Triage Nurse Initiated Radiographs According to OAR

• Fracture missed by Triage Nurse: [ Time Frame: Estimated at 6 months. ] [ Designated as safety issue: No ]
  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
• Triage nurses' satisfaction [ Time Frame: estimated at 6 months ] [ Designated as safety issue: No ]
  Assess triage nurse' feedback regarding comfortability in applying the OAR, training, and whether the OAR has increased workload.
• Percent agreement regarding necessity for X-ray between emergency nurse and physician [ Time Frame: estimated at 6 months ] [ Designated as safety issue: Yes ]
• Emergency physician's compliance with OAR [ Time Frame: estimated at 6 months ] [ Designated as safety issue: No ]
  Determine if emergency physicians are applying OAR during this study period
• Patient satisfaction with triage nurse initiated imaging [ Time Frame: Estimated at 6 months ] [ Designated as safety issue: No ]

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.

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.

• Experimental: OAR group
  Patients with ankle injuries who are assessed by OAR trained triage nurses applying the OAR.
  Intervention: Other: Triage nurses applying the OAR
• No Intervention: Control for OAR Triage Nurses
  Patients with ankle injuries that are seen by OAR triage nurses but not assessed in accordance with the OAR.

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