急诊科分诊护士能否恰当地运用渥太华膝关节规则来开具X光检查单？一项实施试验。

Can emergency department triage nurses appropriately utilize the Ottawa Knee Rules to order radiographs?-An implementation trial.

作者信息

Kec Robert M, Richman Peter B, Szucs Paul A, Mandell Mark, Eskin Barnet

机构信息

Department of Emergency Medicine, Morristown Memorial Hospital, Morristown, NJ, USA.

出版信息

Acad Emerg Med. 2003 Feb;10(2):146-50. doi: 10.1197/aemj.10.2.146.

DOI:10.1197/aemj.10.2.146

PMID:12574012

Abstract

OBJECTIVE

To determine whether triage nurses can successfully interpret the Ottawa Knee Rule (OKR) and order knee radiographs according to the OKR.

METHODS

This was a prospective implementation trial of a clinical decision rule, set in a suburban, community emergency department (ED), evaluating a convenience sample of ED patients aged > 17 years with acute knee injuries. Patients were excluded for altered mental status, distracting injuries, and knee lacerations. Triage nurses and attending emergency physicians (EPs) were trained in appropriate use of the OKR. The triage nurses evaluated eligible patients and radiographs were ordered according to their interpretation of the OKR. EPs who were initially blinded to the triage assessments also evaluated the patients. EPs could add an x-ray order if, according to their assessment of the OKR, one was indicated and a radiograph had not been ordered by the nurse. Nurses and EPs recorded their blinded assessments on standardized data collection instruments. Kappa values were calculated to assess interobserver agreement (IOA) between nurses and EPs; sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated as appropriate.

RESULTS

One hundred three patients were enrolled; 53% were female; 10 fractures were identified (9.7%). The IOAs between the nurses and EPs for each of the criteria were moderate to almost perfect: age-0.94; fibular head tenderness-0.4; isolated patellar tenderness-0.68; inability to bend knee to 90 degrees-0.73; inability to bear weight-0.76. The IOA was moderate (0.52) for the overall interpretation of the OKR by nurses and EPs. Sensitivity of nurse interpretation of the OKR for fracture was 70%, specificity 33%, NPV 91%, PPV 10%. Sensitivity of EP interpretation of the OKR for fracture was 100%, specificity 25%, NPV 100%, PPV 13%.

CONCLUSIONS

Triage nurses showed fair to good ability to appropriately apply the OKR to pre-order knee radiographs.

摘要

目的

确定分诊护士能否成功解读渥太华膝关节规则（OKR）并根据OKR开具膝关节X线检查单。

方法

这是一项临床决策规则的前瞻性实施试验，在一家郊区社区急诊科进行，评估年龄大于17岁的急性膝关节损伤的急诊患者的便利样本。因精神状态改变、多发伤和膝关节撕裂伤而排除患者。分诊护士和主治急诊医师（EP）接受了OKR正确使用的培训。分诊护士对符合条件的患者进行评估，并根据他们对OKR的解读开具X线检查单。最初对分诊评估不知情的EP也对患者进行评估。如果根据EP对OKR的评估需要进行X线检查且护士未开具X线检查单，EP可以添加X线检查医嘱。护士和EP在标准化数据收集工具上记录他们的不知情评估。计算kappa值以评估护士和EP之间的观察者间一致性（IOA）；酌情计算敏感性、特异性、阴性预测值（NPV）和阳性预测值（PPV）。

结果

共纳入103例患者；53%为女性；确诊10例骨折（9.7%）。护士和EP在各项标准上的IOA为中等至几乎完美：年龄 - 0.94；腓骨头压痛 - 0.4；孤立的髌骨压痛 - 0.68；无法将膝关节弯曲至90度 - 0.73；无法负重 - 0.76。护士和EP对OKR总体解读的IOA为中等（0.52）。护士对OKR骨折解读敏感性为70%，特异性为33%，NPV为91%，PPV为10%。EP对OKR骨折解读敏感性为100%，特异性为25%，NPV为100%，PPV为13%。