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The current clinical practice of general orthopaedic surgeons in the treatment of lateral ankle sprain: a questionnaire survey in Miyazaki, Japan. BMC Musculoskelet Disord 2021; 22:636. [PMID: 34303350 PMCID: PMC8310605 DOI: 10.1186/s12891-021-04527-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lateral ankle sprain (LAS) is one of the most common musculoskeletal injuries. Numerous studies regarding LAS have been performed. However, there are few studies evaluating the current clinical practice of orthopaedic surgeons regarding LAS. The purpose of this study was to evaluate the current clinical practice of general orthopaedic surgeons in the treatment of LAS. METHODS A questionnaire survey was conducted from September 2020 to December 2020 in Miyazaki, Japan, to evaluate the clinical practice of general orthopaedic surgeons in the treatment of LAS. The survey was composed of 12 questions that were developed with consideration of the recommendations in the current clinical practice guidelines (CPGs) published by the Dutch orthopaedic society. The questions in this study were focused on the diagnosis, conservative treatment, rehabilitation, and the criteria for return to sports (RTS). RESULTS The survey response rate was 82.7% (129/156). Among the respondents, 95.3% did not consider the Ottawa Ankle Rules in the decision to perform plain radiography for patients. Rehabilitation following LAS was performed in 58.9% of patients. Eighty-five (65.9%) of the surgeons used only one factor as the criterion for RTS. The absence of pain was the most frequently used criterion (45.7%). No objective criteria were used for the RTS decision in athletes with LAS. CONCLUSIONS The present study suggested that most general orthopaedic surgeons do not provide the care for patients with LAS recommended by the current CPGs. No objective criteria for the RTS decision are used for athletes with LAS.
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Effectiveness of nurse-initiated X-ray for emergency department patients with distal limb injuries: a systematic review. Eur J Emerg Med 2019; 26:314-322. [DOI: 10.1097/mej.0000000000000604] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Accuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department. CAN J EMERG MED 2018; 20:746-752. [PMID: 28965519 DOI: 10.1017/cem.2017.399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The Ottawa Ankle Rules (OAR) are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. The OAR are a reliable tool to exclude fractures in children over 5 years of age when applied by physicians. Limited data support its use by other health care workers in children. Our objective was to determine the accuracy of the OAR when applied by non-physician providers (NPP). METHODS Children aged 5 to 17 years presenting with an acute ankle or foot injury were enrolled. Phase 1 captured baseline data on x-ray use in 106 patients. NPPs were then educated on the usage of the OAR and completed an OAR learning module. In phase 2, NPPs applied the OAR to 184 included patients. RESULTS The sensitivity of the foot rule, as applied by NPP's, was 100% (56-100% CI) and the specificity was 17% (9-29% CI) for clinically significant fractures. The sensitivity of the ankle portion of the rule, as applied by NPP's, was 88% (47-99 CI) and the specificity was 31% (23-40% CI) for clinically significant fractures. The only clinically significant fracture missed by NPP's was detected on physician assessment. Inter-observer agreement was κ=0.24 for the ankle rule and κ=0.49 for the foot rule. CONCLUSION The sensitivity of the OAR when applied by NPP's was very good. More training and practice using the OAR would likely improve NPP's inter-observer reliability. Our data suggest the OAR may be a useful tool for NPP's to apply prior to physician assessment.
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Ho JKM, Chau JPC, Chan JTS, Yau CHY. Nurse-initiated radiographic-test protocol for ankle injuries: A randomized controlled trial. Int Emerg Nurs 2018; 41:1-6. [PMID: 29703591 DOI: 10.1016/j.ienj.2018.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/28/2018] [Accepted: 04/19/2018] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Nurse-initiated radiographic-test protocol was compared with usual practice in reducing unnecessary ankle and foot radiographic-test requests and shortening patients' length of stay (LOS) in an emergency department (ED) by reducing their waiting time for physician reassessment. METHODS Patients with ankle injuries were enrolled in an unblinded randomized controlled trial. Participants were randomized to receive either the protocol (n = 56) or usual practice (n = 56). Primary outcome was the proportion of radiographic-test requests. Secondary outcomes were the proportion of fractures detected and patients' LOS and waiting times. RESULTS The proportions of ankle and foot radiographic tests requested by triage nurses implementing the Ottawa Ankle Rules (OARs) in protocol group were smaller than those requested by physicians using their expertise in usual practice group. The proportions of malleolar and midfoot fractures detected by triage nurses implementing the OARs in protocol group were higher than those detected by physicians using their expertise in usual practice group. Patients' LOS and waiting time from consultation to discharge in protocol group were shorter than those in usual practice group. CONCLUSIONS Implementing the nurse-initiated radiographic-test protocol reduced unnecessary ankle and foot radiographic-test requests and shortened patients' LOS in the ED by reducing their waiting time for physician reassessment.
