CORR Synthesis: What Triage Recommendations Are Available for Emergent or Urgent Musculoskeletal Conditions?

In the Beginning… The word “triage” comes from the French word “trier,” initially in use in Middle French starting in 1370; it means to sort, sift, or choose [33]. In medicine, triage was first applied to military operations such as mass casualty incidents or natural disasters, including nuclear warfare [6]. One of the earliest mentions of triage in orthopaedics was in an article from 1964 describing a hospital’s response to an earthquake [13]. Starting in the 1970s, scales such as the Abbreviated Injury Scale and Injury Severity Score were developed for practical application in medicine related to motor vehicle collisions [4, 15]. Triage has since become a key element of resource management and care for patients presenting to the emergency department (ED). The Argument Triage is critical to ensuring that patients receive care according to the severity of their conditions and to preserving human life and health [11, 14]. From a musculoskeletal perspective, patients with emergent (requiring surgery within a few hours) or urgent (requiring surgery within 24 hours) orthopaedic conditions may present to the ED, an urgent care center (UCC), or a musculoskeletal urgent care center (MUCC). Each of these settings has different strengths and resources, and patients could experience a delay of care if they initially seek care at a UCC or MUCC when they require the complex level of care that only an ED can provide. For example, if a patient initially presents inappropriately at an MUCC with a limb-threatening injury that requires emergency surgical care, lifesaving treatment would be delayed if that patient subsequently must visit an ED, be reevaluated, and only then be taken to surgery. On the contrary, a patient with a low-acuity orthopaedic injury might be appropriate for a UCC or MUCC and presenting to an ED will use resources that may be required in an emergency. MUCCs, which are frequently run by practicing orthopaedic surgeons [36], have become an avenue for specialized care for musculoskeletal and orthopaedic injuries and are a way to reduce ED costs and wait times for patients [3]. Given that MUCCs are often under the purview of practicing orthopaedic surgeons, it is essential that these clinics triage orthopaedic injuries appropriately. This review will synthesize the available evidence for the triage of emergent and urgent orthopaedic conditions in the ED, UCC, and MUCC settings and demonstrate the importance of triage for musculoskeletal injuries. Essential Elements We performed a search in the Ovid MEDLINE® and Embase databases covering the concepts “musculoskeletal,” “orthopaedic,” “triage guidelines,” “urgent care,” “emergency care,” and “emergency department triage” (Supplementary Fig. 1; https://links.lww.com/CORR/A864). Our institution’s medical librarian advised us regarding search terms and reviewed the final search strategy. We included studies if they were original research that included triage guidelines for emergent or urgent musculoskeletal conditions in the primary care, UCC, ED, or trauma center settings. We excluded case reports, conference abstracts, symposia articles, review articles, and editorial articles. We also excluded articles that discussed triage for osteoporosis, pain management, cervical injuries, or thoracic injuries. We found 13 articles that met our inclusion criteria (Fig. 1). All articles were screened by the first author, and when questions regarding inclusion/exclusion arose, the first author discussed these articles with the last author.Fig. 1: This flowchart shows the search and study selection process.We found two articles that detailed triage guidelines for use in the primary care setting that described triage for low-risk orthopaedic injuries [9] and general orthopaedic injuries [16]. Two articles described triage guidelines for use in the ED focusing on upper extremity trauma and infections [10] and general orthopaedic injuries [34]. We found two articles detailing triage guidelines for use in the trauma care setting focusing on upper extremity trauma [5] and pelvic fractures [7]. The remaining seven articles were related to triage guidelines to determine when to order imaging in the ED after an ankle [1, 2], wrist [25], knee [12, 19, 32], or distal extremity injury [8] (Table 1). Table 1. - Description of included studies Study Number of patients Setting MSK concern Study type Study purpose Conclusion Triage guidelines for use in primary care setting Fuschini et al. [9] 1283 PCC Low-risk injuries Retrospective study of longitudinally maintained data Assess outcomes of primary care pathway for the management of simple orthopaedic injuries The use of a primary care pathway model is effective for managing specific low-risk orthopaedic injuries without direct orthopaedic review. Includes a list of low-risk orthopaedic injuries that are appropriate for a PCC Rymaszewski et al. [16] 4568 PCC General orthopaedics Clinical trial Organize a coordinated team approach to outpatient management of MSK concerns Team approach involving orthopaedics, rheumatology, specialist