ORIGINAL RESEARCH CONTRIBUTION

The Role of Triage Nurse Ordering on

Mitigating Overcrowding in Emergency
Departments: A Systematic Review
Brian H. Rowe, MD, MSc, CCFP(EM), FCCP, Cristina Villa-Roel, MD, MSc, Xiaoyan Guo, MSc,
Michael J. Bullard, MD, CFPC-EM, FRCPC, Maria Ospina, MSc, Benjamin Vandermeer, MSc,
Grant Innes, MD, FRCPC, Michael J. Schull, MD, MSc, FRCPC, and Brian R. Holroyd, MD, FRCPC

Abstract
Objectives: The objective was to examine the effectiveness of triage nurse ordering (TNO) on mitigating
the effect of emergency department (ED) overcrowding.
Methods: Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE,
CINAHL, SCOPUS, Web of Science, HealthSTAR, Dissertation Abstracts, ABI ⁄ INFORM Global), con-
trolled trial registry websites, conference proceedings, study references, experts in the field, and corre-
spondence with authors were used to identify potentially relevant studies. Interventional studies in
which TNO was used to influence ED overcrowding metrics (length of stay [LOS] and physician initial
assessment [PIA]) were included in the review. Two reviewers independently assessed study eligibility
and methodologic quality. Mean differences were calculated and reported with corresponding 95%
confidence intervals (CIs).
Results: From more than 14,000 potentially relevant studies, 14 were included in the systematic review.
Most were single-center ED studies; the overall quality was rated as weak, due to methodologic deficien-
cies and variable outcome reporting. TNO was associated with a 37-minute mean reduction (95%
CI = )44.10 to )30.30 minutes) in the overall ED LOS in one randomized clinical trial (RCT); a 51-minute
mean reduction (95% CI = )56.3 to )45.5 minutes) was observed in non-RCTs. When applied to injured
subjects with suspected fractures, TNO interventions reduced ED LOS by 20 minutes (95% CI = )37.5 to
)1.9 minutes) in three RCTs and by 18 minutes (95% CI = )23.2 to )13.2) in two non-RCTs. No significant
reduction in PIA was observed in two RCTs.
Conclusions: Overall, TNO appears to be an effective intervention to reduce ED LOS, especially in injury
and ⁄ or suspected fracture cases. The available evidence is limited by small numbers of studies, weak
methodologic quality, and incomplete reporting. Future studies should focus on a better description of
the contextual factors surrounding these interventions and exploring the impact of TNO on other indica-
tors of productivity and satisfaction with health care delivery.
ACADEMIC EMERGENCY MEDICINE 2011; 18:1349–1357 ª 2011 by the Society for Academic
Emergency Medicine

From the Department of Emergency Medicine (BHR, CV, XG, MB, BH), School of Public Health (BHR, CV, MO), University of
Alberta, Edmonton, Alberta; University of Alberta ⁄ Alberta Health Services Evidence-based Practice Centre (BHR, BV), Edmon-
ton, Alberta; the Institute of Health Economics (MO), Edmonton, Alberta; the Department of Emergency Medicine, University
of Calgary (GI), Calgary, Alberta; and the Department Medicine (Division of Emergency Medicine), University of Toronto (MS),
Toronto, Ontario, Canada.
Received December 15, 2010; revision received February 14, 2011; accepted February 17, 2011.
Data from this study were presented at the Canadian Association of Emergency Physicians annual scientific meeting, Montreal,
Canada, May 29–June 2, 2010, and received the Grant Innes Canadian Association of Emergency Physicians Research Award.
This study was funded by a grant from the Canadian Institutes for Health Research (CIHR; 200810KRS). Dr. Schull is supported by
the CIHR as an Applied Chair in Health Services and Policy Research (Ottawa, ON). Dr. Villa-Roel is supported by CIHR in partner-
ship with the Knowledge Translation branch. Dr. Rowe is supported by the 21st Century Canada Research Chairs program through
the Canadian Institutes of Health Research (CIHR) by the Government of Canada (Ottawa, ON).
The authors have no relevant potential conflicts of interest to disclose.
Supervising Editor: Christopher Carpenter, MD.
Address for correspondence: Brian H. Rowe, MD, MSc, CCFP(EM), FCCP; e-mail: [email protected].

