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Vertebrae Fractures: Rural Management Adaptions

Project Added:
27 May 2015
Last updated:
27 May 2015

Vertebrae Fractures: Rural Management Adaptions


This project developed clear management plans with standardised clinical products and processes, formal education and training, and enhanced clinical governance. 

This project was a finalist in the Collaborative Team category of the 2014 NSW Health Awards. Download a poster from the 2014 NSW Health Awards.


To treat 100% of patients who sustain a stable vertebrae fracture without spinal cord injury within Mid North Coast Local Health District (MNCLHD), with no unnecessary transfers to tertiary facilities.


  • Improves patient outcomes, quality and safety of care.
  • Improves continuity of care.
  • Uses a ‘patients as partners’ approach in final transfer decisions.
  • Integrates healthcare with seamless, flexible care in appropriate settings.
  • Reduces length of stay (LoS).

Project Status

Project start date: January 2012.

Project status: Sustained - the project has been implemented, is sustained in standard business.

Traditionally, patients with vertebrae fractures were transferred to tertiary facilities soon after admission, as available services in MNCLHD could not provide optimal treatment for this specialised cohort of patients. This led to unnecessary admissions to the Intensive Care Unit (ICU) and transfers to John Hunter Hospital (JHH) for minor fractures, which placed significant emotional and financial strain on the patient and their family.


Feedback from patients and staff indicated that the existing standard of care could be improved by addressing issues such as product availability and staff training, so patients could be admitted to MNCLHD rather than transferred to a tertiary facility.


Stakeholder consultation

  • 24 stakeholder groups were created, comprising medical, nursing and allied health staff at John Hunter Hospital (JHH) and MNCLHD, as well as local aged care facilities and product representatives.
  • Stakeholders reviewed current practices, services, equipment availability, care transfer and decision-making, identifying actual and potential deficits and gaps for each. A literature review identified best practice.

Clinical Products

  • Product choices were identified by senior clinicians across disciplines, services and local health districts.
  • Laerdel stiff neck cervical immobilisation collars were removed from five emergency departments (EDs).
  • Philadelphia Collars replaced Laerdels and were applied to at-risk trauma patients for up to 48 hours.
  • Long term immobilisation collars were stocked in line with JHH, including Cervical, Miami J, Thoracic and Thoracic Lumbar-Sacral Orthosis (TLSO) braces.
  • All products were stored in an accessible area with stock levels and information sheets clearly visable.

Education and Training

  • A spinal checklist was developed to document the collaborative management plan, which is completed by the ED and designated tertiary facility at the initial consultation.
  • Additional nursing and physiotherapy staff were trained to enable the delivery of a 24/7 service.
  • Education was provided to medical and nursing staff in the ED and surgical wards, delivered by the trauma clinical nurse consultant and trauma director.
  • A competency assessment was developed, for inclusion in the external trauma course curriculum.
  • An eight-minute training film was created and made accessible on HealtheTube for aged care facilities, patients, carers and families.

Clinical Governance

  • Injury surveillance and individual case reviews were undertaken, to ensure problems were quickly recognised and actioned.
  • Compliance with the spinal checklist was monitored through spot audits over a one-month timeframe and during the clinical case review of all traumas.


  • John Hunter Hospital
  • Hunter New England Local Health District (HNELHD)

Implementation sites

  • Coffs Harbour Health Campus
  • Bellingen Hospital
  • Aged care facilities in HNELHD
  • The Hastings Macleay Network, Port Macquarie and Kempsey Hospitals 

The project was initially implemented at Coffs Harbour Health Campus and expanded to all hospitals in MNCLHD. HNELHD and Northern NSW Local Health District are currently implementing a similar process.


Patients are now managed in rural care centres by competent, trained staff who have clear management plans. Patient and staff satisfaction has increased, cost and morbidity had decreased, and patient safety and quality of care has improved.

