Royal Columbian Hospital and Eagle Ridge Hospital

Nurse Initiated X-ray Orders

This is a prospective qualitative study examining the accuracy of the newly implemented nurse initiated x-ray orders for isolated extremity injuries presenting to Royal Columbian Hospital and Eagle Ridge Hospital Emergency Departments.


Accuracy of Nurse Initiated X-ray Orders of Extremity Injuries in the Emergency Department

Research Team:

  1. Dr. Peter Macdonald, MD FRCPC
  2. Dr. Kathryn Morrision, BSc, MD, R2 (Family) UBC
  3. Dr. Adam Lund, BSc, MD, MEd, FRCPC

See link below to view full size poster


The high number of patients seen in the emergency department often leads to long delays and exceeds the resources available. A new protocol has been initiated in the Fraser Health Authority emergency departments allowing nurses to order x-rays that they feel are appropriate as determined by pre-set guidelines. Therefore when the Emergency Physician sees the patient they will have immediate access to the x-ray as opposed to ordering an x-ray then waiting for the patient to return from radiology. The protocol is designed to decrease the wait times for patients without compromising patient safety by minimizing the ordering of unnecessary or inappropriate x-rays.


To determine the accuracy of nurse initiated x-ray orders of upper and lower extremity injuries of patients presenting in the emergency department.


  1. There will be an excellent agreement based on agreement beyond chance (kappa) and high percentage agreement between adult and pediatric extremity x-rays ordered by nurses under the new nurse initiated orders protocol and the x-rays that would have been ordered by emergency physicians
  2. There will be a lower percentage agreement of nurse over ordering (nurse ordered but the physician not), and nurse under ordering (physician ordered but nurse did not)

Inclusion & Exclusion Criteria:

Inclusion Criteria

Exclusion Criteria


-One upper or lower extremity injury


-Critical injuries

-Multiple injuries

-Hip fractures

-Pelvic fractures


Study Process:

  • Patients who meet the inclusion criteria presenting with upper and lower extremity injuries will be included in this study
  • Triage nurses can initiate x-ray orders for these injuries according to pre-set criteria
  • A questionnaire will be attached to each chart by the triage nurse during the study period (December 10th will be a soft roll-out. OFFICIAL start December 16, 2013. Study runs until 250 surveys have been completed)
  • Emergency Physicians will be asked to fill out a survey asking:
    • whether the x-ray was needed
    • whether the appropriate body part was imaged
    • if further x-rays will be required
  • Surveys will be placed in locked research study bins

Potential Impact:

Protocols for nurse initiated x-rays orders for patients presenting with upper and/or lower extremities can improve the efficiency of the ED and patient satisfaction. A barrier to implementing nurse initiated orders for radiographs is the possibility of nurses ordering inappropriate x-rays, including the wrong body part, sub-optimal views for the appropriate body part, or ordering more x-rays than are required. This study aims to evaluate whether there is a high agreement between nurse initiated and emergency physician orders for x-rays in patients with isolated extremity injuries. We will address whether there was inappropriate or excessive ordering of x-rays in both the adult and pediatric populations by nurses under the newly implemented protocol. In particular the evaluation of inappropriate x-rays and the need to limit the exposure to radiation is especially important in the pediatric population.