ª 2011 by the Society for Academic Emergency Medicine ISSN 1069-6563

doi: 10.1111/j.1553-2712.2011.01081.x PII ISSN 1069-6563583 1349
1350 Rowe et al. • TNO SYSTEMATIC REVIEW

O
vercrowding is one of the most important prob- as supporting information in the online version of this
lems facing emergency departments (EDs) in paper).5 Clinical trial registries (ClinicalTrials.gov and
many developed countries.1 The approaches to controlled-trials.com) and Google Scholar Web search
reducing waiting times, improving flow, and expediting were also explored. The search strategy was identical to
disposition decisions have been a challenge for many the one used in the Canadian Agency for Drugs and
emergency care providers and administrators; however, Technologies in Health (CADTH) report entitled ‘‘Inter-
the multidimensional nature of ED overcrowding has ventions to Reduce Overcrowding in ED’’5 and was
made it difficult to design interventions that cover its updated for this study. The CADTH report involved lit-
multiple stressors. The input, throughput, and output erature searches from 1966 to 2005; this study supple-
model outlines a variety of operational processes that mented the previous report by searching for citations
represent practical targets for operations research on between October 2004 and May 2009. Both searches
ED overcrowding.2,3 included non-English languages and unpublished
One of the key causes of delays within the ED research. The overlapping was necessary to ensure that
involves patient flow within the ED or throughput.4 all the new literature indexed after the CADTH report
This is the period from arrival in the ED (triage or reg- was completed would be considered for inclusion.
istration time) to the point where decisions are made
regarding patient disposition (admission or discharge). Specific Search. A more specific literature search was
Interventions to improve throughput have been the conducted in January 2011 in four biomedical electronic
focus of many publications on ED overcrowding;5 tri- databases: MEDLINE, EMBASE, SCOPUS, and
age nurse ordering (TNO) is one of the proposed inter- CINAHL. This search focused on terms such as nurse ⁄
ventions. While TNO has been related to enhanced triage nurse AND test ordering, radiography, x-rays,
patient satisfaction, improved care, and increased team- and test requesting in the ED.
work, little is known about the effectiveness of this Hand searches were performed to identify abstracts
intervention in improving ED time metrics, quality of presented to the following major scientific conferences
care, and cost of care.6 between October 2004 and May 2009: the American Col-
The purpose of this study was to examine the avail- lege of Emergency Physicians, the Australasian College
able evidence for TNO, document contextual issues for Emergency Medicine, the Canadian Association of
associated with this intervention, and determine its Emergency Physicians, the College of Emergency Medi-
effectiveness. Contextual exploration implies the exami- cine in the United Kingdom, and the Society for Aca-
nation of differences among studies in site of imple- demic Emergency Medicine. In addition, the references
mentation (e.g., urban vs. rural; high volume vs. low of identified articles were manually searched. Primary
volume) and the TNO approaches used (single issue vs. authors and experts in the field were contacted to iden-
multiple issues [medical and injury]). We believe that tify additional published, unpublished, or ongoing stud-
these are important factors required to understand the ies. The search results from the CADTH report were
effectiveness of the TNO intervention. Effectiveness merged with those of the updated searches, resulting in
implies influence on length of stay (LOS) metrics, left a comprehensive search strategy that identified poten-
without being seen, medical errors, and satisfaction. tially relevant studies published from 1966 to February
2011.
METHODS
Study Selection
Study Design Eligible studies were primary research that assessed
This was a systematic literature review. the effects of a TNO (but not nurse practitioners or
floor nurses) to mitigate overcrowding in EDs serving
Study Protocol adult (17 years or older) or mixed (child and adult) pop-
An a priori protocol for the systematic review was used ulations. Studies with one of the following designs were
to define the search strategy, set the study selection cri- included: parallel or clustered randomized controlled
teria, outline quality assessment and data extraction trials (RCTs), controlled clinical trials (CCTs), prospec-
procedures, and plan the analysis of the study results. tive or retrospective analytical cohort studies, inter-
While the current review involves TNO, other reviews rupted time series, case–control studies (C-C), and
in this funded program of research include triage liai- before–after (B-A) designs. Studies were required to
son physicians,7 observation units, over-capacity proto- report numeric data on at least one of the following
cols,8 and other interventions. outcomes: ED LOS (time in minutes from patient ED
arrival to departure), physician initial assessment (PIA;
Two Search Strategies Employed in This Review time in minutes from patient ED arrival to physician
Sensitive Search. A comprehensive literature search assessment), and proportion of radiographs ordered by
was conducted in seven biomedical electronic databas- nurses. Non–primary research (e.g., editorials, com-
es: MEDLINE, EMBASE, EBM Reviews - Cochrane mentaries, letters to the editor, narrative reviews, tech-
Central Register of Controlled Trials, HealthSTAR, Sci- nology reports, and systematic reviews), studies
ence Citation Index Expanded, Dissertation Abstracts, conducted in pediatric EDs, multiple publications, and
and ABI ⁄ INFORM Global. Due to the lack of standard- studies comparing two levels of the same intervention
ized medical indexing for ED overcrowding, a wide vari- were excluded.
ety of keywords were used to identify relevant literature Four reviewers (XG, BHR, MO, CVR) independently
(see Data Supplement S1 for a complete listing, available screened titles and abstracts of studies identified by the
ACADEMIC EMERGENCY MEDICINE • December 2011, Vol. 18, No. 12 • www.aemj.org 1351

