Date: October 5th , 2018

Reference: Stiell et al. A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses. Annals of EM Oct 2018

Guest Skeptic: Alison Armstrong is an Emergency Department Nurse, TNCC Course Director, Trauma Program Coordinator and Canadian C-Spine Rule Nurse Champion.

Case: There are two case scenarios this week to try and capture the two common ways patients present to the triage nurse.

  • Case 1: A 51-year-old male patient presents to triage in a collar on a back-board via EMS following a rear-end motor vehicle collision (MVC) at a stop light. He was a belted driver with no past medical history and GCS 15. The driver of the car that hit him was texting and did not appear to slow before striking the rear of the patient’s car at about 50 km/hr. The patient complains of left shoulder and neck pain.
  • Case 2: A 45-year-old female presents to triage at 20:30 walking stating that she fell from a chair this morning. She went to work all day as she thought she was unhurt initially, but pain has started to set in so she stopped by the emergency department on the way home complaining of right wrist and neck pain and stiffness all over. She is worried she may have a serious injury to her neck. 

Background: Clearing the c-spines is a regular activity in the emergency department (ED). This can be done clinically using the Canadian C-Spine Rules/Tools or with imaging. The vast majority of these patients (>99%) do not  have a fractured cervical spine diagnosed.

Blunt trauma patients transported via EMS often arrive on a backboard, c-collar and head restraints. They remain this way often complaining to the nurse until they can be assessed by a physician and have their c-spine cleared.

There are protocols to get blunt trauma patients off spine boards urgently. However, they still can remain in c-spine precautions for a long time waiting to be assessed. This adds to patient discomfort, occupies valuable acute ED space and can contribute to crowding.

The Canadian C-Spine Rule (CCR) is a clinical decision instrument developed to allow clinicians to clear the c-spine without imaging (1). This instrument has been validated to be safe and decrease use of diagnostic imaging (2,3).

Canadian C-Spine Rule (CCR)

The CCR applies to alert (GCS=15) and stable trauma patients where cervical spine injury is a concern

  • Dangerous Mechanism
    • Fall from elevation>=3 feet/ 5 stairs
    • Axial load to head (diving)
    • MVC high speed (>100km/hr), rollover, ejection
    • Motorized recreational vehicle
    • Bicycle collision

Clinical Question: Can emergency department triage nurses apply the Canadian C-Spine Rule to adult blunt trauma patients and safely clear the c-spine?

Reference: Stiell et al. A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses. Annals of EM Oct 2018

  • Population: Alert adults presenting to the ED ambulatory or by EMS with acute blunt trauma occurring within the previous 48 hours with posterior neck pain and were in stable condition. Alert and stable was defined as a Glasgow Coma Scale (GSC) score of 15 with normal vital signs.
    • Exclusions: Age less than 16 years, penetrating trauma, acute paralysis, or known vertebral disease
  • Intervention:
    • Phase 1 (Certification): All ED nurses who performed triage activities had didactic training and then had to demonstrate competence by accurately assessing ten patients before being certified.
    • Phase 2 (Implementation): All triage nurses who had become certified were empowered by a medical directive to “clear” the cervical spine of patients, allowing them to remove cervical spine immobilization of CCR–negative patients and triage them to a less acute area.
  • Comparison: None
  • Outcomes:
    • Primary Outcomes:
      • Clinical: Proportion of eligible trauma patients who had their cervical spine cleared by nurses.
      • Safety: Number of missed clinically important cervical spine injuries.
    • Secondary Outcomes:
      • Clinical: Length of time in the ED
      • SafetyNumber of serious adverse outcomes (neurologic deficit after clearance by the ED nurse)
      • Other: Nurse accuracy in overall interpretation of the rule and nurse comfort with the rule.

Authors’ Conclusions: We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.”

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? Yes
  7. Was the follow up of subjects complete enough? Unsure
  8. How precise are the results? Unsure
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure
  11. Do the results of this study fit with other available evidence? Yes

Key Results: There were two phases to the study and authors focused on phase 2 (Implementation) part of the study which had a total of 1,408 patients. The mean age was 43 years, 52% were female, 64% (898) arrived via EMS and 1.1% (16) were found to have a c-spine injury (2 patients [0.1%] required internal fixation and 14 patients [1.0%] required rigid collars).

Of the 898 patients that arrived via EMS, 806 (90%) were immobilized. There were another 510 who walked into the ED with neck pain and triaged to either have immobilization applied (36%) or not (63%).

Triage nurses removed 41% of immobilized patients’ collars and missed zero c-spine injuries.

