Effect of nurse initiated X-rays of the lower limb on patient transit time through the emergency department

Abstract

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 (172.9minutes (min) for EPIX to 158.6min 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 57.6min EPIX, 93.4min NIX, p<0.001) (median 45.0min in EPIX, 78.0min 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.