***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Patients with isolated limb injuries are often required to wait a long time for treatment and investigation in emergency departments . It was hypothesized that allowing triage nurses to initiate X-rays would reduce transit times for these patients . A prospect i ve , r and omized comparison trial of 175 patients was conducted , comparing transit times between a group of  patients who had X-rays initiated at triage and a  group which did not .  No statistically significant reduction in transit time was demonstrated by this change in practice , either for a group who had sustained fractures or for one which had not . Despite this finding , staff and patient satisfaction with this change in procedure was high . This justifies continuation of the practice and further research OBJECTIVE To compare outcomes of  nurse initiated X-rays ( NIX ) with emergency physician ( EP ) initiated X-rays ( EPIX ) of isolated lower limb injuries in patient transit time ( from triage to discharge ) through the emergency department ( ED ) . METHOD A prospect i ve , interventional study using a historical control group . Data were collected at each contact point from triage ( including time of EP 's initial assessment of patient , X-ray request and review , patient disposition decision and discharge time ) . Initially , data were collected as patients proceeded through the ED having X-rays requested after EP assessment . Following nurse education on use of pre-vali date d foot , ankle and knee X-ray decision instruments , similar data were collected following nurse X-ray request . Time differences between the two groups were compared . RESULTS A total of 206 patients were enrolled , with 105 having EPIX and 101 NIX . Group characteristics were not significantly different . Fractures were identified in 26.7 % of EPIX compared to 34.7 % of NIX ( p=0.300 ) . Despite an observed reduction in the mean transit time ( 172.9minutes ( min ) for EPIX to 158.6min for NIX ) this did not achieve statistical significance ( p=0.230 ) . There were significant differences in times from triage to initial assessment by EP ( mean 57.6min EPIX , 93.4min NIX , p<0.001 ) ( median 45.0min in EPIX , 78.0min in NIX group , p<0.001 ) which delayed transit time in the NIX group . CONCLUSION Although NIX reduced patient transit times , this did not reach statistical significance . In an ED with substantial access block , this suggests that corresponding systems changes are required to improve ED flow Aims : To compare the clinical effectiveness and costs of minor injury services provided by nurse practitioners with minor injury care provided by an accident and emergency ( A&E ) department . Methods : A three part prospect i ve study in a city where an A&E department was closing and being replaced by a nurse led minor injury unit ( MIU ) . The first part of the study took a sample of patients attending the A&E department . The second part of the study was a sample of patients from a nurse led MIU that had replaced the A&E department . In each of these sample s the clinical effectiveness was judged by comparing the “ gold st and ard ” of a research assessment with the clinical assessment . Primary outcome measures were the number of errors in clinical assessment , treatment , and disposal . The third part of the study used routine data whose collection had been prospect ively configured to assess the costs and cost consequences of both models of care . Results : The minor injury unit produced a safe service where the total package of care was equal to or in some cases better than the A&E care . Significant process errors were made in 191 of 1447 ( 13.2 % ) patients treated by medical staff in the A&E department and 126 of 1313 ( 9.6 % ) of patients treated by nurse practitioners in the MIU . Very significant errors were rare ( one error ) . Waiting times were much better at the MIU ( mean MIU 19 minutes , A&E department 56.4 minutes ) . The revenue costs were greater in the MIU ( MIU £ 41.1 , A&E department £ 40.01 ) and there was a great difference in the rates of follow up and with the nurses referring 47 % of patients for follow up and the A&E department referring only 27 % . Thus the costs and cost consequences were greater for MIU care compared with A&E care ( MIU £ 12.7 per minor injury case , A&E department £ 9.66 per minor injury case ) . Conclusion : A nurse practitioner minor injury service can provide a safe and effective service for the treatment of minor injury . However , the costs of such a service are greater and there seems to be an increased use of outpatient services OBJECTIVE --To evaluate whether