Correlation between triage nurse and physician ordering of ED tests

doi:10.1016/S0735-6757(98)90057-2

The American Journal of Emergency Medicine

Volume 16, Issue 1, January 1998, Pages 8-11

https://doi.org/10.1016/S0735-6757(98)90057-2 Get rights and content

Abstract

Triage nurse ordering of tests can reduce patient time in the emergency department. This benefit must be balanced with the extra expense and potential morbidity of unnecessary tests. This study examined whether triage nurse ordering of lab tests and X-rays correlated with physician ordering. In Phase I, a prospective study, triage nurses completed an order form for each patient triaged during randomly selected 2-hour blocks over a 3-week period. In Phase II, Phase I was repeated with test ordering guidelines derived from Phase I results. Correlations of nurse and physician orders were analyzed by kappa statistics and paired t tests. In Phase I, 176 patients were enrolled of a possible 204 (82%). In Phase II, 350 patients were enrolled of a possible 418 (84%). The percentage of nurse overordering of tests in Phase I was 35%; in Phase II, it was 34% (P NS). Kappa values were determined for blood testing (Phase I, 0.48; Phase II, 0.54 [P = .048]), for X-ray (Phase I, 0.68; Phase II, 0.65 [P = .523]), for urinalysis (Phase I, 0.76; Phase II, 0.67 [P = .338]), and for electrocardiogram (Phase I, 0.78; Phase II, 0.77 [P = .438]). The Improved lab correlation in Phase II resulted from the nurses ordering fewer tests (P = .046). Nurses deviated from the test ordering guidelines in 37% of patients. Triage nurse ordering of X-rays, electrocardiogram, and urinalysis has moderate to substantial correlation with physician ordering. Correlation of triage nurse and physician ordering of tests can be improved with the use of test ordering guidelines.

