Do X-rays Requested By Triage Nurses Decrease Waiting Times?

Research in Health and Social Care

Introduction:
Since 1991 when the patient’s charter (Department of Health 1991) was introduced, Accident and Emergency (A&E) departments have been under pressure to see, treat and discharge patients within a certain time period. In 1991 75% of walking wounded who presented to the department had to be discharged within one hour. It was subsequently changed in 2004 when the government decided that 98% of all patients attending an A&E department should be in the department no longer than four hours (Department of Health 2004). And again in 2011 when the department of health introduced the clinical care indicators that relaxed the target to 95% seen, treated and discharged or admitted in 4 hours (Department of Health 2011).
Triage nurses within the accident and emergency department are one of the first people to assess the patients who present with an injury or illness. The patient’s condition is assessed and their need for how quickly they require treatment is prioritised. Triage nurses are usually experienced A&E nurses who have many years A&E experience (Dolan et al 2007).
Patients are then placed in queues to await assessment by a Doctor or Emergency Nurse Practitioner. Once seen they are then put in another queue to await x-ray if necessary before waiting again to see the doctor/ENP that will interpret their x-ray and decided on the best course of treatment (Ward 1999).
Many patients have long waits within the department for x-rays and assessments, and this can increase violence and aggression towards staff. (Davis 1994a, Parris et al 1996).
In 1996 the Audit Commission suggested that NHS trust allow triage nurses to request certain x-rays at triage (limb x-rays). Research Question:-
In view of the above issue of patients waiting to see a Doctor when the triage nurse is able to assess the patients and know that the patient will need an x-ray, I have devised the following research question:
Do x-rays requested by the triage nurse decrease patient waiting times in the Accident and Emergency Department?

Terms:
For this critical appraisal certain terms are used which are defined as follows:
Triage nurse: Qualified nurse with A&E experience who assesses the patients and “sorts” them into categorises of priority. (Dolan et al 2007)
Hit: X-rays taken with positive fractures.

Literature Searching:
“A review of the English Language literature on triage nurse requesting x-rays reduce waiting times was undertaken. Searches for publications on triage nurse requesting x-rays reduce waiting times were made of Medline, the British Nursing Index, CINAHL, Journals, books and relevant national and international organisations, reference lists and other forms of relevant references were encountered. For the Medline, CINAHL and the British Nursing Index searches the following terms were entered: X-rays, A&E waiting times. Specific subjects headings under which searches were made were: Triage nurse requested x-rays, decrease waiting times. The last electronic search was made on the 16th December 2011” (Cowan 2009).

Main:
For this particular study I will critique research literature that has explored how x-rays requested at triage has affected waiting times. It is of interest to me, as working in triage I assess many patients who I feel will need an x-ray to determine their injuries and subsequently their treatment. As a registered nurse I am unable to request x-rays and feel that patients then go on to have a long wait to see the doctor who will then examine the patient and request the x-ray.
Researching this specific subject may, (or may not), depict that this course of action may be warranted to reduce waits in our A&E department and so change our practice for the benefit of the patients.
For this particular study I chose four research papers to explore. The papers were written between 1992 and 2000. I have had particular difficulty in finding papers written more recently on the subject. As to why this is can only be assumed, but with so many recent changes in the NHS this may be an area that needs no further exploration at the present time.
The papers I chose were from different journals including both nursing and medical journals. Each article was of quantatiive research and so are more of a traditional scientific method (Burns et al 2009). The research questions are put forward in advance and the results are displayed in statistical manner. The papers use methods of data collection such as questionnaire surveys and other measuring tools. Data collection is usually empirical and in these articles the objective measures are time. These can be easily observed and recorded and so reduce the degree of error and bias (Polit et al 2012).
Objective measures are thought to be more valid and reliable and so each of these articles has the potential to be superior research papers (Parahoo 2006).

A.J. Macleod and P. Freeland, Should nurses be allowed to request x-rays in an accident and emergency department. 1992.
The authors appeared to be doctors of an A&E dept in Scotland. This was the oldest article of which I critiqued.
The paper however, does not state their credentials or even how long they have worked in the department. It is simplistically written with no literature reviews or references throughout the article.
The article is a quantitative paper that obtains information from a defined group. It starts with a reasonable level one research question and the article explores the reduction of patient waiting times of those whose x-rays are requested by the triage nurse. As there is no abstract there is no justification as to why this piece of research is indicated. It is not until the conclusion that it considers patient waiting time within the department.
A study design is discussed in the article, with a controlled study of 579 randomly selected patients. These patients were selected during one month. How the patients were randomly selected was not discussed. The article goes on to explain the findings of their study but only 493 patients were actually discussed. There is no explanation as to the 86 losses that occurred. This purposive sample uses the available cases during the allocated month.
The article suggests it will test the ability of the triage nurse to request x-rays. However it does not state the nurse’s qualifications or the length of experience within the department. It appears no training was given on requesting x-rays, but a criteria as to what injuries were required for the study to be x-rayed was discussed.
The statistics are from a randomly controlled trial which are fact based and so there is no bias. It provides bivariate data. Comparison of the dependent variable (measurement of doctors waiting time) against the variable data (nurses requesting x-rays waiting time). The statistics are provided as graphs supplying precise data regarding measurement of time.
It ends with not so much a conclusion but more discussion that triage nurses involved with independent decisions on x-rays were successful in decreasing patient waiting times.
Overall I feel the article lacked any credibility. It does provide a good base for future research and is referenced in further work on the subject.

