Specialized emergency nurses treating ankle and foot injuries: a randomized controlled trial

Original Contribution

specialized emergency nurses treating ankle and foot injuries: a randomized controlled trialB

Robert Jan Derksen MDa,*, Fred C. Bakker MD, PhDa,

Elly S.M. de Lange-de Klerk MD, PhDb, Irma M. Spaansc, Emil A. Heilbron MD, PhDd,

Bart Veenings MDa, Henk J.Th.M. Haarman MD, PhDa

aDepartment of Surgery/Traumatology, VU University Medical Center Amsterdam, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands

bDepartment of Clinical Epidemiology and Biostatistics, VU University Medical Center Amsterdam, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands

cEmergency Department, VU University Medical Center Amsterdam, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands

dDepartment of Radiology, VU University Medical Center Amsterdam, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands

Received 23 April 2006; revised 15 June 2006; accepted 16 June 2006


Objective: To cope with emergency departments (EDs) being progressively overcrowded, the concept of specialized emergency nurses (SENs) was conceived. In this study, the ability of SENs to treat ankle/ foot injuries was assessed.

Methods: Regular emergency nurses were trained in a 2-day session that addressed all aspects of ankle/ foot injuries. A randomized controlled trial was set up in which the diagnostic accuracy of SENs was compared with that of house officers (HOs). Secondary outcome parameter was patient satisfaction measured by a standardized questionnaire.

Results: In total, 512 consecutive patients were included. The sensitivity of SENs was 0.94 (95% confidence interval [CI], 0.78-0.99) compared with 0.78 (95% CI, 0.57-0.91) of HOs. Specificity was

0.94 (95% CI, 0.90-0.97) for SENs compared with 0.95 (95% CI, 0.91-0.98) for HOs. The delivered care by SENs was found to be significantly better and the median waiting time at the ED was significantly reduced (21 minutes for SENs vs 32 minutes for HOs).

Conclusions: Specialized emergency nurses are capable of assessing and treating ankle/foot injuries accurately with excellent patient satisfaction and with a reduction of waiting times. Other injury-specific courses are now developed for this approach.

D 2007

B Fundings were supplied by the Surgery/Traumatology/Emergency Department, VU University Medical Center, Amsterdam, the Netherlands.

* Corresponding author. Tel.: +31 6 24748122; fax: +31 20 4443598.

E-mail address: [email protected] (R.J. Derksen).


Emergency departments (EDs) are confronted with progressive crowding, leading to long waiting times and unsatisfied patients [1-3]. Moreover, crowding increases the

0735-6757/$ – see front matter D 2007 doi:10.1016/j.ajem.2006.06.011

workload for the attending physicians and leads to late diagnoses, resulting in unnecessary complications and even, in described cases, in death [4-7].

A major reason for crowding is found in a growing number of patients coming to the ED without first consulting a general practitioner (self-referrals) [8,9]. These patients often present with minor injuries for which a short assessment and treatment usually suffice. With the intro- duction of Triage systems, treating such patients is often postponed on behalf of those with more urgent injuries, leading to even longer waiting times. Another reason for the high workload in EDs is the increasing shortage of physicians. The growing shortage in general practitioners in the Netherlands causes patients to bypass the general practitioners’ office and come to the ED straight away. In addition, there is a decline in the number of junior emergency physicians, making it difficult to address the problem by increasing the number of physicians [1].

To address ED crowding and relieve physician short- age, the professions of advanced nurse practitioner (ANP) and physician assistant (PA) were introduced. These midlevel practitioners have proven to be of good value in the everyday practice of the ED [10-13]. Indeed, the workload of physicians working with ANPs/PAs in EDs has been reduced while maintaining a good standard of care [14-17].

There are, however, disadvantages to the deployment of ANPs and PAs. Training courses are long and expensive, and regular nursing care is not part of the job anymore. This makes employment of additional ED nurses necessary, resulting in higher costs [18]. Unfortunately, however, a shortage in regular emergency nurses has also been reported, making it difficult to find well-trained ED nurses to replace them [19].

A solution that maintains the advantages of ANPs/PAs and takes care of the disadvantages was sought. An idea was conceived to specifically train bregularQ emergency nurses to assess and treat minor injuries according to a protocol, in addition to performing their usual nursing duties: special- ized emergency nurses (SENs). To test the SEN concept, the injury chosen was the ankle/midfoot injury because vali- dated clinical decision rules are available–the Ottawa ankle and foot rules (OAR/OFR) [20-23].

The aim of the study is to compare the accuracy of SENs to the Standard care provided by house officers (HOs) in assessing and treating ankle and foot injuries. In addition, accompanying patient satisfaction results and waiting times are compared between the observer groups.

