Effectiveness of nurse-initiated x-ray for emergency department patients with distal limb injuries: A systematic review

Prof. Julie Considine1, Prof Ramon Shaban2, Prof Kate Curtis3, Prof Margaret Fry4

1School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University – Centre for Quality and Patient Safety Research – Eastern Health Partnership, Melbourne, Australia, 2Sydney Nursing School and Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney – Western Sydney Local Health District, Sydney, Australia, 3Sydney Nursing School, The University of Sydney – Illawarra Shoalhaven Local Health District, Sydney, Australia, 4Faculty of Health, University of Technology Sydney – Northern Sydney Local Health District, Sydney, Australia


Emergency nurses are key partners in the delivery of emergency care and the largest emergency care workforce. Emergency nurses have, over many years, expanded their role and scope of practice to meet the needs of patients and respond to rising demands for emergency care. The aim of this study was to systematically review the literature on the effectiveness of nurse-initiated X-ray (NIXR) for emergency department (ED) patients with distal limb injuries. The primary outcomes were X-ray request practices and accuracy. Secondary outcomes were time to X-ray, waiting time, ED length of stay, patient satisfaction and unplanned ED reattendance.


The review protocol was registered with PROSPERO and CINHAL, MEDLINE, and EMBASE were searched for studies comparing nurse versus physician initiated X-Ray. Due to heterogeneity of patients, providers and outcomes, a meta-analysis was not performed.


The 16 included studies were conducted between 1971 and 2018 and involved 8881 participants. There were 4 randomised trials and 12 observational studies that focused on X-ray request accuracy (n=14), ED processes (n=6) and patient outcomes (n=2). The quality of evidence for each outcome ranged from very low to moderate. Compared to physician initiated X-ray, NIXR uses no more resources, is safe and acceptable to patients. NIXR did not reduce time to X-ray or waiting time but in some studies, reduced ED length of stay and unplanned follow-up.


The evidence related to NIXR is of very low to moderate quality highlighting the need for well-designed randomised controlled trials, in preference to observational studies.


Professor Julie Considine is Deakin University’s Professor of Nursing at Eastern Heath, one of Victoria’s largest health care services. Julie has held clinical, education and research roles in emergency nursing over the last two decades and internationally recognised as a leader in research and education in emergency care. Julie has over 180 publications and has attracted over $5.2M in research and project funding. Julie is a Founding Fellow of the College of Emergency Nursing Australasia (CENA), and in 2013 was awarded the Julie Finucane OAM Medal for leadership in emergency nursing and commitment to CENA. She is a Deputy Editor of the Australasian Emergency Care, represents the College of Emergency Nursing Australasia on the Australian Resuscitation Council, and is a member of the International Liaison Committee of Resuscitation Basic Life Support TaskForce.