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Affiliation(s)
- Jonathan Ka-Ming Ho
- School of Nursing and Health Studies, The Open University of Hong Kong, 30 Good Shepherd Street, Homantin, Kowloon, Hong Kong.
| | - Janita Pak-Chun Chau
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
| | - Jimmy Tak-Shing Chan
- Accident and Emergency Department, Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, New Territories, Hong Kong.
| | - Caroline Hau-Yee Yau
- Accident and Emergency Department, Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, New Territories, Hong Kong
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Barelds I, Krijnen WP, van de Leur JP, van der Schans CP, Goddard RJ. Diagnostic Accuracy of Clinical Decision Rules to Exclude Fractures in Acute Ankle Injuries: Systematic Review and Meta-analysis. J Emerg Med 2017; 53:353-368. [PMID: 28764972 DOI: 10.1016/j.jemermed.2017.04.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 04/20/2017] [Accepted: 04/25/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ankle decision rules are developed to expedite patient care and reduce the number of radiographs of the ankle and foot. Currently, only three systematic reviews have been conducted on the accuracy of the Ottawa Ankle and Foot Rules (OAFR) in adults and children. However, no systematic review has been performed to determine the most accurate ankle decision rule. OBJECTIVES The purpose of this study is to examine which clinical decision rules are the most accurate for excluding ankle fracture after acute ankle trauma. METHODS A systematic search was conducted in the databases PubMed, CINAHL, PEDro, ScienceDirect, and EMBASE. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratio of the included studies were calculated. A meta-analysis was conducted if the accuracy of a decision rule was available from at least three different experimental studies. RESULTS Eighteen studies satisfied the inclusion criteria. These included six ankle decision rules, specifically, the Ottawa Ankle Rules, Tuning Fork Test, Low Risk Ankle Rule, Malleolar and Midfoot Zone Algorithms, and the Bernese Ankle Rules. Meta-analysis of the Ottawa Ankle Rules (OAR), OAFR, Bernese Ankle Rules, and the Malleolar Zone Algorithm resulted in a negative likelihood ratio of 0.12, 0.14, 0.39, and 0.23, respectively. CONCLUSION The OAR and OAFR are the most accurate decision rules for excluding fractures in the event of an acute ankle injury.
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Affiliation(s)
- Ingrid Barelds
- Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences, Eyssoniusplein, Groningen, the Netherlands; Physical Therapy Practice SKS, Thorbeckelaan, Assen, the Netherlands
| | - Wim P Krijnen
- Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences, Eyssoniusplein, Groningen, the Netherlands
| | - Johannes P van de Leur
- School of Health Studies, Physiotherapy, Hanze University of Applied Sciences, Eyssoniusplein, Groningen, the Netherlands
| | - Cees P van der Schans
- Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences, Eyssoniusplein, Groningen, the Netherlands; Department of Rehabilitation Medicine, University Medical Center, University of Groningen, Groningen, the Netherlands
| | - Robert J Goddard
- Physical Therapy Practice Noorderbad, Oosterhamrikkade, Groningen, the Netherlands
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Beckenkamp PR, Lin CWC, Macaskill P, Michaleff ZA, Maher CG, Moseley AM. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. Br J Sports Med 2016; 51:504-510. [PMID: 27884861 DOI: 10.1136/bjsports-2016-096858] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To review the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules and explore if clinical features and/or methodological quality of the study influence diagnostic accuracy estimates. DESIGN Systematic review with meta-analysis. DATA SOURCES MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Primary diagnostic studies reporting the accuracy of the Rules in people with ankle and/or midfoot injury were retrieved. Diagnostic accuracy estimates, overall and for subgroups (patient's age, profession of the assessor and setting of application), were made. Sensitivity analyses included studies with a low risk of bias and studies where all patients received radiographs. RESULTS 66 studies were included. Ankle and Midfoot Rules presented similar accuracies, which were homogeneous and high for sensitivity and negative likelihood ratios and poor and heterogeneous for specificity and positive likelihood ratios (mean, 95% CI pooled sensitivity of Ankle Rules: 99.4%, 97.9% to 99.8%; specificity: 35.3%, 28.8% to 42.3%). Sensitivity of the Ankle Rules was higher in adults than in children, but the profession of the assessor did not appear to influence accuracy. Specificity was higher for Midfoot than for Ankle Rules. There were not enough studies to allow comparison according to setting of application. Studies with a low risk of bias and where all patients received radiographs provided lower accuracy estimates. Specificity heterogeneity was not explained by assessor training, use of imaging in all patients and low risk of bias. CONCLUSIONS Study features and the methodological quality influence estimates of the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules.