literature search. The full-text versions of articles Statistical significance was set at a p value of less
deemed potentially relevant, as well as those that than 0.05. All data were entered into Review Manager
reported insufficient information to determine eligibil- (RevMan, Version 5.0. Copenhagen: The Nordic Coch-
ity, were independently reviewed by two of four rane Centre, The Cochrane Collaboration, 2008).
reviewers (CVR, LW, BHR, MO). Any disagreements
were resolved by consensus. Non-English literature RESULTS
was translated by foreign language reviewers (SMH
and DS). Studies that met all inclusion criteria under- Search Results
went quality assessment and data extraction. The sensitive search resulted in the identification of
14,446 potentially relevant citations, from which 3,615
Quality Assessment studies clearly addressed the topic of ED overcrowding.
A standard quality-rating tool developed by the Effec- After screening study titles and abstracts, 354 full
tive Public Health Practice Project (EPHPP)9 was used manuscripts were retrieved for further examination.
to appraise the methodologic quality of the studies. This The specific search resulted in the identification of 325
tool is based on guidelines set out by Mulrow and potentially relevant citations, from which 54 studies
Oxman10 and Jadad et al.11 and has accepted validity clearly addressed the topic of TNO. The application of
and reliability.12 The rating tool is based on six criteria: the selection criteria to these potentially relevant manu-
selection bias, study design, confounders, blinding, data scripts resulted in 14 studies included (two unique to
collection methods, and withdrawals and dropouts. the sensitive search, eight unique to the specific search,
Each criterion is rated as ‘‘strong,’’ ‘‘moderate,’’ or and four identified by both searches). Figure 1 outlines
‘‘weak,’’ depending on information reported in the arti- the study selection flow for the review. The complete
cle. Once the ratings of characteristics are totaled, each list of references of excluded studies is available from
study receives an overall assessment of strong, moder- the authors upon request.
ate, or weak quality. Two of four assessors (BR, LW,
XG, CVR) independently assessed the quality of Operational Issues
included studies. The kappa (j) statistic was calculated Study Characteristics. Of the 14 included studies, 12
to measure the level of agreement between reviewers.13 were journal publications,14–25 one was an abstract,26
Finally, discrepancies were resolved by consensus. and one was a thesis report.27 Most of them were sin-
gle-center ED studies, and one was a multicenter
Data Extraction study16 (Table 1). Three were RCTs, one was a CCT,
Information regarding the study design and methods two were retrospective cohort studies, three were pro-
(e.g., year, country, type of publication, study duration, spective cohort studies, two were C-C studies, and
number of participating centers), intervention charac- three were B-A studies.
teristics (e.g., nurse experience and training received),
and comparison groups and outcomes of interest were Quality. Based on the EPHPP tool,9 the quality of the
extracted using a pretested data extraction form. 14 studies was rated as weak due to methodologic defi-
Finally, information was collected on study conclusions, ciencies and poor outcome reporting (Figure 2). Before
as reported by the authors of the primary studies. Two the consensus process, the interrater agreement was
reviewers (BHR, XG) independently conducted data good on the overall quality assessment (j = 0.66).
extraction. When standard deviations (SDs) were not
reported in the included articles, they were estimated Nurse Training. From the 14 studies, details of the
based on the reported interquartile ranges (IQRs) using nurses and their training were extracted (Table 2). Most
a standard formula [(IQR upper level – IQR lower studies designated nurses as triage staff; however, sev-
level) ⁄ 1.35]. Attempts were made to communicate with eral employed senior ⁄ experienced nurses only. Training
investigators for clarification or additional data. also varied; however, test ordering was initiated after
brief training programs (1-hour lectures) in most cases.
Data Analysis
Characteristics of the included studies were summa- Primary Outcomes
rized using descriptive statistics. Evidence tables were ED LOS. Most included studies reported outcome data
constructed to report information on each article’s on ED LOS.14–19,21,22,24,26,27 One RCT showed a signifi-
source, study design, study population, treatment cant reduction in ED LOS when comparing TNO inter-
groups, and outcomes. Analyses were focused on ED ventions to emergency physician (EP) and emergency
LOS, PIA, and proportion of radiographs ordered by nurse practitioner (ENP) x-ray ordering (mean differ-
triage nurses. ence = )37.2 minutes; 95% CI = )44.1 to )30.3 minutes);
Outcomes from individual studies were presented as consistent results were observed when pooling the
mean differences with 95% confidence intervals (CIs) results from three non-RCTs (mean difference = )51
for continuous variables and risk ratios (RRs) with 95% minutes; 95% CI = )56.3 to )45.5 minutes; Figure 3).
CIs for dichotomous variables. The small number of For injured patients in whom a fracture was suspected,
studies included in this review precluded generating three RCTs indicated that TNO interventions produced
pooled estimates for some outcomes. Analyses were a significant reduction in ED LOS (pooled mean differ-
divided by study design (RCTs vs. other designs), and ence = )19.7 minutes; 95% CI = )37.5 to )1.9 minutes);
subgroup analyses by injury ⁄ suspected fracture status however, this result is tempered by high heterogeneity
were completed for ED LOS. (I2 = 92%). A lower yet statistically significant difference
1352 Rowe et al. • TNO SYSTEMATIC REVIEW

