Do triage nurse-initiated X-rays for limb injuries reduce patient transit time?

doi:10.1016/S0965-2302(97)90056-4

Accident and Emergency Nursing

Volume 5, Issue 1, January 1997, Pages 14-15

https://doi.org/10.1016/S0965-2302(97)90056-4 Get rights and content

Abstract

Patients with isolated limb injuries are often required to wait a long time for treatment and investigation in emergency departments. It was hypothesized that allowing triage nurses to initiate X-rays would reduce transit times for these patients. A prospective, randomized comparison trial of 175 patients was conducted, comparing transit times between a group of patients who had X-rays initiated at triage and a group which did not. No statistically significant reduction in transit time was demonstrated by this change in practice, either for a group who had sustained fractures or for one which had not. Despite this finding, staff and patient satisfaction with this change in procedure was high. This justifies continuation of the practice and further research.

References (3)

J. Davies
X-ray vision of shorter queues
Nursing Times
(1994)

There are more references available in the full text version of this article.

Cited by (31)

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Triage Nurse-Ordered Testing in the Emergency Department Setting: A Review of the Literature for the Clinician
2021, Journal of Emergency Medicine
Citation Excerpt :
Of the three ‘adequate’ LOS studies, all three showed a minor reduction in LOS for triage nurse-ordered studies with varying degrees of clinical significance. Parris et al. designed an RCT (n = 175 patients) comparing nurse-initiated vs. physician-initiated x-ray study ordering in ED transit time (a correlate of LOS) and found no statistically significant change in transit time for the nurse or physician groups (p = 0.37 and 0.14, respectively) (10). Lee et al. conducted a prospective, observational study (n = 934 patients) comparing nurse-initiated x-ray study vs. physician-ordered x-ray study to determine correlation and impact on LOS (11).
In an effort to decrease length of stay (LOS) and reduce overcrowding, many emergency departments (ED) have implemented triage nurse-ordered testing.
To review the medical literature to determine the utility of triage nurse-ordered testing and to offer evidence-based recommendations to emergency physicians.
A systematic search of the PubMed literature was performed for publication in English from inception to November 30, 2019 using a combination of the following keywords: “triage,” “nurse,” “protocol,” and “emergency.” The articles were screened for relevance and the selected studies were subjected to detailed review by all of the authors and assigned a grade of evidence based on focus, research design, and methodology. Recommendations were drawn from the findings.
The initial search yielded a total of 982 potentially relevant studies; 13 articles were ultimately selected for inclusion. Of these, 10 studies assessed ED LOS, with one study assessing time to diagnosis. The three remaining studies compared triage nurse-ordered testing with physician testing in the ED setting.
Triage nurses have reasonably similar accuracy as physicians in ordering limb x-ray studies and moderate accuracy for laboratory testing. However, we did not identify a clinically meaningful decrease in ED LOS from the use of nursing triage orders.
Initiatives to reduce overcrowding and access block in Australian emergency departments: A literature review
2014, Collegian
Citation Excerpt :
Similarly, nurse initiated X-ray has been introduced in several EDs to decrease length of stay for patients with minor injuries (Blank, Santoro, Maynard, Provost, & Keyes, 2007; Bowman & Gerdtz, 2006; Fry, 2001; Parris, McCarthy, Kelly, & Richardson, 1997), and has been shown to decrease patient length of ED stay (Tambimuttu, Hawley, & Marshall, 2002). It has also been reported that patient satisfaction increased and staff perceived that patients were treated more quickly as a result of nurse initiated X-ray (Bowman & Gerdtz, 2006; Fry, 2001; Parris et al., 1997). Increasing nurses’ scope of practice to encompass nurse initiated analgesia, testing, and X-rays at triage has been shown to reduce patient length of stay and patient quality of care indicators.
Australian emergency departments are experiencing an increasing demand for their services. Patient throughput continues to expand resulting in overcrowding and access block where patients cannot gain entry to appropriate hospital beds. This is despite both state and federal governments implementing numerous schemes to address the complex causes of stress on emergency departments. This paper explores the current literature and highlights the key strategies adopted by different emergency departments to reduce delays and streamline patient flow, including: waiting room nurses; streaming; rapid assessment teams; short stay units and care coordination programmes. Many of these initiatives have proven successful at reducing the number of people re-presenting to the emergency department, addressing time delays and improving the management of existing resources and patient flow. More recent changes include increasing the scope of practice and workload for triage nurses. With the recent introduction of the National Emergency Access Target, which requires that most patients presenting to Australian emergency departments are reviewed and transferred or discharged from the department within 4 h, traditional roles of nurses in the emergency department are changing and expanding to meet the needs of modern healthcare systems.