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Affiliation(s)
- Paula R Beckenkamp
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,School of Science and Health, Western Sydney University, Australia.,Faculty of Health Sciences, The University of Sydney, New South Wales, Australia
| | - Chung-Wei Christine Lin
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Petra Macaskill
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Zoe A Michaleff
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Chris G Maher
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Anne M Moseley
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Ho JKM, Chau JPC, Cheung NMC. Effectiveness of emergency nurses’ use of the Ottawa Ankle Rules to initiate radiographic tests on improving healthcare outcomes for patients with ankle injuries: A systematic review. Int J Nurs Stud 2016; 63:37-47. [DOI: 10.1016/j.ijnurstu.2016.08.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 08/16/2016] [Accepted: 08/22/2016] [Indexed: 12/26/2022]
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Implementation of an Advanced Nursing Directive for Children With Right Lower Quadrant Pain: Identifying Those Requiring Further Investigation and Improving Flow Metrics. Pediatr Emerg Care 2016. [PMID: 26221789 DOI: 10.1097/pec.0000000000000475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Advanced nursing directives (ANDs) empower nursing staff to provide advanced levels of care before physician assessment. The objectives of this study were (1) to determine whether an AND for right lower quadrant (RLQ) pain could identify children who required any further investigation to diagnose appendicitis and (2) to determine whether children meeting AND criteria had better emergency department (ED) flow metrics compared with those who did not meet the criteria. METHODS Health records of children aged 3 to 17 years presenting to the ED with abdominal pain who were managed using the departmental AND for RLQ pain were reviewed. Primary outcomes included (1) the proportion of patients requiring further investigation to diagnose appendicitis and (2) the time interval from triage to blood draw. Secondary outcomes included additional ED flow metrics, perforation rate, and negative appendectomy rate. RESULTS An AND was completed for 210 children. Those who met the AND criteria were more likely to undergo further investigation to rule out appendicitis than those who did not meet the criteria (92/137 [67.2%] vs 32/73 [43.8%]; odds ratio [OR], 2.62; 95% confidence interval [CI], 1.40-4.90). Time to blood draw was significantly lower for those children meeting the AND criteria (74 vs 162 minutes, P < 0.001) as was time to hospital admission (271 vs 395 minutes, P = 0.008) and appendectomy (498 vs 602 minutes, P = 0.015). The negative appendectomy rate was 8.6% (5/58) for children meeting the AND criteria and 9.1% (2/22) for those not meeting the criteria (OR, 0.94; 95% CI, 0.14-10.67); the perforation rate was 29.3% (17/58) and 4.5% (1/22), respectively (OR, 8.17; 95% CI, 1.17-380.86). CONCLUSIONS Children presenting to the ED with RLQ pain who meet the AND criteria are more likely to require further investigation to rule out appendicitis and have better department flow metrics than those who do not meet the criteria. Our results provide further evidence of the utility of ANDs in the ED.
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Smith N, Curtis K. Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: An integrative review. ACTA ACUST UNITED AC 2016; 19:63-74. [PMID: 27005407 DOI: 10.1016/j.aenj.2016.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/22/2016] [Accepted: 01/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Well validated clinical decision rules exist to facilitate the safe removal of collars in the alert, orientated, low risk adult trauma patient, however this practice is traditionally conducted by medical staff. The aim of this review is to synthesise current evidence to determine the efficacy of emergency nurses in safely and accurately removing cervical spine collars using cervical spine rules, in alert, orientated, low risk trauma adult patients. METHODS A multi-method search strategy was used to find primary research studies followed by a rigorous screening and quality appraisal process. Data from included articles were extracted, grouped and synthesised. RESULTS Nine quantitative research articles resulted in four key findings: the inter-rater reliability between nurses and doctors clearing the cervical spine was high (kappa range (0.61-0.80)); nurses can safely implement the cervical spine clinical decision rule; use of a cervical spine clinical decision rule decreases the time patients are immobilised and; nurses felt confident applying a cervical spine clinical decision rule. CONCLUSION Appropriately trained emergency nurses can safely apply cervical spine rules to alert, orientated, low risk adult trauma patients. Implementation of nurses clearing cervical spines should include training and ongoing monitoring.
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Affiliation(s)
- Nicola Smith
- Sydney Nursing School, The University of Sydney, 88 Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Emergency Department, St. Vincents Public Hospital, 390 Victoria Street, Darlinghurst, Sydney 2010, Australia.