Lindley-Jones, M & Finlayson, B.J. Triage Nurse requested x-rays – the results of a national survey. 2000b.
This paper looks at the results of a national survey that was posted to 225 A&E departments to examine how many had a triage nurse request x-ray service and its policy for use. The article states how the departments were chosen and who the questionnaires were sent to. The quantitative paper was a narrative of the results found and did not statically analyse the data collected. It provided non-experimental and descriptive data.
Questionnaire surveys sent out by post tend not to have a good response rate. This paper clearly stated how many surveys were sent (225) and how many replies were received (165). It also clearly stated that it omitted a couple of survey responses as the departments were not accident and emergency departments.
The questions were standardised and structured to ensure that a standard response was received with no debate. They measured the prevalence of the nurse requested x-rays in A/E departments.
The results were presented in fact based manner that gave no room for interpretation. During the result findings there is no biased but in the discussion the author is extremely biased towards his own department and their nurse requested x-ray system. It could be perceived that the authors designed the questionnaire so to endorse own system and the positive outcomes. It clearly stated the more positive results of having a triage nurses requesting x-rays but yet only a third of respondents have this service in place. With no literature search and references there has been no support that this service is evidence based and beneficial to the A&E departments.
The only reference made in the article pertained to a paper written by the same authors in 2000a. This article contained many references that could have been used in research paper.
The conclusion doesn’t support the findings but the results are fact based and as no audit criteria has been added to the research; the results can only be taken at face-value.

Thurston, J. & Field, S. Should Accident and Emergency Nurses request radiographs? Results of a multicentre evaluation. 1996
This article appeared to be the most comprehensive in its evaluation of the study into triage nurse requesting x-rays so as to decrease patient waiting time.
The abstract provided a clear and concise objective, and went onto explain the design of the study. The results were also demonstrated and were the most negative in their findings.
The study involved four a/e departments that were to train their own nurses on radiology requests. There was no protocol to the training and so was very biased as each hospital did the training differently.
The patients were all randomly selected at reception by a random number generator. Each hospital had a sample size of 500 patients that were entered into the study. Although no training protocol an inclusion criteria was established.
Only 1833 patients were used successfully in the study. The losses were explained.
Computer software was used to analyse the statistics from each hospital. The findings from each hospital are displayed as tables breaking down into percentages and median times. The tables did not clearly compare the times waiting by patients but instead seemed to give findings that aren’t explained or appear to have nothing to do with the study. During the summary of findings the author’s state patient waiting times that have not been displayed in any of the previous tables and so confusion as to how these statistics have been found
Despite the study being about nurses requesting x-rays, if the radiographer decided that what the nurse had requested was not appropriate they had been instructed to take x-rays of what they deemed more appropriate. The statistics for these were not stated in the results.
The study contradicts itself throughout the discussion. At one point stating that only a 4 min saved if no x-ray and seen by nurse first, then 36 minutes if seen by nurse first and no x-ray requested. The objective of the paper seems to be lost the findings. The results do show 14 minutes can be saved should a nurse request x-ray at triage.
This study has been referenced since in papers but it is not reliable and validity is questionable.