An audit completed from July 2013 to June 2014 found:

  • no unnecessary transfers to designated tertiary neurosurgical services
  • no inappropriate extended inpatient admissions due to lack of clinical product stock
  • usage compliance of 97.5% with the spinal checklist
  • no collar-related pressure ulcers reported by staff or patients
  • continued use of appropriate bracing products with correct stock levels as of June 2014.


  • The Incident Information Management System (IIMS) found that no relevant adverse events occurred during the project.
  • IIMS reports were reduced from one in two patients prior to the project, to no reports in 2014 despite an increase in patient numbers, indicating enhanced teamwork with reduced conflict between tertiary and rural services.
  • All transfers to tertiary facilities were monitored, with trauma cases reviewed by the trauma clinical nurse coordinator.
  • The risk of collar-related pressure ulcers was reduced, due to early transfer into more appropriate collars.
  • Elderly patients who require rehabilitation are now managed in MNCLHD and integrated into the community, with the use of HealtheTube training.
  • There was a reduced risk of extended hospitalisation and forced immobilisation.
  • Coordinated care with local aged care facilities resulted in early transfer of patients directly from the ED to a familiar aged care facility, decreasing the risk of delirium.
  • Positive family and carer feedback was received on the HealtheTube video availability and content, which was viewed approximately 250 times as of July 2014.
  • Staff feedback indicated that education resulted in increased confidence and problem-solving skills in physiotherapists, with improved decision-making about the choice and availability of products.


  • 2014 NSW Health Award, Collaborative Team, finalist.
  • MNCLHD 2014 Quality Award

Lessons Learnt

  • Stakeholders had transparent discussions about problems, gaps and potential solutions which helped reduce conflict.
  • Consultation with patients and other stakeholders provided an opportunity to explain the reasoning behind decisions and actions.
  • It was important to acknowledge the diversity in healthcare needs within the community and address these differences.
  • There was trust on all sides and at all levels with clear responsibility, accountability and clinical governance.

Further Reading

  • Cervical spine immobilization before admission to the hospital. Neurosurgery 2002; 50(3 Suppl): S7-17.
  • Ackland HM, Cooper DJ, Malham GM, Kossmann T. Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine 2007; 32(11): 1257.
  • Askins V, Eismont F. Efficacy of five cervical orthoses in restricting cervical motion: a comparison study. Spine 1997; 22(11): 1193-1198.
  • Damadi A, Saxe A, Fath J, Apelgren K. Cervical spine fractures in patients 65 years or older: a 3-year experience at a Level 1 trauma center. Journal of Trauma Injury Infection and Critical Care 2008; 64(3): 745-748. DOI:
  • Gawande A. The Checklist Manifesto, How to get things right. Great Britain: Profile Books Ltd; 2011.
  • Hauswald M, Braude D. Spinal immobilization in trauma patients: is it really necessary? Current Opinion in Critical Care 2002; 8(6): 566-570.
  • Jacobson TM, Tescher AN, Miers AG, Downer L. Improving practice: efforts to reduce occipital pressure ulcers. Journal of Nursing Care Quality 2008; 23(3): 283-288. DOI:
  • Jones PS, Wadley J, Healy M. Clearing the cervical spine in unconscious adult trauma patients: a survey of practice in specialist centres in the UK. Anaesthesia 2004: 59(11): 1095-1099.
  • Lee TT, Green BA, Petrin DR. Treatment of stable burst fracture of the atlas (Jefferson fracture) with rigid cervical collar. Spine 1998; 23(18): 1963-1967.
  • Skellett S, Tibby SM, Durward A, Murdoch IA. Lesson of the week: Immobilisation of the cervical spine in children. BMJ 2002; 324(7337): 591-593.
  • Tescher AN, Rindflesch AB, Youdas JW et al. Range-of-Motion Restriction and Craniofacial Tissue-Interface Pressure From Four Cervical Collars. Journal of Trauma Injury Infection and Critical Care 2007; 63(5): 1120-1126.


Patricia Lemin
Trauma Clinical Nurse Consultant
Mid North Coast Local Health District
Phone: 0431 644 807

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