| | - Kate Curtis
- Sydney Nursing School, The University of Sydney, 88 Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Trauma Service, St George Hospital, Gray St, Kogarah 2217, Australia
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Mosher TJ, Kransdorf MJ, Adler R, Appel M, Beaman FD, Bernard SA, Bruno MA, Dempsey ME, Fries IB, Khoury V, Khurana B, Roberts CC, Tuite MJ, Ward RJ, Zoga AC, Weissman BN. ACR Appropriateness Criteria acute trauma to the ankle. J Am Coll Radiol 2016; 12:221-7. [PMID: 25743919 DOI: 10.1016/j.jacr.2014.11.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 11/20/2014] [Indexed: 12/26/2022]
Abstract
Acute ankle injuries are frequently diagnosed and treated in emergency departments and outpatient clinics. Recent evidence-based clinical treatment guidelines and systematic review of economic analyses support the use of 3-view (anteroposterior, lateral, and mortise) radiographic evaluation of patients meeting the criteria of the Ottawa ankle rules. Cross-sectional imaging has a limited secondary role primarily as a tool for preoperative planning and as a problem-solving technique in patients with persistent symptoms and suspected of having occult fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- Timothy J Mosher
- Penn State University, Milton S. Hershey Medical Center, Hershey, Pennsylvania.
| | | | - Ronald Adler
- New York University Center for Musculoskeletal Care, New York, New York
| | - Marc Appel
- Warwick Valley Orthopedic Surgery, Warwick, New York; American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | | | - Stephanie A Bernard
- Penn State University, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Michael A Bruno
- Penn State University, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | - Ian Blair Fries
- American Academy of Orthopaedic Surgeons, Rosemont, Illinois; Bone, Spine and Hand Surgery, Chartered, Brick, NJ
| | - Viviane Khoury
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Adam C Zoga
- Thomas Jefferson University, Philadelphia, Pennsylvania
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Jonckheer P, Willems T, De Ridder R, Paulus D, Holdt Henningsen K, San Miguel L, De Sutter A, Roosen P. Evaluating fracture risk in acute ankle sprains: Any news since the Ottawa Ankle Rules? A systematic review. Eur J Gen Pract 2015; 22:31-41. [PMID: 26691309 DOI: 10.3109/13814788.2015.1102881] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Ankle sprain is frequently encountered, both in primary care and in emergency departments. Since 1992, the Ottawa ankle rules (OAR) can assist clinicians in determining whether an X-ray should be performed to exclude a fracture. Several guidelines recommend the use of OAR based on a systematic review from 2003. Ten years later, one can wonder if this recommendation should be changed. OBJECTIVE To review systematically the current evidence on the most accurate method to assess the fracture risk after an ankle sprain in adults. METHODS A methodical search for systematic reviews, meta-analyses and primary studies was carried out in Medline, Cochrane Database of systematic reviews, Embase, Pedro, CINAHL, Medion and specific guideline search engines. At least two independent researchers performed selection, quality appraisal (with validated checklists) and data extraction. RESULTS One systematic review and 21 primary studies were selected. Sensitivity and specificity of the OAR range from 92-100% and from 16-51%, respectively. To improve the OAR specificity, other tools are proposed such as the Bernese ankle rules. Vibrating tuning fork test and ultrasound could be useful in patient with OAR positive to decrease the need for radiographs. No evidence was found in favour of the use of magnetic resonance imaging (MRI) or computed tomography (CT) in the acute phase of ankle sprain. CONCLUSION The findings confirm the value of the OAR at ruling out fractures after an ankle sprain and propose other or additional tools to decrease the need for X-rays.
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Affiliation(s)
| | - Tine Willems
- b Department of Physiotherapy and Orthopedics , Ghent University , Belgium ;,c Department of Rehabilitation Sciences and Physiotherapy , Ghent University , Belgium
| | - Roel De Ridder
- c Department of Rehabilitation Sciences and Physiotherapy , Ghent University , Belgium
| | | | | | | | - An De Sutter
- d Department of Family Medicine and Primary Health Care , Ghent University , Belgium
| | - Philip Roosen
- c Department of Rehabilitation Sciences and Physiotherapy , Ghent University , Belgium
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Derksen RJ, Knijnenberg LM, Fransen G, Breederveld RS, Heymans MW, Schipper IB. Diagnostic performance of the Bernese versus Ottawa ankle rules: Results of a randomised controlled trial. Injury 2015; 46:1645-9. [PMID: 25933807 DOI: 10.1016/j.injury.2015.03.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/30/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE The Ottawa ankle rules (OAR) brought about a reduction of radiographs on the Emergency Department (ED). However, still 50% of patients with ankle injuries undergo unnecessary radiography. Compared to the OAR, the Bernese ankle rule (BAR) has an acclaimed 84% reduction in radiography without loss of sensitivity. The primary aim of this study was to compare the diagnostic accuracy and reproducibility of both rules. Furthermore, the ability of triage nurses to accurately interpret the BAR was assessed. METHODS Participants were assessed by both the ED resident and the triage nurse, applying the OAR and the BAR. After standardised data collection, ankle and foot radiographs were performed in all patients. Sensitivity and specificity of both tests applied by both observers were obtained and compared by McNemar's test. Reproducibility was calculated with Cohen's kappa. RESULTS A total of 203 patients with ankle trauma were included. For the OAR obtained by the ED residents, the sensitivity and specificity were 0.97 and 0.29, respectively. For the BAR, the sensitivity and specificity of the ED residents were 0.69 and 0.45, respectively. For the triage nurses, the OAR sensitivity and specificity were 0.86 and 0.25, respectively. The BAR sensitivity and specificity for the nurses were 0.86 and 0.40, respectively. The reproducibility of the OAR was 0.45, and for the BAR, it was 0.48. CONCLUSION Both rules showed comparable reproducibility. Although the BAR showed a superior specificity compared to the OAR, its sensitivity was too low to promote clinical use. The triage nurses demonstrated too low sensitivity on both rules to allow safe application. Therefore, the OAR remain the decision rules of choice for ankle injuries despite its modest 'ruling out' capacity.
