Prehospital guidelines on in-water traumatic spinal injuries for lifeguards and prehospital emergency medical services: an international Delphi consensus study

Abstract

Background: Trauma guidelines on spinal motion restriction (SMR) have changed drastically in recent years. An international group of experts explored whether consensus could be reached and if guidelines on SMR performed by trained lifeguards and prehospital EMS following in-water traumatic spinal cord injury (TSCI) should also be changed.

Methods: An international three-round Delphi process was conducted from October 2022 to November 2023. In Delphi round one, brainstorming resulted in an exhaustive list of recommendations for handling patients with suspected in-water TSCI. The list was also used to construct a preliminary flowchart for in-water SMR. In Delphi round two, three levels of agreement for each recommendation and the flowchart were established. Recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three; recommendations with moderate consensus (75-85% agreement) underwent major revisions in two consecutive phases; and recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2.

Results: Twenty-four experts participated in Delphi round one. The response rates for Delphi rounds two and three were 92% and 88%, respectively. The study resulted in 25 recommendations and one flowchart with four flowchart paths; 24 recommendations received strong consensus (≥ 85%), and one recommendation received moderate consensus (81%). Each of the four paths in the flowchart received strong consensus (90-95%). The integral flowchart received strong consensus (93%).

Conclusions: This study produced expert consensus on 25 recommendations and a flowchart on handling patients with suspected in-water TSCI by trained lifeguards and prehospital EMS. These results provide clear and simple guidelines on SMR, which can standardise training and guidelines on SMR performed by trained lifeguards or prehospital EMS.

Keywords: Delphi; Drowning; Emergency medical service (EMS); Guideline; Lifeguard; Spinal cord injuries; Spinal fractures; Spinal injuries; Trauma; Water.

Fig. 1

Study flow. Members of the International Life Saving Federation (ILS) Medical Committee (ILS-MC), the ILS Rescue Commission (ILS-RC), and the International Drowning Researchers’ Alliance (IDRA) with a background in clinical health care as a medical doctor, nurse, paramedic/EMT or similar were eligible for inclusion as potential experts. The inclusion criteria included at least one of the following three criteria: (1) Having clinical expertise in handling patients with suspected in-water TSCI, (2) Having teaching expertise in handling patients with suspected in-water TSCI, and (3) Having research expertise on in-water TSCI. The study was initiated in October 2022, concluded in November 2023, and consisted of three Delphi rounds. In Delphi round two, the level of agreement for each recommendation and the flowchart was calculated as the frequency of “agree” (3) and “strongly agree” (4) on a 4-point Likert-like scale and divided into three levels: (1) recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three, (2) recommendations with moderate consensus (75–85% agreement) underwent major revisions and repeated round two, (3) recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2. The consensus threshold was an agreement of ≥ 75% among the experts

Fig. 2

Workflow diagram of the modified Delphi study. The study was initiated in October 2022, concluded in November 2023, and consisted of three Delphi rounds. In Delphi round two, the level of agreement for each recommendation and the flowchart was calculated as the frequency of “agree” (3) and “strongly agree” (4) on a 4-point Likert-like scale and divided into three levels: (1) recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three, (2) recommendations with moderate consensus (75–85% agreement) underwent major revisions and repeated round two, (3) recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2. The consensus threshold was an agreement of ≥ 75% among the experts

Fig. 3

In-water spinal trauma flowchart—prehospital guidelines for trained lifeguards and prehospital EMS. The flowchart was constructed and adjusted according to the recommendations. The flowchart received strong consensus (93%) in Delphi round 3. Each of the four routes in the flowchart received strong consensus: Route 1 to the left (90%), route 2 in the middle left (95%), route 3 in the middle right (95%), and route 4 to the right (90%). Footnotes are provided and should be used together with the flowchart