Sensive search Specific search

Unique citaons retrieved from Unique citaons retrieved from

electronic searches = 14,446
14 446 electronic
l  searches
h = 325

Grey literature Hand

searches = 270 searches = 9

References selected aer pre- References selected aer pre-

pre
screening = 3,615 screening = 206

References selected aer screening of References selected aer screening of

tles and abstracts = 354 tles and abstracts = 54

Arcles Arcles Arcles Arcles

excluded =348 included = 6 included = 12 excluded =42

Reasons for exclusion Reasons for exclusion

- Not primary research = 199 Total arcles - Not primary research = 16
- Did not meet study design criteria = 18 included = - Did not meet study design criteria = 9
- Not on an adult ED = 8 14* - Not on an adult ED = 5
- Not on a triage nurse protocol intervenon - Compared two levels of the same
to reduce ED overcrowding = 294 intervenon = 5
- No numeric/measurable data = 3 - Other nurses (no TNs) = 6
- Not retrieved = 1 - No roune exam in the ED = 1
- Compared two levels of the same
intervenon = 4
- MP of excluded study = 1
* Four arcles were idenfied by both searches

Figure 1. Study selection flow. MP = multiple publications; not retrieved = not found; ED = emergency department; TN = triage
nurse.

(pooled mean difference = )18.2 minutes; 95% CI = with a comprehensive search of related articles,
)23.2 to )13.2 minutes) was observed in five non- detailed data collection, and reproducible methods.
RCTs. In contrast, a nonsignificant improvement was Overall, the review demonstrated that the TNO inter-
observed in two RCTs that included patients without vention was associated with a 37-minute reduction in
suspicion of injury or fracture (pooled mean differ- the overall ED LOS, as reported in one of the included
ence = 0.93 minutes; 95% CI = )5.44 to 7.31 minutes). RCTs.14 A higher and statistically significant difference
Details for non-RCT designs are illustrated in Figure 4. (51-minute reduction) was observed when analyzing
other study designs.18,21,27 For TNO interventions
PIA. Three studies reported outcome data on applied to injured subjects suspected of having a frac-
PIA.14,16,17 Two RCTs indicated a nonsignificant reduc- ture, ED LOS was reduced by 19 minutes in three
tion in PIA when comparing TNO interventions to RCTs;14,16,19 a similar, statistically significant difference
EP ⁄ ENP x-ray ordering (pooled mean difference = )3.00 (18-minute reduction) was observed in five non-
minutes; 95% CI = )6.99 to 0.99 minutes); one prospec- RCTs.15,17,22,24,26 No statistically significant differences
tive cohort study showed a 10 min reduction on PIA were identified when TNO interventions were applied
(Figure 5). to subjects without injury or a suspected fracture in the
highest quality study designs.14–16 Only two RCTs
Proportion of Radiographs Ordered. Two studies reported data on PIA, and while a reduction was
reported data on the proportion of radiographs ordered observed, it failed to reach statistical significance;14,16
by triage nurses compared to EPs.14,16 Pooled analysis poor outcome reporting from other study designs pre-
of two RCTs indicated that the risk of ordering radio- cluded PIA data pooling.17 Finally, our results sug-
graphs was the same when comparing TNO interven- gested that TNO interventions have no significant effect
tions to EP ⁄ ENP x-ray ordering (RR = 0.98; 95% on x-ray ordering or results, from both the clinical and
CI = 0.83 to 1.15); the risk of obtaining positive results the statistical perspectives.
was also the same when comparing these two groups Differences were observed regarding the nature of
(RR = 1.03; 95% CI = 0.85 to 1.23). the TNO interventions. For example, studies differed
somewhat with respect to study populations, and that
DISCUSSION may have influenced the fact that some included radio-
graph ordering only,14–17 while other studies included
This systematic review summarizes the best available additional diagnostic test requesting such as blood
evidence on the operational issues and effectiveness of tests, urinalysis, and electrocardiogram.27 The experi-
TNO in reducing ED metrics such as ED LOS, PIA, and ence level of triage nurses in ordering radiologic exam-
the proportion of radiographs ordered by triage nurses. inations varied among studies, from having no
To our knowledge, this is the first review of this topic previous training to receiving special training as part
ACADEMIC EMERGENCY MEDICINE • December 2011, Vol. 18, No. 12 • www.aemj.org 1353