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Affiliation(s)
- Robert J Derksen
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands.
| | - Lisa M Knijnenberg
- Department of Emergency Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Gerwin Fransen
- Department of Radiology, Zaans Medical Centre, Zaandam, The Netherlands
| | | | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
| | - Inger B Schipper
- Department of Traumasurgery, Leiden University Medical Centre, Leiden, The Netherlands
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Effect of Triage Nurse Initiated Radiography Using the Ottawa Ankle Rules on Emergency Department Length of Stay at a Tertiary Centre. CAN J EMERG MED 2015; 18:90-7. [PMID: 26189587 DOI: 10.1017/cem.2015.67] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the effect of triage nurse initiated radiographs using the Ottawa Ankle Rules (OAR) on emergency department (ED) throughput. We hypothesized OAR use would reduce median ED length of stay (LOS) by 25 minutes or more. METHODS A randomized controlled trial was conducted at a tertiary centre ED with an annual census of over 90,000 patients. Adult patients presenting within 10 days of isolated blunt ankle trauma were eligible. Participants were randomly assigned to standard triage or OAR application by 15 explicitly trained triage nurses. Our primary outcome was ED LOS. Secondary outcomes included triage nurses' and patients' satisfaction. A power calculation indicated 142 patients were required. The Mann-Whitney U test was used to compare the medians between the two groups. RESULTS Of 176 patients with blunt ankle injury screened, 146 were enrolled (83.0%); baseline characteristics in the two groups were similar. The median/mean ED LOS in the control and OAR groups were 128/143 minutes and 108/115 minutes respectively (median difference 20 minutes; p=0.003). Agreement in OAR use between emergency physicians and nurses was moderate (kappa 0.46/0.77 for foot/ankle rule components), and satisfaction of both nurses and participants was high. CONCLUSION Triage nurse initiated radiography using OAR leads to a statistically significant decrease of 20 minutes in the median ED LOS at a tertiary care centre. The overall impact of implementing such a process is likely site-specific, and the decision to do so should involve consideration of the local context.
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Gould SJ, Cardone DA, Munyak J, Underwood PJ, Gould SA. Sideline coverage: when to get radiographs? A review of clinical decision tools. Sports Health 2014; 6:274-8. [PMID: 24790698 PMCID: PMC4000478 DOI: 10.1177/1941738114529701] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
CONTEXT Sidelines coverage presents unique challenges in the evaluation of injured athletes. Health care providers may be confronted with the question of when to obtain radiographs following an injury. Given that most sidelines coverage occurs outside the elite level, radiographs are not readily available at the time of injury, and the decision of when to send a player for radiographs must be made based on physical examination. Clinical tools have been developed to aid in identifying injuries that are likely to result in radiographically important fractures or dislocations. EVIDENCE ACQUISITION A search for the keywords x-ray and decision rule along with the anatomic locations shoulder, elbow, wrist, knee, and ankle was performed using the PubMed database. No limits were set regarding year of publication. We selected meta-analyses, randomized controlled trials, and survey results. Our selection focused on the largest, most well-studied published reports. We also attempted to include studies that reported the application of the rules to the field of sports medicine. STUDY DESIGN Retrospective literature review. LEVEL OF EVIDENCE Level 4. RESULTS The Ottawa Foot and Ankle Rules have been validated and implemented and are appropriate for use in both pediatric and adult populations. The Ottawa Knee Rules have been widely studied, validated, and accepted for evaluation of knee injuries. There are promising studies of decision rules for clinically important fractures of the wrist, but these studies have not been validated. The elbow has been evaluated with good outcomes via the elbow extension test, which has been validated in both single and multicenter studies. Currently, there are no reliable clinical decision tools for traumatic sports injuries to the shoulder to aid in the decision of when to obtain radiographs. CONCLUSION Clinical decision tools have been developed to aid in the diagnosis and management of injuries commonly sustained during sporting events. Tools that have been appropriately validated in populations outside the initial study population can assist sports medicine physicians in the decision of when to get radiographs from the sidelines.