waiting time in accident and emergency ( A&E ) departments is shortened when experienced nurses request peripheral limb radiographs before a patient is assessed by a doctor . DESIGN --Simultaneous prospect i ve trial in four A&E departments in the United Kingdom with doctors and nurses requesting radiographs ; 2000 patients were r and omly allocated to either a " Nurse First " or " Doctor First " category . SUBJECTS-- Patients older than 5 years presenting with recent peripheral limb injuries . MAIN OUTCOME MEASURES --Timing of the various stages of a patient 's passage through the A&E department comparing the orthodox route with a group of patients in whom an experienced A&E nurse had the option of requesting a radiograph before a medical assessment . RESULTS --There was a significant reduction in the time spent in A&E when no radiograph was requested ( P < < 0.001 ) . The mean time saved in the  " Doctor First "  ( DF ) group was 51 min , and in the " Nurse First " ( NF ) group 36 min . For those who were sent for an x ray 14 min was saved by getting the patient to see the nurse first . However , because the overall referral rate for x rays was greater in the NF group , ( 78 % of patients compared with 74 % of the DF group , a significant 4 % increase ( P = 0.05 ) this potential benefit was largely lost . Overall the average waiting time in the DF group of 92.5 min ( 95 % confidence interval : 89.2 to 96.1 min ) was reduced to 88.5 min ( 95 % CI:85.2 to 91.8 min ) in the NF group , a non-significant saving of 4 min . There was no overall difference between the proportion of relevant abnormalities reported by the radiologists for the DF or NF groups ( G2 = 0.739 , 1df , P = 0.30 ) ; however , there was a significant association between the number of relevant abnormalities reported by the radiologists and the different hospitals ( G2 = 9.7626 , 3df , P = 0.02 ) . Hospital C had the highest abnormality rate reported by the radiologists in both the DF ( 45 % ) and the NF ( 51 % ) groups . The most time saved in A&E was in the DF category when comparing those who did not have an x ray [ 58 ( CI 54 - 63 ) min ] with those who did [ 109 ( CI 104 - 114 ) min ] , a saving of 51 min . The corresponding time saved in the NF category between those who did not have an x ray [ 59 ( CI 53 - 65 ) min ] and those who did [ 95 ( CI 91 - 99 ) min ] was 36 min . CONCLUSIONS --14 min can be saved by getting the patient to see the nurse first ; however , because nurses in three out of four hospitals requested more radiological examinations than doctors , overall only 4 min waiting time was saved when peripheral limb radiographs were requested by nurses . The findings are somewhat against expectations but do identify that specific training and constant monitoring is essential if nurses are to request peripheral limb radiographs , as reflected in hospital C results In the emergency department ( ED ) Registered Nurses ( RNs ) often perform triage , i.e. the sorting and prioritizing of patients . The allocation of acuity ratings is commonly based on a triage scale . To date , three reliable 5-level triage scales exist , of which the Canadian Triage and Acuity Scale ( CTAS ) is one . In Sweden , few studies on ED triage have been conducted and the organization of triage has been found to vary considerably with no common triage scale . The aim of this study was to investigate the accuracy and concordance of  emergency nurses acuity ratings  of patient scenarios in the ED setting . Totally , 423 RNs from 48 ( 62 % ) Swedish EDs each triaged 18 patient scenarios using the CTAS . Of the 7,550 triage ratings , 57.6 % were triaged in concordance with the expected outcome and no scenario was triaged into the same triage level by all RNs . Inter-rater agreement for all RNs was kappa = 0.46 ( unweighted ) and kappa = 0.71 ( weighted ) . The fact that the kappa-values are only moderate to good and the low concordance between the RNs call for further studies , especially from a patient safety perspective Objectives : To assess whether initial patient consult by senior clinicians reduces numbers of patients waiting to be  seen as an indirect measure of waiting time throughout the emergency department ( ED ) . Methods : An emergency medicine consultant and a senior ED nurse ( G or F grade ) , known as the IMPACT team , staffed the triage area for four periods of four hours per week , Monday to Friday between 9 am to 5 pm for three months between December 2001 and February 2002 when staffing levels permitted . Patients normally triaged by a nurse in this area instead had an early consultation with the IMPACT team . Data were collected prospect ively on all