Triage Nurse Initiated Radiographs According to OAR

Study Overview
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Brief Summary
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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.

Detailed Description
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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.

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

Conditions
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Ankle Fracture

Intervention / Treatment
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* Other: Triage nurses applying the OAR


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 19 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

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


Arms and Interventions

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

What is the study measuring?
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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 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Triage nurse, Ottawa ankle rules