Table 1
Descriptive Characteristics of Studies Included in the Review

First Author Intervention

(Year) Location Sample Period Study Design TNP Intervention Comparison
Bliss (1971)25 United States 100 Unknown Retrospective Triage nurse initiated ED physician
cohort study distal limb x-rays initiated x-ray
only.
Stiell (1993)26 Canada 1,180 5 months B-A Triage nurse initiated ED physician
foot ⁄ ankle x-rays initiated x-ray
only.
Lee (1996)17 Hong Kong 1,633 3 months Prospective Triage nurse initiated ED physician
cohort study x-rays. initiated x-ray
Thurston United Kingdom 1,833 NR RCT Triage nurse initiated ED physician
(1996)16 x-rays. initiated x-ray
Parris (1997)15 Australia 175 3.25 months CCT Triage nurse initiated ED physician
x-rays. initiated x-ray
24
Ching (1999) Singapore 276 3 months C-C Triage nurse initiated ED physician
limb ⁄ skull x-rays initiated x-ray
using a standardized
form.
Lindley-Jones United Kingdom 675 2 weeks RCT Triage nurse initiated ED physician ⁄ ENP
(2000)14 x-rays. initiated x-ray
Winn (2001)27 United States 40 2 months Retrospective Triage nurse initiated ED physician
cohort study diagnostic test (e.g., initiated diagnostic
x-ray, blood test, test
urinalysis, ECG).
Cheung (2002)18 Canada 250 NR B-A Triage nurse initiated ED physician
x-ray and blood test. initiated x-ray and
blood test
Australia 1,806 12 months Prospective Triage nurse initiated ED physician
cohort study isolated distal upper initiated x-ray
or lower limb x-rays
only.
Fan (2006)19 Canada 130 3 months RCT Triage nurse initiated ED physician
x-rays. initiated x-ray
Pedersen Denmark 106 NR Prospective Triage nurse initiated ED physician
(2009)23 cohort study x-rays on low-energy initiated x-ray
injuries.
Rosmulder Netherlands 704 22 days B-A Triage nurse initiated ED physician
(2010)22 foot ⁄ ankle x-rays initiated x-ray
only.
Retezar (2011)21 United States 15,188 2 years Retrospective Triage nurse requested ED physician
nested C-C investigations for chest initiated
study pain, shortness of investigations.
breath, abdominal pain,
or genitourinary
complaints.
Totals (n = 14) Three Canada; 100–15,188 2 weeks–2 Variable Triage nurse. ED physician
Three United years
States

B-A = before–after study; CCT = controlled clinical trial; C-C = case-controlled study; ECG = electrocardiography; ENP = emer-
gency nurse practitioner; NR = not reported; RCT = randomized controlled trial; TNP = triage nurse protocol.

of the intervention or having extensive experience important reduction of the overall ED LOS; in the
ordering radiographs. Recently, ordering agreement future, a more comprehensive research design address-
for diagnostic tests between triage nurses and physi- ing cost-effectiveness and quality of care issues could
cians has been summarized, and many concerns have identify nursing investigation protocols applicable to
been put to rest.28 While the research conducted on similar ED settings.
this specific aspect of the TNO intervention is not meth- In most of the studies, the comparison group con-
odologically strong, good training and the use of sisted of EPs; in one study the comparison group
accepted protocols seem to improve health-related out- included EPs or ENPs.14 The level of training and expe-
comes associated with some of the disadvantages iden- rience of the comparison group was not reported in
tified by previous studies (e.g., nurses requesting more detail in most of the included studies. Variations in this
or inappropriate radiographs and missing important training and experience (e.g., junior vs. senior physi-
initial findings).16,29 Although few studies reported on cians) and in the process of attending patients (e.g.,
the time and costs of implementing this strategy, most orders approved, or not, by consulting physicians)
training appeared to be limited. Regardless of the study could explain some of the results observed in our out-
design, the studies included in this review showed an comes of interest. Finally, the description of other
1354 Rowe et al. • TNO SYSTEMATIC REVIEW

Figure 2. Frequency of the six components of the EPHPP tool and global ratings. Note: Global rating was strong for studies with
no weak rating and at least four strong rating of component items; global rating was moderate for studies with one weak rating
and less than four strong rating of component items; global rating was weak for studies with two or more weak ratings of compo-
nent items. EPHPP = Effective Public Health Practice Project.

