Triage Nurse Initiated Radiographs According to OAR

Can Triage Nurse Initiated Radiographs in Accordance With the Ottawa Ankle Rule Shorten Emergency Department Length of Stay At a Tertiary Care Center?

The purpose of the study is to help doctors in emergency departments know whether triage nurse initiated radiographs, in accordance to the Ottawa ankle rule, before emergency physician assessment will shorten emergency patients' visit. The investigators will examine the number of missed fractures between the two groups, the emergency physicians' willingness to apply OAR and triage nurses' satisfaction.

Study Overview

• Status: Unknown
• Conditions: Ankle Fracture
• Intervention / Treatment: Other: Triage nurses applying the OAR

Detailed Description

Overcrowding in the emergency department (ED) has been an ongoing issue for many hospitals in North America. Numerous strategies have been implemented and explored in hopes of reducing wait times and length of stay. The Ottawa ankle rules are one such strategy developed and proven to reduce cost and wait time without patient dissatisfaction and missed fractures. As a result, they have gained widespread acceptance from emergency physicians around the world.

Since the implementation of the Ottawa ankle rules (OAR), numerous studies have examined nurses' application and interpretation of these rules. It has been shown that nurses' application of the rule yield similar sensitivity and negative predictability for diagnosis of fractures as physicians. It is believed that emergency nurses can make accurate assessment in the determination of the patients who require radiographs. What is unclear, however, is whether or not triage nurse initiated radiographs shortens patients' length of stay in the emergency department, a factor inversely correlated to patient satisfaction. Only a couple of studies have looked at this issue in the context of the Ottawa ankle rules. One is a retrospective study conducted at an A&E department in a small city while the other, although randomized prospectively, was carried out in an urgent care center rather than in a busy academic tertiary care hospital.

Our primary objective for this study is to investigate the median length of stay of patients presenting to a tertiary care academic center with blunt ankle injuries and assess whether triage nurse initiated radiographs in accordance to the Ottawa ankle rules would shorten their stay versus current standard of care. Presently, the emergency physician orders the x-ray at the time of patient encounter.

• Study Type: Interventional
• Enrollment (Anticipated): 142
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Jan Buchanan, BSN; Phone Number: 6048754205; Email: Jan.Buchanan@vch.ca
• Study Contact Backup: Name: Lyne Filiatrault, MD; Email: filiatra@mail.ubc.ca

Study Locations

• Canada
  • British Columbia
    • Vancouver, British Columbia, Canada, V5Z 1M9
      • Recruiting
      • Vancouver General Hospital
      • Contact: Jan Buchanan, BSN; Phone Number: 6048754205; Email: Jan.Buchanan@vch.ca
      • Contact: Wailliam W Lee, MD; Email: wailliamlee37@gmail.com
      • Principal Investigator: Wailliam Lee, MD
      • Principal Investigator: Lyne Filiatrault, MD, FRCPC
      • Principal Investigator: Ryiad Abu-Laban, MD, MHSc, FRCPC

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 19 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients aged ≥ 19 presenting with an isolated blunt ankle injury

Exclusion Criteria:

• Injury >10 days
• Isolated skin injury
• Referred patient with outside x-ray
• Obvious fracture or deformity
• Polytrauma
• Pregnancy
• Diminished sensation due to neurological deficit
• Uncooperative, intoxicated or patients with altered mental status
• Patients returning for reassessment of same injury
• Injury due to or suspicious for domestic violence

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: OAR group; Patients with ankle injuries who are assessed by OAR trained triage nurses applying the OAR.	Other: Triage nurses applying the OAR; Triage nurses applying the OAR during assessment and ordering foot/ankle x-rays as necessary.
No Intervention: Control for OAR Triage Nurses; Patients with ankle injuries that are seen by OAR triage nurses but not assessed in accordance with the OAR.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Median length of stay (LOS) of patients presenting to a tertiary care academic center with blunt ankle injuries	Median LOS will be measured and compared among patients with ankle injuries that were assessed by OAR trained triage nurses who applied the OAR and ordered X-rays if necessary vs those patients who were triaged as per usual practice, with no OAR application.	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Fracture missed by Triage Nurse:	Assess if fractures were missed by triage nurse via + X-rays ordered by EP or via follow-up questionnaire 2 weeks later to determine if other investigations were performed after the pt's visit to the ED	Estimated at 6 months.
Triage nurses' satisfaction	Assess triage nurse' feedback regarding comfortability in applying the OAR, training, and whether the OAR has increased workload.	estimated at 6 months
Percent agreement regarding necessity for X-ray between emergency nurse and physician		estimated at 6 months
Emergency physician's compliance with OAR	Determine if emergency physicians are applying OAR during this study period	estimated at 6 months
Patient satisfaction with triage nurse initiated imaging		Estimated at 6 months

Collaborators and Investigators

• Sponsor: Vancouver Coastal Health
• Collaborators: University of British Columbia
• Investigators: Principal Investigator: Lyne Filiatrault, MD, FRCPC, Vancouver Coastal Health Authorities; Principal Investigator: Wailliam W Lee, MD, Vancouver Costal Health Authorities; Principal Investigator: Ryiad Abu-Laban, MD, MHSc, FRCPC, Vancouver Costal Health Authorities

Study record dates

Study Major Dates

• Study Start: July 1, 2012
• Primary Completion (Anticipated): January 1, 2013
• Study Completion (Anticipated): February 1, 2013

Study Registration Dates

• First Submitted: July 27, 2012
• First Submitted That Met QC Criteria: July 30, 2012
• First Posted (Estimate): July 31, 2012

Study Record Updates

• Last Update Posted (Estimate): September 12, 2012
• Last Update Submitted That Met QC Criteria: September 10, 2012
• Last Verified: September 1, 2012

More Information

Terms related to this study

• Keywords: Triage nurse; Ottawa ankle rules
• Additional Relevant MeSH Terms: Fractures, Bone; Wounds and Injuries; Ankle Fractures
• Other Study ID Numbers: H12-01352