Patients and methods

The study was conducted from July 2004 to March 2005 in a university teaching ED (VU University Medical Center, Amsterdam, the Netherlands) with an annual patient census of 35000.

Selection of patients

All consecutive patients with an ankle/foot injury were approached to enter the study. Exclusion criteria were age younger than 18 years or older than 65 years, trauma sustained more than 48 hours before presentation, mental or physical conditions known to complicate assessment of the injury, ankle/foot injuries as part of a more severe (poly)trauma, and prior injury to the ipsilateral ankle/foot that required surgery. Written informed consent was obtained from all patients. After giving informed consent, the patients were randomized to be assessed and treated either by a SEN or an HO. Randomization was conducted by computer, which allocated patients unstratified into the 2 observer groups in blocks of 20.

The protocol was approved by the scientific committee and medical ethics committee and was carried out in accordance with the Declaration of Helsinki (1989) of the World Medical Association.

Observer groups

Of 32 certified emergency nurses, 16 were voluntarily recruited. The mean age for the nurses was 36 years (range, 26-56 years) and the mean clinical experience in the ED was 5 years (range, 6 months-12 years).

Before the study started, the nurses were trained in the anatomy and biomechanics (trauma mechanisms) of the ankle and foot, and they were taught how to treat specific injuries. Furthermore, they were trained on the radiographic assessment of skeleton x-rays in general and those of the ankle and foot in particular. Emphasis was put on the detection of acute fractures and dislocations. Both the clinical and radiologic aspects of the injuries were combined in a 2-day course provided by a trauma surgeon and a radiologist. Completion of the course led to the SEN qualification. The SENs kept participating in the usual nursing care and assessed ankle/foot injuries only when a patient was randomized to the SEN group. Furthermore, all junior physicians, 24 in total, participated in the study. These were junior emergency physicians/HOs solely en- gaged in emergency medicine and will be referred to as HOs in the remainder of this article. The mean age for HOs was

28 years (range, 26-30 years) and their mean clinical experience (in an ED) was 1 year (range, 6 months- 1.5 years).

Study design

All included patients were assessed according to the algorithm presented in Fig. 1. The trauma mechanism and history of the patient (prior injuries to the affected limb, Systemic conditions affecting healing, and medicine use) were recorded. Then, the injury was assessed by means of the OAR/OFR to determine the need for radiography. If a fracture was found on x-ray, a surgeon was consulted to determine the need for operation in all cases except for

Fig. 1 Flow diagram depicting the assessment and treatment algorithm for ankle and foot injuries by SENs.

nondislocated Jones or Weber A fractures. If there was no indication for radiography, the anterior drawer test (ADT) was performed. Every significant fracture or complete rupture of the collateral ligaments (grade 3) was treated with a cast until reassessment at the outpatient department after 1 week. Avulsion chips smaller than 2 mm were regarded as collateral ligament injury and treatment depended on ankle stability, as tested with the ADT [24,25]. Other injuries, such as partial rupture of the ligaments or contusion by blunt trauma, were treated with a pressure bandage.

After assessment and treatment, all subjects received a patient satisfaction questionnaire based on a translated version of the Press Ganey ED patient satisfaction ques- tionnaire 2002 (Press Ganey Associates, Inc, South Bend, IN) ED patient Satisfaction survey (Tables 3 and 4). All radiographs were reviewed the next morning to prevent serious fractures to pass without noticing before the control visit. All patients were reassessed after 1 week at the outpatient department by one trauma surgeon to verify the diagnosis (gold standard). At this control visit, radiographs were made of all injuries that were not radiographed earlier, as part of the gold standard. To determine the presence of complete collateral ligaments laceration, the surgeon (re)performed the ADT. The completed questionnaires were collected in a closed envelope. After the surgeon established the definitive diagnosis, patients were treated as required, and their participation in the trial ended.

Outcome measures

The primary outcome measure was the accuracy of the observer (groups) in making a diagnosis of an injury

requiring a cast/operation (eg, any type of significant fracture or complete collateral ligaments laceration). significant fractures were defined as any fracture needing immobiliza- tion with a cast or needing Operative treatment, in other words, all fractures except for avulsion chips smaller than 2 mm. It should be stated that the mentioned diagnostic accuracy does not concern the specific diagnosis (such as Jones fracture), but it is the sensitivity with regard to the recognition of an injury requiring initial treatment with a cast or an operation. The diagnostic accuracy parameters calcu- lated were sensitivity, specificity, and positive and negative predictive values.