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Affiliation(s)
- Sara J Gould
- Regional Orthopedics, New York, New York ; Department of Emergency Medicine, NYU Langone Medical Center, New York, New York
| | - Dennis A Cardone
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York ; Center for Musculoskeletal Care, NYU Langone Medical Center, New York, New York
| | - John Munyak
- Department of Orthopedics Surgery, Maimonides Medical Center, Maimonides Bone & Joint Center, New York, New York
| | - Philipp J Underwood
- Department of Emergency Medicine, Sports Medicine, North Shore-LIJ Health System, Manhasset, New York
| | - Stephen A Gould
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
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Nigrovic LE, Schonfeld D, Dayan PS, Fitz BM, Mitchell SR, Kuppermann N. Nurse and physician agreement in the assessment of minor blunt head trauma. Pediatrics 2013; 132:e689-94. [PMID: 23979081 DOI: 10.1542/peds.2013-0909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) clinical prediction rules identify children with minor blunt head trauma who are at low risk for clinically important traumatic brain injuries. We measured the agreement between the registered nurse (RN) and physician (MD) assessments. METHODS We performed a cross-sectional study of all children <18 years of age with minor blunt head trauma who presented to a single emergency department. RNs and MDs independently assessed each child and recorded age-based PECARN predictors. As symptoms can change over time, we included cases only when both evaluations were completed within 60 minutes. We used the κ statistic to measure RN-MD agreement, with the main analysis focusing on the overall PECARN rule agreement. RESULTS Of the 1624 eligible children, 1191 (73%) had evaluations completed by both RN and ED providers, of which 437 (37%) were in children <2 years of age. The median time between completions of the provider forms was 12 minutes (interquartile range 4-25 minutes). The overall agreement between the RN and MD was higher for the older children (κ 0.55, 95% confidence interval 0.49-0.61 for children 2-18 years versus κ 0.32, 95% confidence interval 0.23-0.41 for children <2 years). CONCLUSIONS The overall agreement between RN and MD for the PECARN TBI prediction rules was moderate for older children and fair for younger children. Initial RN assessments should be verified by the MD before clinical application, especially for the youngest children.
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Affiliation(s)
- Lise E Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA.
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Nurse practitioners treating ankle and foot injuries using the Ottawa Ankle Rules: A comparative study in the emergency department. ACTA ACUST UNITED AC 2013; 16:110-5. [DOI: 10.1016/j.aenj.2013.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 04/18/2013] [Accepted: 05/27/2013] [Indexed: 12/26/2022]
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Wang X, Chang SM, Yu GR, Rao ZT. Clinical value of the Ottawa ankle rules for diagnosis of fractures in acute ankle injuries. PLoS One 2013; 8:e63228. [PMID: 23646202 PMCID: PMC3640009 DOI: 10.1371/journal.pone.0063228] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 04/04/2013] [Indexed: 12/26/2022] Open
Abstract
Background The Ottawa ankle rules (OAR) are clinical decision guidelines used to identify whether patients with ankle injuries need to undergo radiography. The OAR have been proven that their application reduces unnecessary radiography. They have nearly perfect sensitivity for identifying clinically significant ankle fractures. Objectives The purpose of this study was to assess the applicability of the OAR in China, to examine their accuracy for the diagnosis of fractures in patients with acute ankle sprains, and to assess their clinical utility for the detection of occult fractures. Methods In this prospective study, patients with acute ankle injuries were enrolled during a 6-month period. The eligible patients were examined by emergency orthopedic specialists using the OAR, and then underwent ankle radiography. The results of examination using the OAR were compared with the radiographic results to assess the accuracy of the OAR for ankle fractures. Patients with OAR results highly suggestive of fracture, but no evidence of a fracture on radiographs, were advised to undergo 3-dimensional computed tomography (3D-CT). Results 183 patients with ankle injuries were enrolled in the study and 63 of these injuries involved fractures. The pooled sensitivity, specificity, positive predictive value and negative predictive value of the OAR for detection of fractures of the ankle were 96.8%, 45.8%, 48.4% and 96.5%, respectively. Our results suggest that clinical application of the OAR could decrease unnecessary radiographs by 31.1%. Of the 21 patients with positive OAR results and negative radiographic findings who underwent 3D-CT examination, five had occult fractures of the lateral malleolus. Conclusions The OAR are applicable in the Chinese population, and have high sensitivity and modest specificity for the diagnosis of fractures associated with acute ankle injury. They may detect some occult fractures of the malleoli that are not visible on radiographs.
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Affiliation(s)
- Xin Wang
- Department of Orthopedics, Tongji Hospital of Tongji University, School of Medicine, Shanghai, China.
