A randomized, controlled trial of radiograph ordering for extremity trauma in a pediatric emergency department

Ann Emerg Med. 1993 Oct;22(10):1524-9. doi: 10.1016/s0196-0644(05)81252-1.


Study objectives: The objectives of this study were to determine whether triage nurses using the Brand protocol would order fewer radiographs than would physicians carrying out standard practice procedures, without missing an increased number of joint or bone injuries; the test characteristics and the interobserver reliability of the Brand protocol; and whether having triage nurses order radiographs could reduce total patient waiting time in the emergency department.

Design: Randomized, controlled trial.

Setting: The ED of a free-standing children's hospital with approximately 55,000 visits annually.

Type of participants: Children less than 18 years of age who had a history of extremity trauma in the preceding seven days.

Interventions: Triage nurses applied the Brand protocol to determine the need for a radiograph.

Measurements and results: Of the Brand protocol group, 81.9% had radiographs ordered compared with 87.1% of the control group (P = .03). The percent of positive radiographs was 40.8% in the Brand protocol group compared with 42.6% in the control group (P = .21). There were 3.2% (16) missed radiographic findings in the Brand protocol group compared with none in the control group (P < .001). Patients randomized to the Brand protocol group spent 3.3 hours in the ED compared with 3.6 hours for the control group (P < .001).

Conclusion: Having triage nurses use the Brand protocol reduced the number of radiographs ordered but at the same time increased the number of missed radiographic findings. However, having triage nurses order radiographs also significantly shortened waiting time in the ED.

Publication types

  • Clinical Trial
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Arm Injuries / diagnostic imaging*
  • Arm Injuries / nursing
  • Child
  • Child, Preschool
  • Clinical Protocols
  • Emergency Service, Hospital
  • Hospitals, Pediatric
  • Humans
  • Leg Injuries / diagnostic imaging*
  • Leg Injuries / nursing
  • Nursing Diagnosis
  • Observer Variation
  • Predictive Value of Tests
  • Radiography / standards
  • Radiography / statistics & numerical data
  • Sensitivity and Specificity
  • Triage / methods*
  • Triage / standards