The secondary outcome measure was patient satisfaction determined by the results of the questionnaires returned at the control visit. A control question was added to determine equality among patients in both groups: bWhat is your opinion on the courtesy of the personnel at the registration desk of the ED?Q

Sample size

Our aim was to establish whether SENs were as accurate as HOs in the assessment and treatment of ankle/foot injuries (or at least not inferior to HOs). The estimated sensitivity of the detection of more severe injuries (eg, those requiring initial treatment with a cast or operation) by HOs is approximately 95% [22]. Because we do not attempt to prove that the new approach is better than the standard treatment, we could do a 1-sided test. The sample size of 235 patients per observer group allowed the detection of a Clinically meaningful difference (N10%) with respect to the primary sensitivity outcome.

Primary data analysis

The primary outcome measures being the accuracy parameters per observer group were calculated together with the 2-sided 95% CIs by Metatest (Metatest 0.6, Lau J, New England Medical Center, Boston, MA). Subsequently, these results were compared using Z statistics.

Secondary data analysis

The group results for the questionnaires on patient satisfaction were compared using v2 statistics. For the questions on which answers were given on an ordinal scale, linear-by-linear v2 statistics (SPSS 11.0, SPSS Inc, Chicago, IL) was used to determine if significant differences between observer groups were found. To determine if waiting times for first contact with the treatment officer differed signifi- cantly between groups, the difference in median waiting time was calculated as well as its 2-sided 95% CI

(Confidence interval analysis [CIA] v2.0.0.41, BMJ Pub- lishing London).


During the 9-month study, 24105 patients visited the ED of whom 2505 had an ankle or foot condition. Of the 1949 who had experienced a traumatic injury to the ankle/foot, 1348 patients were between 18 and 65 years and were assessed for eligibility to enter the study (Fig. 2). After applying the exclusion criteria and taking into account the patients who declined to participate (unwillingness or living too remotely), 512 patients were included in the trial: 263 were randomized to the SEN group and 249 to the HO group. Thirty-seven patients did not return for the control visit after 1 week (loss to follow-up 7.2%), 32 of whom could be contacted by phone and revealed to have no

Fig. 2 Flow diagram depicting the enrollment and allocation of patients in both treatment groups.

SEN group

HO group


(n = 242)

(n = 233)

type of injury


Distorsion grade 1

132 (54.5)

131 (56.2)

Distorsion grade 2

38 (15.7)

47 (20.2)

Distorsion grade 3

3 (1.2)

1 (0.4)

Distorsion + avulsion chip

14 (5.8)

14 (6.0)

Significant fracture (cast)

23 (9.5)

21 (9.0)

Significant fracture

7 (2.9)

5 (2.1)



25 (10.3)

14 (6.0)

complaints meriting return to the hospital. As a conse- quence, the data for 475 patients (242 in the SEN group) were analyzed.

Table 1 Amount of specific injuries per observer group

Number of specific diagnoses as verified at control visit (percentage of

all injuries seen in the observer group). Linear-by-linear v2 statistics revealed no significant difference between distribution of specific injuries in the observer groups ( P = .124).

Characteristics of study subjects

There were no significant differences in baseline characteristics between the 2 groups. The mean age was

36.5 years in the SEN group compared with 35.5 in the HO group ( P = .43). As for the sex distribution, 48.7% was male in the SEN group vs 46.2% in the HO group ( P = .60). Both groups encountered similar amounts of each type of injury (Table 1). The prevalence of significant fractures was 13.2% for the SEN group and 11.9% for the HO group.

Primary outcome

Table 2 shows the accuracy parameters for both groups with regard to the detection/exclusion of significant fractures/complete laceration of collateral ligaments. Sensi- tivity was 0.94 (95%, CI 0.78-0.93) for the SEN group compared with 0.78 (95%, CI 0.57-0.91) for the HO group

( P = .14). The specificity was 0.94 (95% CI, 0.90-0.97) for the SEN group and 0.95 (95% CI, 0.91-0.98) for the HO group ( P = 0.71). The positive predictive value was 0.74 (95% CI, 0.58-0.86) for the SEN group vs 0.70 (95% CI,

Table 2 Diagnostic accuracy per observer group

SEN group HO group P

(n = 228) (n = 219)

Accuracy parameters

0.51-0.85) for the HO group ( P = .73); the negative


0.94 (0.78-0.99)

0.78 (0.57-0.91)


predictive value was 0.99 (95% CI, 0.99-1.00) for the SEN


0.94 (0.90-0.97)

0.95 (0.91-0.98)


group compared with 0.97 (95% CI, 0.93-0.99) for the HO

Positive predictive

0.74 (0.58-0.86)

0.70 (0.51-0.85)


group ( P = .07). None of the parameters were significantly


different between the 2 groups.