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Recent decades have seen a steady increase in noncontrast head CT utilization in the emergency department with a concurrent rise in the practice of physician assistants (PAs) and nurse practitioners (NPs). The goal of this study was to identify ordering and patient characteristics predictive of positive noncontrast head CTs in the ED. We hypothesized NP/PAs would have lower positivity rates compared to physicians, suggestive of relative overutilization.
We retrospectively identified ED patients who underwent noncontrast head CTs at a single institution: a nonlevel 1 trauma center, during a 7-year period, recording examination positivity, ordering provider training/experience, and multiple additional ordering/patient attributes. Exam positivity was defined as any intracranial abnormality necessitating a change in acute management, such as acute hemorrhage, hydrocephalus, herniation, or worsening prior findings.
6624 patients met inclusion criteria. 4.6% (280/6107) of physician exams were positive while 3.7% (19/517) of NP/PA exams were positive; however, differences were not significant. Increasing provider experience was not associated with positivity. Attributes with increased positivity were patient age (p < 0.001), daytime exam (p < 0.05), and indications regarding malignancy (p < 0.001) or focal neurologic deficit (p = 0.001). Attributes with decreased positivity were indications of trauma (p < 0.001) or vertigo/dizziness (p < 0.05).
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Triage Nurse-Ordered Testing in the Emergency Department Setting: A Review of the Literature for the Clinician
2021, Journal of Emergency Medicine
Citation Excerpt :
Of these, two studies showed a decreased ED LOS from 55 to 46 min, and one showed a significant increase of 212 min between triage nurse-ordered and standard testing (14–16). Three studies compared triage nurse-ordered testing with physician testing in the ED setting (11,17,18). All three studies found reasonably good correlation between physicians and triage nurse-ordered imaging protocols, with 10.9% to 12.9% disagreement in two studies and a kappa of 0.65 to 0.68 in the third (11,17,18).
In an effort to decrease length of stay (LOS) and reduce overcrowding, many emergency departments (ED) have implemented triage nurse-ordered testing.
To review the medical literature to determine the utility of triage nurse-ordered testing and to offer evidence-based recommendations to emergency physicians.
A systematic search of the PubMed literature was performed for publication in English from inception to November 30, 2019 using a combination of the following keywords: “triage,” “nurse,” “protocol,” and “emergency.” The articles were screened for relevance and the selected studies were subjected to detailed review by all of the authors and assigned a grade of evidence based on focus, research design, and methodology. Recommendations were drawn from the findings.
The initial search yielded a total of 982 potentially relevant studies; 13 articles were ultimately selected for inclusion. Of these, 10 studies assessed ED LOS, with one study assessing time to diagnosis. The three remaining studies compared triage nurse-ordered testing with physician testing in the ED setting.
Triage nurses have reasonably similar accuracy as physicians in ordering limb x-ray studies and moderate accuracy for laboratory testing. However, we did not identify a clinically meaningful decrease in ED LOS from the use of nursing triage orders.
Experimental design and simulation applied to a paediatric emergency department: A case study
2019, Computers and Industrial Engineering
Citation Excerpt :
First, ED managers and physicians tend to be sceptical about the appropriateness of allowing nurses to prescribe, and second, parents tend to press for a physician’s assessment before submitting their children to tests they perceive as painful or harmful (e.g. blood tests, X-rays). However, evidence from general EDs (Fry, 2001; Lee et al., 1996; Seaberg & Macleod, 1998) suggests that nurses’ prescriptions do not differ significantly from those of physicians. Given that complementary examinations such as lab tests and radiology exams strongly determine patient LOS (Gardner, Sarkar, Maselli, & Gonzales, 2007), allowing a nurse to prescribe such tests early in the process (i.e. during triage) seems a promising way of reducing LOS and rationalising the utilisation of consultation rooms and physicians.
This study assesses the effectiveness of a novel organisational solution called anticipated treatment as a means of reducing crowding in paediatric emergency departments (PEDs) by shortening patient wait time and length of stay. This is the first published account of such an intervention in a PED, in which triage nurses can prescribe diagnostic tests for non-urgent respiratory or trauma patients before first assessment by a physician. The effectiveness of the proposed solution was assessed by simulating a real case at a leading Italian children’s hospital. Coupled with increased triage nurse staffing in winter months, implementation of anticipated treatment was found to reduce average pre-triage wait time, time to initial physician assessment and length of stay by 7.7%, 5% and 8.7%, respectively. More significantly, anticipated treatment shortened length of stay among respiratory and trauma patients by up to 44.6% and 14.5%, respectively. The study also compares the relative effectiveness of anticipated treatment and the see and treat protocol and discusses how these solutions can interact.
Registered nurse scope of practice and ED complaint-specific protocols
2013, Journal of Emergency Nursing
Citation Excerpt :
Likewise, the nurse may select a different set of orders from within an abdominal pain protocol for an elderly man with alcoholism who has upper right quadrant abdominal pain than for a sexually active, otherwise healthy, young female patient with pelvic pain. However, studies on the use of CSPs in the emergency department either do not outline the training offered, relay the training as a brief (1-hour) site-specific orientation, or assume that knowledge and skills are acquired through practice experience.3,4,18-20 Development of a standardized education program, modeled after Emergency Severity Index training,33 with documentation of individual RN knowledge, skill, and competency is indicated for states where CSPs may be allowed in the RN’s scope of practice.26