Lindley- Jones, M & Finlayson, B.J. Triage Nurse requested x-rays – are they worthwhile? 2000a
This article I chose as the one to critique as it addressed the research question the most. This article once read appeared a very credible and robust research. It is well laid out, concise and grammatically correct.
Unfortunately, though the researchers’ credentials have not been listed. One of the authors is a consultant in the Accident and Emergency Department where the study was introduced. Equally the paper may be reliable and valid on its own merits and not just based on the researchers’ qualifications.
The abstract provided information on the purpose of the study, methodology used in pertaining the results, sample size, findings and conclusion.
As with all the other articles there is no literature review stated. The references date back 8 years with some more current within the last 5 years. It does relate back to a hypothetical study carried out by Davies and Finlayson in 1992, showing correlation and results of the nurse requested and the doctor requested x-rays. This however is the only study mentioned.
At the beginning of the article some theoretical framework is discussed. The researchers hypothesis that nurse requesting x-rays at triage, then patient waiting to see a Doctor or Emergency Nurse Practitioner, will give some advantages. Such as reducing patient waiting time, staff and patient satisfaction, and the patients will that believe that something is being done. Before the study was started the ENP and Doctors were treated as one group. This was validated to see ensure that both professionals were consistent in there requesting of x-rays. It was stated in the paper how this was observed and the outcomes.
There was a clear link between the purpose of the study and how the study was to be conducted with clear objectives presented.
The study describes itself to be a randomised control trial. Patients are randomly allocated into one of two groups. Those seen by a nurse and an x-ray requested and those in a control group – the more traditional triage of seeing the nurse and then waiting to see the doctor who would order the necessary x-rays. This random allocation avoids bias in the selection of patients.
The paper illustrated well, the design of the study and how it measured the concept of the study. It articulated well the process in which the data were collected. It was consistent and therefore reliable. Validity comes into question, as it was down to those filling in the forms correctly and concisely. The sample size selected was less than 0.5% of total annual patients presenting to the department each year. This could be seen as a comparatively small sample size, and not representative of the population. This may lead to an inability to prove that nurse requested x-rays do decrease waiting times. A comprehensive criterion to include/exclude patients was provided but as to qualifications of the triage nurse it was just stated that the nurse was “well-established”.
The results were well laid out and tables and graphs were used to explain the results. As over 50% of the sample participated bias could be avoided.
During the discussion the authors indicate in the study that patient waiting times did decrease if triage nurses requested x-rays. They go onto to support these findings from previous literature. Within the discussion there is a bit about how nurses have lower request rates but higher hit rate. It goes onto explain how this is due to nurses x-ray those who are very likely to have a fracture, whereas doctors/ENP may x-ray to exclude pathology.
The authors also discuss how a previous article by Thurston and Field portrayed the research question with negative results. Having had personal communication with the authors, Lindley and Finlayson, explain how the triage nurses for Thurston paper had variable x-ray requesting experience. Whereas the nurses in this study all had a one day training programme on how to request x-rays.
In the paper it is explained how with the appropriate designed protocols and training for the triage nurses on requesting x-rays, the study can be
The authors explain the clinical significance of the study and how it has gone on to improve patient experience within the department and better communication between staff. They are going to continue with this system.
No ethical rights/approval was sort for this study but it was clear that the researchers treated all as equals and beneficence.
The references used were up to date and applied to the research question.

Longitudinal study over a month? Problem of sample attrition
Sample probability
Verification of hypothesis being correct.
Does not describe personal experience of patient

Conclusion
Generally most of the research into triage nurses requesting x-rays to decrease waiting time is over a decade old. The studies have all shown to have an impact on waiting times and so, with new guidelines and policies demanded by the government into reducing waiting times, it is indicated that more research.
The quantitative papers explored in this study are important in underpinning evidence based practice. They are all testing an intervention that has positive outcomes for the patients.
For further research to be valid, the studies would need to be more robust. With adequate training the triage nurse is more than capable in displaying this vital role that can improve patient care.

.
Concerned with objective measurement – statistics.

