Requesting Wrist Radiographs in Emergency Department Triage

Abstract

Crowding is extremely problematic in Canada, as the emergency department (ED) utilization is considerably higher than in any other country. Consequently, an increase has been noted in waiting times for patients who present with injuries of lesser acuity such as wrist injuries. Wrist fractures are the most common broken bone in patients younger than 65 years. Many nurses employed within EDs are requesting wrist radiographs for patients who present with wrist complaints as a norm within their working practice. Significant potential advantages can ensue if EDs adopt a triage nurse-requested radiographic protocol; patients can benefit from a significant time-saving of 36% in ED length of stay (M. Lindley-Jones & B. J Finlayson, 2000)— when nurses initiated radiographs in triage. In addition, the literature suggests that increased rates of patient and staff satisfaction may be achieved, without compromising quality of radiographic request or quality of service (W. Parris,S. McCarthy, A. M. Kelly, & S. Richardson, 1997). Studies have shown that nurses are capable of requesting appropriate radiographs on the basis of a preset protocol. As there are no standardized set of rules for assessing patients, presenting with suspected wrist fractures, a training program as well as a diagnostic algorithm was developed to prepare emergency nurses to appropriately request wrist radiographs. The triage nurse-specific training program includes the following topics: wrist anatomy and physiology, commonly occurring wrist injuries, mechanisms of injury, physical assessment techniques, and types of radiographic images required. The triage nurse algorithm includes the clinical decision-making process. Providing triage nurses with up-to-date evidence-based educational material not only allowed triage nurses to independently assess and request wrist radiographs for patients with potential wrist fractures but also strengthening the link between competent nursing care and better patient outcomes. A review of the literature also found that such initiatives increase patient and staff satisfaction as well as promoting efficient use of right staff at the right time.

CORR Synthesis: What Triage Recommendations Are Available for Emergent or Urgent Musculoskeletal Conditions?

“…We found a variety of studies describing triage practices in the outpatient primary care or orthopaedic setting [9, 16], ED setting [1, 2, 8, 10, 12, 19, 25, 32, 34], and in the trauma center setting [5, 7]. Although we did not find any studies related specifically to triage practices in the UCC or MUCC setting, some of the triage guidelines intended for use in the ED may be adapted for use in urgent care facilities.…”

“…The triage providers ordered fewer radiographs than medical staff, and these radiographs were more likely to reveal abnormalities [8]. We found another study in which the authors developed a triage algorithm for wrist radiographs that providers could use in the ED [25], but this study did not include patient data. This algorithm was designed to assess patients for injuries that would require radiographs and includes questions that address whether the patient has a history of wrist trauma, any evidence of an open fracture or neurovascular compromise, severe wrist pain or other serious injuries, deformity or swelling of the wrist, anatomic snuff box tenderness, or distal radius or ulna tenderness [25].…”

“…We assessed eight studies using the MINORS criteria for comparative studies, for which the We assessed four studies using the MINORS criteria for noncomparative studies, for which the ideal score is 16 and the median (range) score of these studies was 8 (8 to 12) (Supplementary Table 2; http://links.lww.com/CORR/A866). We could not assess one study using the MINORS criteria because this article did not include patient data [25].…”

“…We found two articles detailing triage guidelines for use in the trauma care setting focusing on upper extremity trauma [5] and pelvic fractures [7]. The remaining seven articles were related to triage guidelines to determine when to order imaging in the ED after an ankle [1,2], wrist [25], knee [12,19,32], or distal extremity injury [8] (Table 1).…”

“…Additionally, many of the studies we found in our review were published in the early 2000s. Of the 13 studies included in our final review, only four were published after 2010 [5,9,10,25]. Of the seven studies specific to imaging in the ED, only one was published after 2010 [25].…”