards as quickly as possible. The most convenient time is during the logroll to examine the back during the ATLS evaluation. Note: do not do a rectal exam during the logroll because this will cause the patient to wiggle more than you would like while they are up on their side. The goal should be to get the backboard removed within 20 minutes of patient arrival. I recommend placing a slider board under them if they will be visiting diagnostic areas like CT scan. But as soon as all studies are finished, pull the slider board as this can cause skin problems as well. Ideally, board removal should be documented, and this whole process can become a PI project.
EMS is very good about immobilizing the spine in trauma patients prior to transporting them to the Emergency Department. Healthcare personnel in the ED are not as good about getting people off of those rigid boards.
As always, it boils down to a risk and benefit assessment. What is the risk of keeping someone on a board, especially if they may have a spine injury? There is a well-known downside to spine immobilization: skin breakdown, which can occur in as little as 2 hours. Less appreciated is the fact that it is very uncomfortable lying on one’s back on any type of board, be it a spine board or even a simple plastic slider board.
What is the risk to the spine if it is indeed injured? In a cooperative patient, essentially zero. Think about it this way: what are spine-injured patients placed on once they are admitted to the hospital? A regular bed with a standard hospital mattress! They are kept on logroll precautions until they have an operative procedure or receive a brace.
The bottom line: All patients should be moved off the EMS spine board onto the ED cart unless they are being transferred to another hospital within an hour or less. The ED cart should have a regular mattress, but the patient must be cooperative. If they cannot or will not cooperate, and the probability of spine injury is high, they may need to be chemically restrained. A plastic slider board may be placed under the patient when they are ready to go to diagnostic studies, and should be removed immediately when they are complete. No board of any kind should ever be left under a patient for more than 2 hours.