Effect of triage-based use of the Ottawa foot and ankle rules on the number of orders for radiographic imaging.

CONTEXT: Reducing unnecessary testing lessens the cost burden of medical care, but decreasing use depends on consistently following evidence-based clinical decision rules. The Ottawa foot and ankle rules (OFARs) are validated, longstanding evidence-based guidelines to predict fractures. Frequently, radiography is automatically ordered for acute ankle injuries despite findings from OFARs suggesting no fracture. OBJECTIVES: First, to determine whether implementation of protocol-driven use of the OFARs at triage would decrease the number of radiography orders and length of stay (LOS) in the emergency department. Second, to quantify the incidence of OFARs use at triage and to assess patient expectations of radiography use and patient satisfaction as rated by both patients and clinicians. METHODS: In this prospective, 2-stage sequential pilot study, patients with acute ankle and foot injuries were screened in the emergency department between January 2013 and October 2013. In the first stage, clinicians (physician assistants, residents, and attending physicians) performed their usual practice habits for radiography use in the control group. For the second stage, they were educated to appropriately apply the OFARs before ordering radiography. For patients who were suspected of having a fracture at triage, nursing staff ordered radiography. For patients who were not suspected of having a fracture at triage, a clinician reassessed them using the OFARs after their triage assessment. Radiography was then ordered at the discretion of the clinician. Results gathered after training in the OFARs comprised the intervention group. After discharge, patients were surveyed regarding their expectations and satisfaction, and clinicians were surveyed on their perceptions of patient satisfaction. RESULTS: A total of 131 patients were screened, 62 patients were enrolled in the study after consent was obtained, and 2 patients withdrew from the study prematurely, leaving 30 patients in each group. Fifty-eight of the 60 patients (97%) underwent radiography. Emergency department LOS decreased from 103 minutes to 96.5 minutes (P=.297) after the OFARs were applied. There was also a decrease in LOS in patients with a fracture (137 minutes vs 103 minutes [P=.112]). Radiography was expected to be ordered by 27 of 30 patients in the control group (90%) and 24 of 30 in the intervention group (80%) (P=.472). Patients were equally satisfied among the groups (54 of 60 [90%]) (with no difference between groups), and 27 of 30 (90%) vs 30 of 30 (100%) clinicians in the control and intervention groups, respectively, perceived that patients were satisfied with their treatment. CONCLUSION: There was no statistical evidence that application of the OFARs decreases the number of imaging orders or decreases LOS. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.

An examination of ESI triage scoring accuracy in relationship to ED nursing attitudes and experience.

INTRODUCTION: This research was designed to examine if there is a difference in nurse attitudes and experience for those who assign Emergency Severity Index (ESI) scores accurately and those who do not assign ESI scores accurately. Studies that have used ESI scoring discussed the role of experience, but have not specifically addressed how the amount of experience and attitude towards patients in triage affect the triage nurse's decision-making capabilities. METHODS: A descriptive, exploratory study design was used. Data from 64 nurses and 1,644 triage events at 3 emergency departments was collected. Participants completed demographic data, attitude (Caring Nurse Patient Interaction, CNPI-23) survey, and triage data collection tools during the continuous 8-hour triage shift. Clinical nurse expert raters retrospectively reviewed the charts and assigned an ESI score to be compared with the nurse. Descriptive statistics were used to describe the nurse and Pearson's correlation was used to examine the relationship between experience and attitude. RESULTS: In this study of 64 nurse participants, the ESI score assigned by nurse participants did not differ significantly based on years of experience or CNPI mean score. The Kappa statistic ranged from a high of 0.63 in the nurse participant with 1.00 to 1.99 years of experience to a low of 0.51 in the nurse participant with 15 to 19 years of experience. The nurse participants with an overall mean CNPI-23 score of 106 to 115 achieved the highest agreement compared with a single participant with a CNPI-23 overall mean score of less than 77 who had a Kappa agreement of 0.50. The nurse participants with a CNPI-23 overall mean score between 81 and 92 demonstrated agreement of 0.54 to 0.60. DISCUSSION: Based on the high level of liability the triage area presents, special consideration needs to be made when deciding which nurse should be assigned to that area. The evidence produced from this study should provide some reassurance to ED managers and nurses alike that nurses with minimal ED experience and a working understanding of the ESI 5-level triage algorithm possess the knowledge and the capacity to safely and appropriately triage patients in the emergency department.