Table 2
Nurse Experience and Training for Test Ordering at Triage

First Author (Year) Experience of Triage Nurses Type of Training

Bliss (1971)25 Experienced triage nurses Triage nurses attended a lecture by a staff orthopedic surgeon. Signs
and symptoms of orthopedic fractures were given, as well as instructions
for filling out x-ray requisitions.
Stiell (1993)26 Not specified Not specified
Lee (1996)17 Not specified Triage nurses received a 1-hour training session on the inclusion ⁄
exclusion criteria for x-rays requesting as set out in the study protocol.
This training took place 1 month before the study.
Thurston (1996)16 Not specified Not specified.
Parris (1997)15 Experienced ED nurses Triage nurses underwent a training program in the skills of triage.
Ching (1999)24 Triage nurses with >1 yr Triage nurses attended a standardized instructional course on
of experience. examination skills, inclusion and exclusion criteria conducted within
the ED. They were also instructed on the criteria for x-rays requisitions
as in the pre-set protocol used in the study.
Lindley-Jones (2000)14 Not specified Not specified.
Winn (2001)27 Triage nurses, 1–12 yr Not specified.
of experience.
Cheung (2002)18 Not specified Triage nurses participated in a 4-hour workshop to introduce the concept
of ‘‘advanced triage.’’ This was followed by supervised practice sessions
at the triage desk.
Fry (2001)20 Not specified Triage nurses participated in an education program that included a
20-minute video developed for the study and a 1-hour lecture conducted
by an ED staff and a clinical nurse consultant.
Fan (2006)19 Not specified Triage nurses received a 1-hour training session on the study protocol
and the use of the Ottawa Ankle Rules and 2 weeks to clarify
misconceptions with the study investigators.
Pedersen (2009)23 Not specified Not specified.
Rosmulder (2010)22 Not specified Not specified.
Retezar (2011)21 Not specified Triage nurses were instructed to use their clinical judgment with regard
to x-ray ordering. They were also instructed to execute their orders only
when patients could not be placed in a treatment room within a
reasonable period.

important factors surrounding these interventions, such ED champions during the early stages of the research
as the previous existence of hospital TNO protocols for process, was not consistently reported across the stud-
specific cases (e.g., patients with limb injuries), the ies. A careful description of such factors (facilitators vs.
availability of 24-hour radiology service to ED patients, potential barriers) may help to decide whether research
and the engagement of multidisciplinary groups and results can be translated into practice. Because
ACADEMIC EMERGENCY MEDICINE • December 2011, Vol. 18, No. 12 • www.aemj.org 1355

Figure 3. Emergency department LOS according to TNO interventions. LOS = length of stay; non-TNO= EP ⁄ nurse practitioner
x-ray ordering; RCT= randomized controlled trial; TNO = triage nurse ordering (triage nurses with and without previous experience
or training of x-ray requesting).

(a)

(b)

Figure 4. Emergency department LOS in patients with and without suspicion of injury ⁄ fracture. LOS = length of stay; non-TNO=
EP ⁄ nurse practitioner x-ray ordering; RCT= randomized controlled trial; TNO= triage nurse ordering (triage nurses with and without
previous experience or training of x-ray requesting).

research has the potential to improve our under- designed implementation research may further inform
standing of the implementation of complex health care those who wish to employ this approach.
interventions such as TNO, future research should It is rare to find experimental designs in operations
focus on these reporting issues.30 Alternatively, well- research conducted in ED settings; however, from the 14
1356 Rowe et al. • TNO SYSTEMATIC REVIEW

Figure 5. Physician initial assessment according to TNO interventions. Non-TNO= EP ⁄ nurse practitioner x-ray ordering; RCT =
randomized controlled trial; TNO = triage nurse ordering (triage nurses with and without previous experience or training of x-ray
requesting).