Reference.
Audit Commission. 1996. By Accident or design: Improving Emergency Care in Acute Hospitals. London, HMSO.
Burns, N. & Grove, S.K., 2009. The Practice of Nursing Research.6 th ed. Missouri, Saunders Elsevier.
Chudleigh, J. 2004, "Nurse requested X-rays in A&E department", Emergency Nurse, vol. 11, no. 9, pp. 32-36.
Cowan, D. 2009. Research Issues in Health and Social Care. 1st ed. Cumbria, M&K Update Ltd.
Cutcliffe, J. & Ward, M. 2007. Critiquing Nursing Research. 2nd ed. London, Quay Books.
Davies, J. 1994 “Establishing a nurse request x-ray service”, Accident and Emergency Nursing, vol. 2, pp. 54-56.
Department of Health. 1991. The Patients Charter and You. London HMSO.
Department of Health. 2004. 4 Hour Checklist – Reducing delays for A&E Patients. London HMSO.
Department of Health. 2011. Reforming Urgent and Emergency Care Performance Management. London HMSO.
Dolan, B. & Holt, L. 2007. Accident and Emergency – Theory into Practice. 2nd ed. Missouri, Elsevier Health Sciences.
Holloway, I, & Wheeler, S. 2010. Qualitative Research in Nursing and Healthcare. 3rd ed. Oxford, Wiley-Blackwell.
Kelly, A.M., McCarthy, S., Richardson, S., Parris, W. & Kerr, A.M., 1995 “Triage nurse initiated x-rays are accurate”, Emergency Medicine, vol. 7, no. 2, pp. 81-84.
Lee, K.M., Wang, T.W., Chan, R., Lau, C.C., Fu, Y.K. & Fung, F.H. 1996 “Accuracy and efficiency of x-ray requests initiated by triage nurses in A&E”, Accident and Emergency Nurse, vol. 4, no. 4, pp. 179-181. Lindley-Jones, M. & Finlayson, B.J. 2000, “Triage nurse requested x rays – are they worthwhile?”, Journal of Accident and Emergency Medicine, vol.17, pp.103-107. Lindley-Jones, M. & Finlayson, B.J. 2000, “Triage nurse requested x rays – the results of a national survey”, Journal of Accident and Emergency Medicine, vol17. Pp108-110.
Lobiando-Wood, G & Haber, J. 2010 Nursing Research, Methods and Critical Appraisal for Evidence Based Practice. 7th ed. Missouri, Mosby Elsevier.
Macleod, A.J. & Freeland, P. 1992, “Should nurse be allows to request x-rays in an accident and emergency department?”, Archives of Emergency Medicine, Vol. 9, pp. 19-22.
Parahoo, K. 2006. Nursing Research, Principles, Process and Issues. 2nd ed. Basingstoke. Palgrave Macmillan
Parris, W., Mc McCarthy, S., Kelly, A.M. & Richardson, S., 1997 “Do triage nurse initiated x-rays for limb injuries reduce patient transit times?”, Accident and Emergency Nursing, vol. 5 pp. 14-15.
Polit, D.F., & Beck, C.T., 2012. Nursing Research. 9th ed. Philadelphia, Lippincott, Williams & Wilkins.
Thurston, J. & Field, S. 1996. “Should Accident and Emergency Nurses Request radiographs? Result of a multicentre evaluation”, Journal of Accident and Emergency Medicine, Vol. 13. pp 83-89.
Ward, W. 1999. “Key issues in nurse requested x-rays”, Emergency Nurse, vol. 6, no9, pp.19-23.

Do I Need?
Christien, Lin, Deboom, R., Naomi & Lucas, C. 2011, "Refining a triage system for use in emergency departments", Emergency Nurse, vol. 19, no. 2, pp. 22-24.
Gardner, A. & Gardner, G. 2005, "A trial of nurse practitioner scope of practice", Journal of Advanced Nursing, vol. 49, no. 2, pp. 135-145.
Griffin, M. & Melby, V. 2006, "Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors", Journal of Advanced Nursing, vol. 56, no. 3, pp. 292-301. Keane, A.K., Tyrrell, M. & O'Keefe, A. 2008, "Advanced nurse practitioners: improving patients' journeys", Emergency Nurse, vol. 16, no. 6, pp. 30-35. Lankova, A. 2006, "The accountability of emergency nurse practitioners", Emergency Nurse, vol. 14, no. 6, pp. 20-25.
Larkin, G.L. & Hooker, R.S. 2010, "Patient Willingness to Be Seen by Physician Assistants, Nurse Practitioners, and Residents in the Emergency Department: Does the Presumption of Assent Have an Empirical Basis?", American Journal of Bioethics, vol. 10, no. 8, pp. 1-10
Lowe, G. 2010, "Scope of emergency nurse practitioner practice: where to beyond clinical practice guidelines?", Australian Journal of Advanced Nursing, vol. 28, no. 1, pp. 74-82.
Matheny Antommaria, A. & Melini, J. 2010, "Is It Reasonable to Refuse to Be Seen by a Nurse Practitioner in the Emergency Department?", American Journal of Bioethics, vol. 10, no. 8, pp. 15-17.
Norris, T. & Melby, V. 2006, "The Acute Care Nurse Practitioner: challenging existing boundaries of emergency nurses in the United Kingdom", Journal of Clinical Nursing, vol. 15, no. 3, pp. 253-263. Rowe, R. & Crouch, R. 2003, "Faculty of emergency nursing pilot study: part one", Emergency Nurse, vol. 10, no. 9, pp. 32-37.
Wilson, A. & Shifaza, F. 2008, "An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department", International Journal of Nursing Practice, vol. 14, no. 2, pp. 149-156.
Wilson, A., Zwart, E., Everett, I. & Kernick, J. 2009, "The clinical effectiveness of nurse practitioners' management of minor injuries in an adult emergency department: a systematic review", International Journal of Evidence-Based Healthcare, vol. 7, no. 1, pp. 3-14.
Wilson, G. 2005, "Issues. The case for advanced practice nurses in ED", Australian Nursing Journal, vol. 13, no. 4, pp. 17.