  • Primary Outcomes:
    • Clinical: Proportion of eligible trauma patients who had their cervical spine cleared by nurses was 41.1%. The number of c-spines cleared by nurses before the study was zero.
    • Safety: Number of missed clinically important c-spine injuries was zero.
  • Secondary Outcomes:
    • ClinicalLength of time in the ED was reduced by 26% (3.4 vs. 4.6 hours)
    • Safety: Number of serious adverse outcomes (neurologic deficit after clearance by the ED nurse) was zero.
    • Other: Nurse comfort and compliance with the rule was high. Only 1.3% of nurses indicated they were uncomfortable or very uncomfortable following the rule.

Before we talk nerdy, we would just like to point out one thing. Medical research rarely focuses on recognizing that the nursing staff have a great capacity for critical thinking and application of many of the tools used by physicians.

  1. Not Randomized Trial: This was not an RCT and therefore there was no comparisons group. We do not know definitively if this would have decreased the length of stay compared the existing system. The LOS in the ED was shorter for those who had the collar removed compared to those who did not, which makes sense. Those without the collar being removed would have further evaluation and potentially imaging. How would this new protocol compare to physicians evaluating the patient? I suspect it would be faster with shorter LOS having the triage nurse apply the CCR but this study does not provide data to answer this question.
  2. Compliance: One hospital withdrew after phase 1 due to compliance issues. This suggests there may be difficulties implementing this in other sites. It would have been nice to have more information on why this happened. Was it compliance issues with the physicians, nurses, administration or a combination?
  3. External Validity: They mention small and rural hospitals. There may not be enough volume for triage nurses to feel comfortable using the CCR infrequently. The other issue is places like the US with a zero-miss culture. Would it be accepted in a much different medical-legal environment?
  4. Precision: It is hard to comment on the precision of the results with the event rate being so low. There were only 7/806 immobilized patients who arrived by ambulance who had clinically im portant c-spine injuries (0.7%). While no injuries were missed in this study it would only take one or two misses to call into question the validity of the results.
  5. Follow-Up: Was follow-up long enough and comprehensive enough? They monitored visit logs for 30 days, but some patients could have arrived with an injury past one month. It is also possible that patients went to another hospital rather than going back to the hospital they originally presented.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: Properly educated emergency department triage nurses can apply the Canadian C-Spine Rule to adult blunt trauma patients and safely clear the c-spine.

Case Resolution:  

  • Case 1The triage nurse could apply the CCR to the patient because he was involved in a simple rear-end MVC which is one of the low risk criteria. The triage nurse removed the front of his collar and palpated his c-spines. The patient reported pain all over. The triage nurse then asked the patient to look 45 degrees to the right, then the left. He was able to do the motion, so the triage nurse removed the collar and asked that the patient be offloaded to a regular stretcher.
  • Case 2: The female patient who fell from the chair also qualifies for the CCR to be used as it was not a dangerous mechanism and she had delayed onset of neck pain. The triage nurse palpated her c-spines and the patient complained of right lateral neck pain. The triage nurse then asked if she could rotate her head 45 degree to the right and then the left. The patient was able to do the motion, so the triage nurse knew that the patient did not need a c-spine collar and to be immobilized at triage.

Clinical Application: The triage nurses at Victoria Hospital at London Health Sciences Centere were the nerdiest of all nine sites in this study with over 90% of them volunteering to be a part of the implementation. Since the study completion, triage nurses at Victoria Hospital are using the CCR to clear c-spines and you know what, this Canadian C-Spine Rule is now being used in the pre-hospital environment all over Ontario now!

Alison Armstrong RN

What Do I Tell My Patient? 

  • Patient 1: I know being in a collar and on a backboard can be very uncomfortable. The paramedics correctly put one on because of the pain you were having in your neck. We have a way to safely remove the collar and so a few little tests without missing any serious neck injuries. You don’t need to be in that collar anymore so we can move you over to a regular stretcher or a chair if you like.
  • Patient 2: I know you are worried about your neck being injured but we have a tool that we use that can safely assure that you don’t have a serious injury and won’t need a c-spine collar. You can wait in the waiting room safely until the doctor is able to see you.

Keener Kontest: There was no winner last week. 1922 was the year intraosseous access was first described in the literature?

Listen to the SGEM podcast on iTunes to hear this the new keener question. If you know the answer send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’Guide to Emergency Medicine.


  1. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian Cervical Spine Radiography Rule for alert and stable trauma patients. JAMA. 2001;286:1841-1848.
  2. Stiell IG, Clement C, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349:2510-2518.
  3. Stiell IG, Clement CM, Grimshaw J, et al. Implementation of the Canadian C-Spine Rule: prospective 12-centre cluster randomised trial. BMJ. 2009;(339):B4146.