An integrative review: Triage protocols and the effect on ED length of stay
2013, Journal of Emergency Nursing
Citation Excerpt :
The greatest time savings were recorded in those patients with acuity level 3. When protocols were initiated in triage, the mean time savings for TLOS ranged from 2.45 to 74 minutes.1,3,5,6,8,10,12 A mixture of variables were included in these statistics: multiple protocols, the presence or absence of procedures (casting/splinting), various sprains or fractures, and the presence or absence of fractures.
The purpose of this integrative review is to identify the effectiveness of using triage protocols to decrease ED length of stay. The review method described by Ganong was used to guide the review process. Data sources included CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline, the Cochrane Library, Mosby's Nursing Consult, and the National Guideline Clearinghouse. In addition, reference lists of all articles were reviewed, 3 authors of previous articles were contacted for more current or updated work, and a hand search of the Journal of Emergency Nursing was conducted. The search generated 56 articles, 8 of which met inclusion criteria. Data were interpreted and evaluated by use of a data summary sheet. Key conclusions drawn from the appraisals included that a decrease in length of stay was related to protocol use and nurses were able to initiate diagnostic testing and treatments appropriately. These conclusions apply to acuity levels 3 and 4, which require either little or no testing or require testing to facilitate a disposition decision. The implications for nursing are that appraisals of evidence lead to better practice decisions, protocols can provide greater nursing autonomy and satisfaction, and protocols are able to increase the facilitation of patient care in the emergency department.
Effect of nurse initiated X-rays of the lower limb on patient transit time through the emergency department
2012, Australasian Emergency Nursing Journal
Citation Excerpt :
A similar study by Salomone et al.,13 with 247 patients also showed that nurses could correctly apply the OAR, and Kec et al.14 showed good inter observer agreement (IOA) between nurses and EP's with regard to use of the validated Ottawa Knee Rules15 (OKR). Further studies have postulated16,17 a reduction in patient transit times through the ED with NIX, and although some have noted a reduction in this time, have failed to do so with statistical significance.17 It was noted that in our department, nurses would often ask EP's to sign X-ray requests for patients that they had assessed as needing X-rays, in order to expedite care.
To compare outcomes of nurse initiated X-rays (NIX) with emergency physician (EP) initiated X-rays (EPIX) of isolated lower limb injuries in patient transit time (from triage to discharge) through the emergency department (ED).
A prospective, interventional study using a historical control group. Data were collected at each contact point from triage (including time of EP's initial assessment of patient, X-ray request and review, patient disposition decision and discharge time). Initially, data were collected as patients proceeded through the ED having X-rays requested after EP assessment. Following nurse education on use of pre-validated foot, ankle and knee X-ray decision instruments, similar data were collected following nurse X-ray request. Time differences between the two groups were compared.
A total of 206 patients were enrolled, with 105 having EPIX and 101 NIX. Group characteristics were not significantly different. Fractures were identified in 26.7% of EPIX compared to 34.7% of NIX (p = 0.300). Despite an observed reduction in the mean transit time (172.9 minutes (min) for EPIX to 158.6 min for NIX) this did not achieve statistical significance (p = 0.230). There were significant differences in times from triage to initial assessment by EP (mean 57.6 min EPIX, 93.4 min NIX, p < 0.001) (median 45.0 min in EPIX, 78.0 min in NIX group, p < 0.001) which delayed transit time in the NIX group.
Although NIX reduced patient transit times, this did not reach statistical significance. In an ED with substantial access block, this suggests that corresponding systems changes are required to improve ED flow.
Can nurses, working in the emergency department, independently clear cervical spines?: A review of the literature
2004, Accident and Emergency Nursing
The prompt clearance of a patient’s cervical spine is extremely beneficial both to the patients and the department however correct guidelines and education must be estabilished before this can be undertaken safely. This paper examines whether nurses given the appropriate training and education using appropriate diagnostic and clinical criteria can safely, effectively clear cervical spines without consulting a medical practitioner. The paper explores the use of the Nexus Guidelines [J.R. Hoffman, W.R. Mower, A.B. Wolfson, New England Journal of Medicine 343 (2) (2000) 94–99] as a clinical prediction tool and presents evidence for its use.

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Do triage nurse-initiated X-rays for limb injuries reduce patient transit time?

Abstract

X-ray vision of shorter queues

Nursing Times