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Salazar L, Best TM, Hiestand B. Incomplete documentation of elements of Ottawa Ankle Rules despite an electronic medical record. Am J Emerg Med 2011; 29:999-1002. [DOI: 10.1016/j.ajem.2010.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 04/16/2010] [Accepted: 05/17/2010] [Indexed: 12/26/2022] Open
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Clement CM, Stiell IG, Davies B, O'Connor A, Brehaut JC, Sheehan P, Clavet T, Leclair C, MacKenzie T, Beland C. Perceived facilitators and barriers to clinical clearance of the cervical spine by emergency department nurses: A major step towards changing practice in the emergency department. Int Emerg Nurs 2011; 19:44-52. [PMID: 21193167 DOI: 10.1016/j.ienj.2009.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 11/25/2009] [Accepted: 12/14/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We conducted a validation study on use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients (N=3633). This survey sought to identify potential facilitators and barriers to an implementation policy that would allow nurses to clinically clear the c-spine of minor trauma patients. METHODS We conducted a prospective quantitative survey of ED nurses in six hospitals. Questions were developed from a previous qualitative survey at the same validation study EDs. RESULTS 158 ED nurses were surveyed and 137 (86.7%) responded. Nurses strongly endorsed potential facilitators for nursing clearance of the c-spine, including 'Like to try new things at work' (96.4%) and 'Easy for me to take on new responsibilities' (96.4%). Most respondents were comfortable applying the rule (89.1%). Nurses endorsed potential barriers but at much lower rates, with the most common being 'Heavy workload makes it difficult to use the rule' (37.2%). Variation existed among hospitals for the facilitator 'Use of the rule would be useful to my practice', ranging from 81.8% to 100% endorsement (P=0.004). CONCLUSIONS This survey was an important step towards the goal of empowering ED nurses to clinically clear the c-spine of alert and stable trauma patients. There was a high rate of endorsement of facilitators and a low rate of endorsement of barriers. We found variation between hospitals, emphasizing the importance of understanding local beliefs when seeking to change clinical practice. We are conducting an implementation trial based on this feedback.
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Affiliation(s)
- Catherine M Clement
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.
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Boutis K, Constantine E, Schuh S, Pecaric M, Stephens D, Narayanan UG. Pediatric emergency physician opinions on ankle radiograph clinical decision rules. Acad Emerg Med 2010; 17:709-17. [PMID: 20653584 DOI: 10.1111/j.1553-2712.2010.00787.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The Low Risk Ankle Rule (LRAR) is a validated clinical decision rule (CDR) about the indications for ankle radiographs in children with acute blunt ankle trauma. Although application of the LRAR has the potential to safely reduce the rate of ankle radiography by 60%, current x-ray rates in most emergency departments (EDs) in the United States and Canada remain unnecessarily high (85%-100%). To evaluate this gap between knowledge and practice, physicians who treat pediatric ankle injuries in EDs were surveyed to determine physician awareness and use of the LRAR, acceptability of the LRAR as measured by the Ottawa Acceptability for Decision Rules Scale (OADRS), and perceived barriers to the use of a validated pediatric ankle x-ray rule. METHODS An on-line survey of members of two national pediatric emergency medicine (PEM) physician associations in the United States and Canada was conducted using a modified Dillman technique. RESULTS Response rates were 75.6% (149/197) in Canada and 45.7% (352/770) in the United States, yielding an aggregate rate of 51.8%. Only 119 of 478 respondents (24.9%) had heard of the LRAR, and 53 of 432 (12.3%) were sufficiently familiar with the LRAR to apply it. The LRAR scored a mean (+/- standard deviation [SD]) OADRS score of 4.28 out of 6 (+/-0.67), comparable to published OADRS scores for two well-known CDRs used in adults. Of the respondents, 434 of 471 (92.1%) at least "slightly agreed" that ankle x-ray CDRs would be useful in their practice, with no significant differences between the two sides of the border (p = 0.28). Ankle x-ray rules were felt to save time by 342 (72.6%) of the participants, and the pediatric ankle exam was considered easy enough to apply a CDR by 306 (65.0%). The most common barriers reported for use of any ankle x-ray rule included perceived reduction in family satisfaction without imaging in 380 (80.7%), nurse-initiated x-ray protocols not based on ankle x-ray rules in 285 (60.5%), concerns about missing a significant fracture in 248 (52.7%), and a preference for own clinical judgment in 246 (52.2%). CONCLUSIONS Although the LRAR had a high acceptability score among respondents in this survey, this validated CDR is not widely known and is even less frequently applied by PEM physicians in the United States and Canada. Barriers were identified that will guide efforts to improve the knowledge translation of the LRAR into pediatric EDs.
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Affiliation(s)
- Kathy Boutis
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Ontario, Canada.
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Stiell IG, Clement CM, O'Connor A, Davies B, Leclair C, Sheehan P, Clavet T, Beland C, MacKenzie T, Wells GA. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ 2010; 182:1173-9. [PMID: 20457772 DOI: 10.1503/cmaj.091430] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospectively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses. METHODS We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form. RESULTS Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%-100.0%) and specificity of 43.4% (95% CI 42.0%-45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%-95.0%) and a specificity of 43.9% (95% CI 42.0%-46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases. CONCLUSION Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Department of Nursing, Ottawa Hospital, Ottawa, Ontario.
