De ‘Amsterdam wrist rules’-app

OBJECTIVE: To evaluate the safety of implementing the Amsterdam Wrist Rules (AWR) during Emergency Department (ED) nurse triage, and to assess the potential reduction of radiographic images. DESIGN: Prospective cohort study METHODS: Based on patient characteristics and clinical variables the AWR-application advised triage nurses if radiographic imaging was necessary of patients (>3 years) presenting with trauma of the wrist. The triage nurse was allowed to perform radiographic imaging if the advice was negative. Safety was assessed by the number of missed clinically relevant distal radius fractures (DRFs) when the AWR advised not to perform imaging. The potential reduction of radiographic images was assessed by the proportion of patients in whom the AWR-application advised not to perform imaging. Compliance was defined as following this advice. Patient satisfaction was assessed if no radiographic imaging was performed. RESULTS: The AWR-application advised not to perform imaging in 18% of children (n=153) and in 9% of adults (n=204). In children, one clinically relevant DRF was missed (sensitivity 99%, specificity 33%) and none in adults (sensitivity 100%, specificity 19%). The compliance was 22% in children and 32% in adults. If no radiographic imaging was performed, 100% of children and 75% of adults were satisfied. CONCLUSION: Implementation of the AWR during ED nurse triage of patients presenting with wrist trauma can safely contribute to reducing unnecessary radiographic imaging. If other injuries than a clinically relevant DRF are suspected based on triage, an ED physician should decide if imaging is necessary.