多中心前瞻性验证分诊护士在急诊科使用加拿大颈椎规则。
Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department.
机构信息
Department of Emergency Medicine, University of Ottawa, and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Department of Nursing, Ottawa Hospital, Ottawa, Ontario.
出版信息
CMAJ. 2010 Aug 10;182(11):1173-9. doi: 10.1503/cmaj.091430. Epub 2010 May 10.
OBJECTIVES
The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospectively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses.
METHODS
We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form.
RESULTS
Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%-100.0%) and specificity of 43.4% (95% CI 42.0%-45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%-95.0%) and a specificity of 43.9% (95% CI 42.0%-46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases.
CONCLUSION
Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.
目的
加拿大颈椎影像学规则（Canadian C-Spine Rule）是为医生设计的，用于对颈椎进行影像学检查。我们认为，急诊科的护士也可以使用该规则来对颈椎进行临床筛查。本研究前瞻性评估了护士使用加拿大颈椎影像学规则的准确性、可靠性和可接受性。
方法
本项为期 3 年的前瞻性队列研究在加拿大的 6 家急诊科开展，纳入了意识清醒且病情稳定的成年创伤患者。我们对 191 名分诊护士进行了 2 小时的培训。然后，护士使用加拿大颈椎影像学规则对患者进行评估，包括确定颈部压痛和活动范围、重新应用固定以及填写数据表单。
结果
在 3633 例研究患者中，42 例（1.2%）存在有临床意义的颈椎损伤。对 498 例患者的加拿大颈椎影像学规则进行观察者间评估的kappa 值为 0.78。我们计算出，调查人员解读加拿大颈椎影像学规则的敏感性为 100.0%（95%置信区间[CI]为 91.0%-100.0%），特异性为 43.4%（95%CI 为 42.0%-45.0%）。护士的分类敏感性为 90.2%（95%CI 为 76.0%-95.0%），特异性为 43.9%（95%CI 为 42.0%-46.0%）。在研究早期，尽管存在明确的高危因素，但有 4 例损伤未被护士识别。这些患者均未出现后遗症，经过再培训后，再无漏诊病例。我们估计，40.7%的患者可由护士进行临床颈椎筛查。仅有 4.8%的护士报告在应用加拿大颈椎影像学规则时感到不适。
结论
护士使用加拿大颈椎影像学规则的准确性、可靠性和临床可接受性良好。在加拿大和其他地方广泛推广护士使用该规则，将减轻患者的不适并改善拥挤的急诊科的患者流程。
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