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Derksen RJ, Coupé VMH, van Tulder MW, Veenings B, Bakker FC. Cost-effectiveness of the SEN-concept: Specialized Emergency Nurses (SEN) treating ankle/foot injuries. BMC Musculoskelet Disord 2007; 8:99. [PMID: 17908322 PMCID: PMC3225880 DOI: 10.1186/1471-2474-8-99] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Accepted: 10/01/2007] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Emergency Departments (EDs) are confronted with progressive overcrowding. As a consequence, the workload for ED physicians increases and waiting times go up with the risk of unnecessary complications and patient dissatisfaction. To cope with these problems, Specialized Emergency Nurses (SENs), regular ED-nurses receiving a short, injury-specific course, were trained to assess and treat minor injuries according to a specific protocol. METHODS An economic evaluation was conducted alongside a randomized controlled trial comparing House Officers (HOs) and SENs in their assessment of ankle and foot injuries. Cost prices were established for all parts of healthcare utilization involved. Total costs of health care utilization were computed per patient in both groups. Cost-effectiveness was investigated by comparing the difference in total cost between groups with the difference in sensitivity and specificity between groups in diagnosing fractures and severe sprains. Finally, cost-effectiveness ratios were calculated and presented on a cost-effectiveness plane. RESULTS No significant differences were seen between treatment groups for any of the health care resources assessed. However, the waiting times for both first assessment by a treatment officer and time spent waiting between hearing the diagnosis and final treatment were significantly longer in the HO group. There was no statistically significant difference in costs between groups. The total costs were euro 186 (SD euro 623) for patients in the SEN group and euro 153 (SD euro 529) for patients in the HO group. The difference in total costs was euro 33 (95% CI: - euro 84 to euro 155). The incremental cost-effectiveness ratio was euro 27 for a reduction of one missed diagnosis and euro 18 for a reduction of one false negative. CONCLUSION Considering the benefits of the SEN-concept in terms of decreased workload for the ED physicians, increased patient satisfaction and decreased waiting times, SENs appear to be a useful solution to the problem of ED crowding.
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Affiliation(s)
- Robert J Derksen
- Department of Surgery/Traumatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Veerle MH Coupé
- Department of Clinical Epidemiology and Biostatistics, VU University Medical Center Amsterdam, The Netherlands
- Institute for Research in Extramural Medicine (EMGO), VU University Medical Center Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Institute for Research in Extramural Medicine (EMGO), VU University Medical Center Amsterdam, The Netherlands
- Institute for Health Sciences, Faculty of Earth and Life Sciences, VU University, Amsterdam, The Netherlands
| | - Bart Veenings
- Department of Surgery/Traumatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Fred C Bakker
- Department of Surgery/Traumatology, VU University Medical Center, Amsterdam, The Netherlands
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Derksen RJ, Bakker FC, de Lange-de Klerk ESM, Spaans IM, Heilbron EA, Veenings B, Haarman HJTM. Specialized emergency nurses treating ankle and foot injuries: a randomized controlled trial. Am J Emerg Med 2007; 25:144-51. [PMID: 17276802 DOI: 10.1016/j.ajem.2006.06.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2006] [Revised: 06/15/2006] [Accepted: 06/16/2006] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To cope with emergency departments (EDs) being progressively overcrowded, the concept of specialized emergency nurses (SENs) was conceived. In this study, the ability of SENs to treat ankle/foot injuries was assessed. METHODS Regular emergency nurses were trained in a 2-day session that addressed all aspects of ankle/foot injuries. A randomized controlled trial was set up in which the diagnostic accuracy of SENs was compared with that of house officers (HOs). Secondary outcome parameter was patient satisfaction measured by a standardized questionnaire. RESULTS In total, 512 consecutive patients were included. The sensitivity of SENs was 0.94 (95% confidence interval [CI], 0.78-0.99) compared with 0.78 (95% CI, 0.57-0.91) of HOs. Specificity was 0.94 (95% CI, 0.90-0.97) for SENs compared with 0.95 (95% CI, 0.91-0.98) for HOs. The delivered care by SENs was found to be significantly better and the median waiting time at the ED was significantly reduced (21 minutes for SENs vs 32 minutes for HOs). CONCLUSIONS Specialized emergency nurses are capable of assessing and treating ankle/foot injuries accurately with excellent patient satisfaction and with a reduction of waiting times. Other injury-specific courses are now developed for this approach.
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Affiliation(s)
- Robert Jan Derksen
- Department of Surgery/Traumatology, VU University Medical Center Amsterdam, 1007 MB Amsterdam, The Netherlands.
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