Negative predictive

0.99 (0.96-1.00)

0.97 (0.93-0.99)


3.2.2. Clinical assessment

In total, clinical suspicion and thus an indication for radiography was found in 82.9% of patients in the SEN group compared with 76.3% in the HO group ( P = .08). The sensitivity for clinical assessment (separate from radiograph

interpretation) was 0.97 (95% CI, 0.81-1.00) for the SEN


The diagnostic accuracy parameters (95% CI) are given per observer group with regard to the overall diagnostic process (clinical assessment and, when indicated, radiograph interpretation). Diamond statistics was used to calculate 95% CIs. P values were calculated using Z statistics. Cases concerning clinically insignificant avulsion chips are excluded here.

group compared with 0.85 (95% CI, 0.64-0.95) for the HO group (P = .08); specificity was 0.19 (95% CI, 0.14-0.26) for the SEN group vs 0.26 (95% CI, 0.20-0.33) for the HO group ( P = .12). The positive predictive value was 0.15 (95% CI, 0.11-0.21) for the SEN group as opposed to 0.14 (95% CI, 0.09-0.20) for the HO group ( P = .59); the negative predictive value was 0.97 (95% CI, 0.85-1.00) for the SEN group and 0.93 (95% CI, 0.81-0.98) for the HO group ( P = .35). None of the parameters were significantly different between the 2 groups.

      1. Radiograph interpretation

The sensitivity of radiograph interpretation was 0.97 (95% CI, 0.82-1.00) for the SEN group compared with 0.91 (95% CI, 0.71-0.98) for the HO group ( P = .29). The specificity was 0.94 (95% CI, 0.88-0.97) for the SEN group vs 0.94 (95% CI, 0.88-0.97) for the HO group ( P = 1.00).

The positive predictive value was 0.76 (95% CI, 0.59-0.87) for the SEN group compared with 0.70 (95% CI, 0.51-0.85) for the HO group ( P = .60); the negative predictive value was 0.99 (95% CI, 0.96-1.00) for the SEN group and 0.99 (95% CI, 0.94-1.00) for the HO group ( P = 1.00). None of the parameters were significantly different between the 2 observer groups.

      1. Avulsion chips

In total, 28 avulsion chips were seen in the study, 14 in each group. In the SEN group, all 14 chips were detected by means of the OAR/OFR. Furthermore, on the 14 requested x-rays, 9 were detected, and 5 were not identified. In the HO group, 13 of the 14 avulsion chips were clinically detected, and radiography was requested; 9 chips were detected on these radiographs, but 4 were not identified.

Secondary outcome

      1. Patient satisfaction questionnaire

The questions and results of the patient satisfaction questionnaire are shown in Tables 3 and 4. In total,

464 completed questionnaires were collected: 245 from

Table 3 Questions and answers from the patient satisfaction questionnaire with regard to delivered care

Per observer group, the percentage of patients who gave a certain answer to a specific question is given. For clarity purposes, the small percentage of patients who did not answer a question (missing) is not mentioned in the table. For yes/no questions, Pearson v2 statistics was performed. For questions on which answers on an ordinal scale could be given, linear-by-linear v2 statistics was performed.

the SEN group and 219 from the HO group. All patients lost to follow-up received an extra patient questionnaire by mail of which 11 were returned.

      1. Waiting time

Measurements of the waiting time for first contact with the treatment officer in the ED (time spent in the waiting room) were recorded in 432 cases: 201 recordings in the SEN group and 231 in the HO group. The median waiting time was 21 minutes for patients in the SEN group and 32 minutes for patients in the HO group. Consequently, the

difference in median waiting times between groups was 9 minutes (95% CI, 5-13 minutes).


Experienced emergency nurses have always provided junior physicians working in the ED with assistance and advice. In many settings, it is customary for these nurses to perform triage tasks such as requesting radiographs [26,27]. However, nurses are not officially authorized to

Table 4 Questions and answers from the patient satisfaction questionnaire with regard to waiting times

For explanations, please see the first footnote to Table 3.

perform these activities, which raises liability issues. The introduction of ANPs and PAs addressed this medicolegal gap, and these practitioners are now recognized by law in the United States [28,29]. Other countries are working on a legal position for these practitioners as well. We propose the deployment of regular ED nurses trained to perform diagnostic tasks and treat patients within a well- defined protocol.

