A RANDOMIZED, CONTROLLED TRIAL OF RADIOGRAPH ORDERING FOR EXTREMITY TRAUMA IN A PEDIATRIC EMERGENCY DEPARTMENT

Study objectives: The objectives of this study were to determine wheth er triage nurses using the Brand protocol would order fewer radiograph s than would physicians carrying out standard practice procedures, wit hout missing an increased number of joint or bone injuries; the test c haracteristics and the interobserver reliability of the Brand protocol ; and whether having triage nurses order radiographs could reduce tota l patient waiting time in the emergency department. Design: Randomized , controlled trial. Setting: The ED of a free-standing children's hosp ital with approximately 55,000 visits annually. Type of participants: Children less than 18 years of age who had a history of extremity trau ma in the preceding seven days, Interventions: Triage nurses applied t he Brand protocol to determine the need for a radiograph. Measurements and results: Of the Brand protocol group, 81.9% had radiographs order ed compared with 87.1% of the control group (P = .03). The percent of positive radiographs was 40.8% in the Brand protocol group compared wi th 42.6% in the control group (P = .21). There were 3.2% (16) missed r adiographic findings in the Brand protocol group compared with none in the control group (P < .001). Patients randomized to the Brand protoc ol group spent 3.3 hours in the ED compared with 3.6 hours for the con trol group (P < .001). Conclusion: Having triage nurses use the Brand protocol reduced the number of radiographs ordered but at the same tim e increased the number of missed radiographic findings. However, havin g triage nurses order radiographs also significantly shortened waiting time in the ED.