patients seen by the IMPACT team . The number of patients waiting to be seen ( for triage , in majors and in minors ) was assessed every two hours during the IMPACT sessions and at corresponding times when no IMPACT team was operational . Results : There was an overall reduction in the number of patients waiting to be seen in the department from 18.3 to 5.5 ( p<0.0001 ) at formal two hourly assessment s. The largest difference was seen in minors . Of the patients seen at triage by the IMPACT team , 48.9 % were discharged home immediately after assessment and treatment . With the IMPACT team present , no patient waited more than four hours for initial clinical consult . Conclusions : By using a senior clinical team for initial patient consultation , the numbers of patients waiting fell dramatically throughout the ED . Many patients can be effectively treated and discharged after initial consult by the IMPACT team This study examined the  emergency nurse practitioner c and i date ( ENPC ) scope of practice in a Victorian emergency department ( ED ) . The emergency nurse practitioner ( ENP ) role is relatively new in Victoria and the scope of the ENP(C ) practice is yet to be defined . International research literature regarding the ENP role has focused on outcomes such as patient satisfaction , waiting times and /or ED length of stay , accuracy and adequacy of documentation , use of radiography , and patient education , health promotion and communication issues . A prospect i ve exploratory design was used to conduct this cohort study . There were 476 ENPC-managed patients between 14 July 2004 and 31 March 2005 with an average age of 29 years . The majority ( 77.2 % ) of ENPC-managed patients were discharged from the ED . The majority of the ENPC time was devoted to clinical practice ( 55 % ) and development of clinical practice guidelines ( 25 % ) . Of patients managed by the ENPC , 49.6 % required medications , 51 % required diagnostic imaging and 8.6 % required pathology testing during their ED stay . The most common discharge referrals were made to local medical officers ( 73.5 % ) and the most common referrals made for patients requiring admission were made to the plastic surgery ( 37.3 % ) and orthopaedic ( 35.5 % ) units . Extensions to the current scope of emergency nursing practice are pivotal to effective management of specific patient groups by ENP . The ENP model of care is an important strategy for the management of increased service dem and s in Victoria ; however , little is known about the scope of the ENPC practice and many outcomes of the ENP care are yet to be defined . Further research to better underst and the relationships between ENP outcomes is required if the contribution that ENPs make to emergency care is to be accurately quantified Objective —To study an established triage nurse x ray requesting system to determine whether sending defined groups of patients for radiography before assessment by doctors or emergency nurse practitioners ( ENPs ) result ed in shorter waiting times for patients without compromising quality of care . Methods — Prospect i ve r and omised controlled study of “ walking wounded ” patients attending a district general hospital . Data were collected over two separate two week periods , six months apart , in the middle of two senior house officer appointment periods . A total of 675 patients were entered into the study . Analysis of results was achieved using st and ard statistical methods . Results —Altogether 335 patients were in the nurse x ray group and 340 in the control group .  The triage categories of the groups were similar . A 36 % mean time reduction of 37.2 min ( 95 % confidence interval 30.2 to 44.2 , p=0.000 ) from time of triage to time of treatment decision was achieved in the nurse requested group . Triage nurses requested 8 % ( p=0.002 ) fewer x rays than doctors or ENPs and had a 6 % higher positive “ hit ” rate ( p=0.03 ) . In 7.8 % ( 26 cases ) , patients in the triage nurse group were judged to require  radiographs or further views by the doctor or ENP ; of these , 11 cases showed a positive finding on radiography . The time from triage to assessment by doctor or ENP was not lengthened by prior requesting of radiography ( nurse x ray group 64.4 min , control group 6 
    Output:
    
Advanced practice nursing roles , physician-assisted triage and medical assessment units are models of care that can positively impact ED throughput .
They have been shown to decrease ED LOS and DNW rates .
Confounding factors , such as site specific staffing requirements , patient acuity and rest-of-hospital processes , can also impact on patient throughput through the ED