The use of complaint-specific protocols (CSPs) by emergency registered nurses (RNs) can improve ED efficiency. However, RN practice is influenced by regulatory environments that may facilitate or inhibit the use of protocols. The purpose of this policy analysis was to explore the language of state boards of nursing scope-of-practice documents related to the use of RN-initiated CSPs in the ED setting.
A qualitative descriptive design was used to investigate how the RN’s scope of practice relates to the use of CSPs in ED settings across states. Data were collected from state boards of nursing Web site documents.
Three major themes emerged: cautiously within scope, intentionally vague/silent, and outside scope. Seven states (Connecticut, Illinois, Kansas, Louisiana, New Jersey, New York, and Oklahoma) were identified where RN-initiated CSPs appear to be currently outside the RN’s scope of practice. Therefore 18% of the US population, or 55,973,900 people, resides in states where CSPs are not allowed.
State-to-state inconsistencies in the RN’s scope of practice may interfere with the implementation of practices that enhance ED efficiency. RNs in all states must ensure that they have the requisite knowledge, skill, and documented competency to implement CSPs, if supported by their employing facility. Efforts to standardize ED RN education and policy are warranted. Continued research is needed assess the impact of RN-initiated CSPs on the efficiency of ED care.
Expanding nurse initiated X-rays in emergency care using team-based learning and decision support
2013, Australasian Emergency Nursing Journal
Triage nurse initiated X-rays (NIXRs) are safe and effective, however, little is known about the ability of other RNs, particularly those without postgraduate qualifications in emergency nursing, to order NIXRs. The aim of this study was to evaluate an innovative NIXR education programme for emergency nurses.
The education programme was multi-faceted, delivered using Team-Based Learning (TBL) and augmented by a decision support checklist. Using a prospective exploratory design, 276 NIXR requests from June to December 2011 were audited. Three groups were compared: (i) RNs with and without postgraduate qualifications irrespective of how they were educated in NIXR, (ii) RNs with and without postgraduate qualifications who undertook the NIXR education programme, and (iii) RNs who did and did not undertake the NIXR programme irrespective of postgraduate qualifications.
There were 130 NIXRs by 28 RNs with postgraduate qualifications and 146 NIXRs by 12 RNs without postgraduate qualifications. Analysis of all RNs showed RNs without postgraduate qualifications had higher incidence of appropriate NIXRs (83.6% vs 66.2%, p = 0.003) however when controlled for the NIXR education programme, statistical significance was lost (83.6% vs 67.5%, p = 0.017). RNs who undertook the NIXR education programme had superior documentation of patient assessment findings and higher incidence of appropriate X-ray requests than RNs who did not undertake the NIXR education programme (80.4% vs 65.2%, p = 0.042).
With appropriate educational preparation, RNs without postgraduate qualifications in emergency nursing can safely engage in NIXR. Structured education using TBL and a decision support checklist produces superior assessment and X-ray requests when compared to ad hoc education and role modelling.
Optimizing Emergency Department Front-End Operations
2010, Annals of Emergency Medicine
Citation Excerpt :
Triage-based care protocols, also known as advanced triage protocols, have been offered as a way to improve ED front-end throughput. These standardized pathways are developed for specific disease conditions or complaints and allow the initiation of diagnostic, therapeutic, and management regimens based on patients' chief complaint or triage staff/primary nurse assessment when there is no immediate ED bed availability.32-40 The addition of a physician or physician extender (midlevel provider) to the triage assessment is an alternative strategy to advanced triage protocols.41-47
As administrators evaluate potential approaches to improve cost, quality, and throughput efficiencies in the emergency department (ED), “front-end” operations become an important area of focus. Interventions such as immediate bedding, bedside registration, advanced triage (triage-based care) protocols, physician/practitioner at triage, dedicated “fast track” service line, tracking systems and whiteboards, wireless communication devices, kiosk self check-in, and personal health record technology (“smart cards”) have been offered as potential solutions to streamline the front-end processing of ED patients, which becomes crucial during periods of full capacity, crowding, and surges. Although each of these operational improvement strategies has been described in the lay literature, various reports exist in the academic literature about their effect on front-end operations. In this report, we present a review of the current body of academic literature, with the goal of identifying select high-impact front-end operational improvement solutions.

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Supported by the Emergency Medicine Association of Pittsburgh.

Presented at the American College of Emergency Physicians Scientific Assembly, February 1995, San Francisco, CA, and the Pennsylvania Chapter of the American College of Emergency Physicians Annual Scientific Meeting, April 1993, Harrisburg, PA.

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Original contributionCorrelation between triage nurse and physician ordering of ED tests☆

Abstract

Ann Emerg Med

Ann Emerg Med

J Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Am J Emerg Med

Original contribution
Correlation between triage nurse and physician ordering of ED tests☆