Our results show that SENs are at least as accurate as HOs in the assessment and management of ankle/foot injuries. Indeed, SENs were more sensitive, but not significantly so, in detecting injuries requiring treatment with a cast/operation ( P = .14). Previous studies provided discrepant results regarding the ability of nonphysicians to appropriately request radiographs [30-34]. In 1992, Macleod and Freeland [34] assessed the ability of emer- gency nurses to accurately request x-rays. They found that nurses were able to do so both correctly and with a reduction of waiting times. Thurston and Field [33] assessed time-savings when emergency nurses requested x-rays for peripheral limb injuries. They found that significant time- saving (16 minutes) occurred when nurses requested radio- graphs. However, after correction for the fact that nurses requested more radiographs than physicians, a nonsignifi- cant time-saving of 4 minutes remained.

As for the ability of nonphysicians to clinically assess minor injuries, Sakr et al [32] have provided evidence that ANPs are able to do so both accurately and in a manner equal to the care provided by HOs. Fiesseler et al [31] performed an interobserver study to assess the reproduc- ibility and accuracy of ED nurses in interpreting the OAR. They found an overall sensitivity of 0.92 for both the nurses and the HOs. Specificity for the nurses was 0.36 compared with 0.47 for the HOs. In our own prospective interobserver study (SEN vs HO), SENs displayed good accuracy while indicating ankle/foot injuries for radiography based on the OAR [35].

However, no study up to now has assessed the accuracy of regular ED nurses for the overall diagnostic process (clinical and x-ray assessment) of minor injuries. In our study, SENs seemed slightly more cautious in their Clinical interpretation, judging from the higher radiography request rate (although not significantly higher; P = .08). However, this caution seems to be appropriate because SENs missed less fractures than HOs, who missed 4 significant fractures by not requesting radiography compared to 1 missed by SENs. Moreover, SENs showed a higher sensitivity in the clinical detection of significant fractures or total collateral ligament laceration (although not significantly higher; P = .08).

The results from the patient satisfaction questionnaire revealed that patients were significantly more satisfied with the care provided by SENs than that provided by HOs. In addition, patients in the SEN group were more satisfied about the shorter waiting time in the ED compared with those in the HO group. These results are consistent with

earlier findings concerning patient satisfaction with ANPs/ PAs in the ED [19,32,36,37]. The reason for better satisfaction results in the SEN group is probably that SENs provided the postassessment care for their patients them- selves, whereas HOs delegated this to ED nurses. Special- ized emergency nurses therefore spent more time with patients, providing them with practical information about the injury and how to deal with it at home.

The waiting time to clinical assessment was significantly shorter in the SEN group than in the HO group. Because of the greater availability of SENs, they start assessing patients earlier than the HOs, the latter often having other (earlier arrival or more urgent) patients to attend to. The shorter overall length of stay in the SEN group can be explained by the shorter waiting time and by SENs treating patients immediately after informing them about their diagnosis. Patients assessed by HOs usually had to wait for a nurse to apply treatment.

In the presented solution, ED nurses are flexible employees with regular nursing as a basis, although with the ability to take over diagnostic tasks from physicians. This proposed alternative (SEN) is accessible to all certified ED nurses. When applied to multiple injuries/ conditions in the future, this could mean a career perspective for all ED nurses. In contrast, the ANP/PA training programs only provide career possibilities for the limited number of ED nurses that is able to meet the stringent entry requirements.

Our study may have had some limitations. We random- ized patients to the 2 observer groups, but it was not possible to blind patients in terms of the treatment officer. This could, however unlikely, have affected the patient satisfaction results.

One trauma surgeon reassessed the patients at the follow- up visit to prevent Interobserver variability from influencing the results. However, the surgeon was not blinded to the initial treatment officer because this was not feasible (the surgeon may have recognized the treatment officer’s handwriting or been told by the patients who treated them). Although the surgeon was obviously committed to reassess each patient in a similar manner, lack of blinding could have influenced the results.

In any prospective clinical study, the fact that the study is taking place can alter the behavior of observers (Hawthorne effect). Because the SENs and HOs were fully informed of the study and the method of assessment, it is possible that one group put extra effort into the manage- ment of patients during the study. This could have been the case for the SENs who were allowed to treat patients themselves for the first time and who may have been more eager to perform well.

In conclusion, SENs working in our ED are capable of assessing and treating patients with an ankle/foot trauma accurately. Moreover, SENs accomplish this with better patient satisfaction than the junior ED physicians (HOs). Furthermore, waiting times are decreased for patients with

this type of injury. Therefore, we feel that the treatment of ankle/foot injuries by SENs is an effective solution to the problem of ED crowding, and further development of short courses for the treatment of other common nonurgent injuries should take place.


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