studies identified by our search, three were RCTs and from a review of this nature. Second, included studies
one was a CCT. While results from observational studies had variable research methodologies and incomplete
(e.g., B-A studies and analytical cohort studies) should reporting, and this limits the confidence one has in the
not be dismissed, they need to be interpreted with cau- results. Third, missing data were common in these stud-
tion, because they are more vulnerable to bias than ies; however, efforts to contact the investigators made it
higher-quality designs.31 It is imperative that operations possible to add some original data, and appropriate and
researchers use more robust designs and methods and widely accepted imputation techniques were used to
improve outcome reporting. Moreover, future research ensure valid inference.34 Fourth, due to insufficient data,
needs to include other outcomes such as patient and anticipated subgroup comparisons and sensitivity analy-
staff satisfaction, patient outcomes, and costs. ses were not always possible; however, subgroup analy-
Currently, there are no standard guidelines for TNO ses based on injury or suspected fracture were possible.
interventions. TNO interventions have been employed Fifth, the possibility of ordering a test and having a
during the process of triage in an effort to ensure that patient leave prior to review by a physician is real in the
appropriate diagnostic tests are undertaken at the earli- ED setting, and this is a problem for both the patient (if
est possible time according to the severity of individual the results are positive) and the physician or their
patients presenting to the ED. The promising effect of department ⁄ hospital (who may be medically and legally
reducing the overall LOS, and particularly in patients responsible for the outcome). This outcome was not doc-
with suspicion of injury or fracture, suggests that TNO umented in the included studies. Finally, all abstracts and
in the ED should be considered as an alternative to mit- manuscripts were screened by at least two independent
igate the effects of ED overcrowding. Because effective- reviewers using standardized eligibility criteria in an
ness is often driven by local needs and champions, in effort to decrease the likelihood of selection bias.
settings where injury is common TNO seems a reason-
able consideration; perhaps this intervention would be CONCLUSIONS
less successful in tertiary care referral settings where
minor injuries are less commonly encountered.19 The evidence regarding triage nurse ordering interven-
Finally, although rarely examined in the literature, tions is derived from a small number of studies with
the success of TNO interventions appears to be cost- variable research methodologies and variable outcome
effective. For example, for moderate reductions in LOS, reporting; however, triage nurse ordering appears to
the implementation of a TNO intervention can be be an effective intervention to reduce ED length of stay,
achieved using existing triage nurses and brief addi- especially in injured patients suspected of having a frac-
tional staff training. Especially if applied to the patients ture. In addition, this success can likely be achieved
with suspected fracture, this strategy has the potential using triage nurses and little additional staff training.
to improve nursing, patient, and physician satisfaction Future studies must focus on a more comprehensive
without any obvious safety concerns. description of the contextual factors surrounding these
interventions and on exploring the effect of triage nurse
LIMITATIONS ordering on other indicators of quality and crowding
with health care delivery.
Some limitations of this review should be acknowledged.
First, only a small number of studies that specifically The authors thank the corresponding authors, Drs. Thurston and
assessed the effect of a TNO intervention on mitigating Lee, for their responding to our request on additional data and
clarification. The authors are grateful to Donna Ciliska and Donna
ED overcrowding were identified. We believe that scope Fitzpatrick-Lewis for their explanation on the EPHPP quality
and selection bias were limited by the comprehensive assessment tool and to Diana Satanovsky-Feldman and Siri
search and inclusion of unpublished and non-English Margrete Holm for their assistance in translation.
language studies in this review; however, the possibility
of missing unpublished and ⁄ or negative studies still References
remains. Due to the small number of studies, the effect of
publication bias in the review could not be assessed.32 1. Bond K, Ospina MB, Blitz S, et al. Frequency, deter-
Evidence suggests that publication bias is less pervasive minants and impact of overcrowding in emergency
in the ED literature;33 however, negative trials are less departments in Canada: a national survey. Healthc
likely to be published and more likely to be excluded Q. 2007; 10:32–40.
ACADEMIC EMERGENCY MEDICINE • December 2011, Vol. 18, No. 12 • www.aemj.org 1357

2. Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie 21. Retezar R, Bessman E, Ding R, Zeger SL, McCarthy
N, Camargo CA Jr. A conceptual model of emer- ML. The effect of triage diagnostic standing orders
gency department crowding. Ann Emerg Med. on emergency department treatment time. Ann
2003; 42:173–80. Emerg Med. 57:89–99.
3. Fatovich DM. Emergency medicine. BMJ. 2002; 22. Rosmulder RW, Krabbendam JJ, Kerkhoff AH,
324:958–62. Schinkel ER, Beenen LF, Luitse JS. [Advanced tri-
4. Holroyd BR, Bullard MJ, Latoszek K, et al. Impact age’ improves patient flow in the emergency
of a triage liaison physician on emergency depart- department without affecting the quality of care]
ment overcrowding and throughput: a randomized [Dutch]. Ned Tijdschr Geneeskd. 2010; 154:A1109.
controlled trial. Acad Emerg Med. 2007; 14:702–8. 23. Pedersen GB, Storm JO. [Emergency department
5. Bond K, Ospina MB, Blitz S, et al. Interventions to x-rays requested by physicians or nurses] [Danish].
reduce overcrowding in emergency departments Ugeskr Laeger. 2009; 171:1747–51.
[abstract]. CJEM. 2006; 8:203. 24. Ching TK, Leng LY, See NB. Initiation of x-rays by
6. Emergency Nurses Association. Triage: Meeting the triage nurse: competency and its effect on
the Challenge. Park Ridge, IL: Emergency Nurses patients’ total time spent in the accident and emer-
Association, 1998. gency department. Singapore Nurs J. 1999; 26:22–6.
7. Rowe BH, Guo X, Villa-Roel C, et al. The role of tri- 25. Bliss A, Decker L, Southwick WO. The emergency
age liaison physicians in emergency department room nurse orders x-rays of distal limbs in orthope-
overcrowding: a systematic review of the literature. dic trauma. Nurs Res. 1971; 20:440–3.
Acad Emerg Med. 2011; 18:111–20. 26. Stiell IG, Greenberg G, McKnight RD, et al. Triage
8. Villa-Roel C, Guo X, Holroyd BR, et al. The role of full nurse use of decision rules for radiography in ankle
capacity protocols on mitigating crowding in EDs. injuries [abstract]. Ann Emerg Med. 1993; 22:948.
Am J Emerg Med. 2011. Feb 28 [Epub ahead of print]. 27. Winn KD. Emergency Department Efficiency
9. Thomas BH, Ciliska D, Dobbins M, Micucci S. A Through Utilization of Triage Nurse Protocols. (2001).
process for systematically reviewing the literature: Dissertation ⁄ thesis. Available at: http://en.scientific-
providing the research evidence for public health commons.org/2274833. Accessed Mar 28, 2011.
nursing interventions. Worldviews Evid Based 28. Free B Lee GA, Bystrzycki A. Literature review of
Nurs. 2004; 1:176–84. studies on the effectiveness of nurses ability to
10. Mulrow CD, Oxman AD. The Cochrane Collaboration order and interpret x-rays. Australas Emerg Nurs J.
Handbook. Oxford, UK: Cochrane Database, 1994. 2009; 12:8–15.
11. Jadad AR, Moore RA, Carroll D, et al. Assessing the 29. Seaberg DC, MacLeod BA. Correlation between tri-
quality of reports of randomized clinical trials: is blind- age nurse and physician ordering of ED tests. Am J
ing necessary? Controlled Clin Trials. 1996; 17:1–12. Emerg Med. 1998; 16:8–11.
12. Deeks JJ, Dinnes J, D’Amico R, et al., International 30. Glasgow RE, Emmons KM. How can we increase
Stroke Trial Collaborative Group, European Carotid translation of research into practice? Types of evi-
Surgery Trial Collaborative Group Evaluating non- dence needed. Annu Rev Public Health. 2007;
randomised intervention studies. Health Technol 28:413–33.
Assess (Winchester, England). 2003; 7:1–173. 31. Kunz R, Oxman AD. The unpredictability paradox:
13. Landis JR, Koch GG. The measurement of observer review of empirical comparisons of randomised and
agreement for categorical data. Biometrics. 1977; non-randomised clinical trials. BMJ. 1998; 317:1185–90.
33:159–74. 32. Daya S. Funnel plots and publication bias-work in
14. Lindley-Jones M, Finlayson BJ. Triage nurse progress? [editorial]. Evid Based Obstet Gynecol.
requested x rays: are they worthwhile? J Accid 2006; 8:71–2.
Emerg Med. 2000; 17:103–7. 33. Ospina MB, Kelly K, Klassen TP, Rowe BH. Publica-
15. Parris W, McCarthy S, Kelly AM, Richardson S. Do tion bias of randomized controlled trials in emer-
triage nurse-initiated x-rays for limb injuries reduce gency medicine. Acad Emerg Med. 2006; 13:102–8.
patient transit time? Accid Emerg Nurs. 1997; 5:14–5. 34. Wiebe N, Vandermeer B, Platt RW, Klassen TP,
16. Thurston J, Field S. Should accident and emergency Moher D, Barrowman NJ. A systematic review iden-
nurses request radiographs? Results of a multicen- tifies a lack of standardization in methods for han-
tre evaluation. J Accid Emerg Med. 1996; 13:86–9. dling missing variance data. J Clin Epidemiol. 2006;
17. Lee KM, Wong TW, Chan R, Lau CC, Fu YK, Fung 59:342–53.
KH. Accuracy and efficiency of x-ray requests initi-
ated by triage nurses in an accident and emergency Supporting Information
department. Accid Emerg Nurs. 1996; 4:179–81.
18. Cheung WW, Heeney L, Pound JL. An advanced The following supporting information is available in the
triage system. Accid Emerg Nurs. 2002; 10:10–6. online version of this paper:
19. Fan J, Woolfrey K. The effect of triage-applied Data Supplement S1. Exact search strings.
ottawa ankle rules on the length of stay in a cana- The document is in DOC format.
dian urgent care department: a randomized con- Please note: Wiley Periodicals Inc. is not responsible
trolled trial. Acad Emerg Med. 2006; 13:153–7. for the content or functionality of any supporting infor-
20. Fry M. Triage nurses order x-rays for patients with mation supplied by the authors. Any queries (other than
isolated distal limb injuries: a 12-month ED study. missing material) should be directed to the correspond-
J Emerg Nurs. 2001; 27:17–22. ing author for the article.