CJEM Articles: randomized controlled trial

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  • A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles fractures
    May 2010 12 3
    Colin Jackson, Eric Grafstein, Grant Innes, Jim Christenson, Keith Stothers, Rob Stenstrom, Robert MacCormack, Tom Goetz

    Objective: Our primary objective was to determine the effectiveness of 3 immobilization methods (circumferential casting [CC], volar–dorsal splinting [VDS] and modified sugartong [MST] splinting) in maintaining the position of displaced distal radius fractures after successful closed reduction. Our secondary objective was to assess longterm functional outcomes associated with immobilization with fibreglass splinting versus standard CC in patients maintaining initial nonoperative reductions.

    Methods: We conducted a prospective randomized singleblind controlled trial in patients over 18 years of age who presented to the emergency department with a displaced fracture of the distal radius requiring closed reduction. The primary outcome was loss of reduction (defined as radiologic slippage or the need for surgical fixation during the 3–4 week primary immobilization period after initial successful reduction). Secondary outcomes included DASH (disabilities of the arm, shoulder and hand) score, return to work, activities of daily living, wrist pain, range of motion and grip strength assessed at 8 weeks and 6 months.

    Results: Thirty participants were randomly assigned to receive MST splinting, 31 to receive VDS and 40 to receive CC. Baseline characteristics were similar among groups. Radiographic loss of reduction occurred in 16% (95% confidence interval [CI] 3.1%–28.9%) of participants in the VDS group, 20% (95% CI 7.6%–32.4%) in the CC group and 30% (95% CI 13.6%–46.4%) in the MST splinting group (p = 0.17). Based on multivariate analysis of variance, functional outcomes at 8 weeks were similar among groups (p = 0.89). DASH scores at 8 weeks and 6 months were similar among groups, based on 1way analysis of variance (p > 0.25).

    Conclusion: Rates of loss in anatomic position were not statistically significant among the 3 types of dressings used. However, there was a clinically important trend of increased loss of reduction with the use of MST splinting. Functional outcomes at 8 weeks and 6 months were not significantly different between CC, VDS and MDS splinting. Ease of application and familiarity with use should guide clinical decisions when choosing a dressing type for displaced Colles fractures.

  • Assessment of inter-observer reliability of two five-level triage and acuity scales: a randomized controlled trial
    July 2004 6 4
    Andrew Worster, Christopher M. Fernandes, David Eitel, Kevin Eva, Nicki Gilboy, Paula Tanabe, Rose Geisler

    Introduction: The Emergency Severity Index (ESI

    ©) is an initial measure of patient assessment in the emergency department (ED). It rates patients based on acuity and predicted resource intensity from Level 1 (most ill) to Level 5 (least resource intensive). Already implemented and evaluated in several US hospitals, ESI has yet to be evaluated in a Canadian setting or compared with the five-level Canadian Emergency Department Triage and Acuity Scale (CTAS).

    Objective: To compare the inter-observer reliability of 2 five-level triage and acuity scales.

    Methods: Ten triage nurses, who had all been trained in the use of CTAS, from 4 urban, academic Canadian EDs were randomly assigned either to training in ESI version 3 (ESI v.3) or to refresher training in CTAS. They independently assigned triage scores to 200 emergency cases, unaware of the rating by the other nurses.

    Results: Number of years of nursing practice was the only significant demographic difference found between the 2 groups (p = 0.014). A quadratically weighted kappa to measure the inter-observer reliability of the CTAS group was 0.91 (0.90, 0.99) and not significantly different from that of the ESI group 0.89 (0.88, 0.99). An inter-test generalizability (G) study performed on the variance components derived from an analysis of variance (ANOVA) revealed G(5) = 0.90 (0.82, 0.99).

    Conclusions: After 3 hours of training, experienced triage nurses were able to perform triage assessments using ESI v.3 with the same inter-observer reliability as those with experience and refresher training in using the CTAS.