PT, and podiatry effective in decreasing orthopaedic wait times. Includes a list of “fast-track” concerns that would require immediate care Triage guidelines for use in ED Hartzell et al. [10] 1172 ED Upper extremity trauma and infections Retrospective multisite study Aim to evaluate the treatment of patients with upper extremity injuries and infections who are transferred compared with those who are not Many patients with upper extremity injuries are unnecessarily transferred and the use of triage guidelines may be associated with better resource use. Includes table with transfer guidelines for patients with acute hand injuries or infections Washington et al. [34] 448 ED General orthopaedics Consensus process and field test Describe the development and implementation of deferred-care guidelines for adults with MSK concerns Guidelines suggest that a substantial proportion of patients with musculoskeletal concerns can have their care deferred (24%) Triage guidelines for imaging in the ED setting Allerston and Justham [1] 350 ED Ankle injuries Retrospective institutional study Goal to investigate the proportion of nurse practitioners compared with medical practitioners who ordered radiographs for patients presenting with ankle injuries Nurse practitioners who applied the OAR requested fewer radiographs than medical practitioners who may or may not have applied the OAR. However, the number of fractures found was not different. Concluded that the OAR should be used at triage Allerston and Justham [2] 183 ED Ankle injuries Retrospective case-control study Aim to investigate whether application of the OAR at initial triage is associated with reduced transit time in the ED Implementation of the OAR at initial triage was associated with reduced ED transit time Fry [8] 1806 ED Distal limb injuries Retrospective study of longitudinally maintained data Assess whether triage nurses can appropriately order radiographs for patients with distal limb injuries Triage nurses can assess patients and order appropriate radiographs for distal limb injuries. Triage nurses ordered fewer radiographs than medical staff, and these radiographs were more likely to demonstrate abnormalities. Study includes exclusion criteria for triage radiography policy for patients who may have more severe injuries Kec et al. [12] 103 ED Knee injuries Retrospective study of longitudinally maintained data Evaluate whether triage nurses can successfully implement the OKR for patients with knee injuries Triage nurses appropriately applied the OKR to patients presenting with knee injuries Simon et al. [19] 152 ED Knee injuries Retrospective study of longitudinally maintained data Aim to compare use of PDR between triage nurses and physicians Triage nurses successfully applied the PDR to patients with knee injuries. However, the PDR had a low sensitivity in this patient population Streppa et al. [25] ED Wrist injuries Guideline development based on the development of collective orders Develop a training program and diagnostic algorithm for use by triage nurses when evaluating wrist injuries so they can request radiographs Describes an algorithm for triage nurses that can be used to determine when wrist radiographs should be ordered for patients Szucs et al. [32] 96 ED Knee injuries Retrospective study of longitudinally maintained data Evaluate interobserver agreement between triage nurses and emergency physicians There was moderate interobserver agreement between triage nurses and emergency physicians for four of the five OKR Triage guidelines for use in trauma center setting Daly et al. [5] 12,009 Upper extremity TC Upper extremity trauma Retrospective institutional study Aim to evaluate whether Medicaid expansion is associated with the volume of patients with upper extremity trauma Medicaid expansion was associated with a decrease in the proportion of uninsured patients with upper extremity trauma. Using the Hand Trauma Severity Matrix, the appropriateness of transferred patients was unchanged while the appropriateness of nontransferred patients decreased Fox et al. [7] 175 TC Pelvic fractures Retrospective institutional study Use a prehospital regional triage protocol for patients with pelvic fractures and evaluate management at TC Trauma score alone is not reliable in prehospital triage of patients with pelvic fractures MSK = musculoskeletal; PCC = primary care clinic; PT = physical therapy; OAR = Ottawa Ankle Rules [21, 22]; OKR = Ottawa Knee Rules [23, 24]; PDR = Pittsburgh Decision Rule [17, 18]; TC = trauma center. We used the Methodological Index for Non-Randomized Studies (MINORS) criteria [20] for comparative and noncomparative studies to critically appraise the included articles. We assessed eight studies using the MINORS criteria for comparative studies, for which the ideal score is 24 and the median (range) of score of these studies was 14 (12 to 19) (Supplementary Table 1; https://links.lww.com/CORR/A865). We assessed four studies using the MINORS criteria for noncomparative studies, for which the ideal score is 16 and the median (range) score of these studies was 8 (8 to 12) (Supplementary Table 2; https://links.lww.com/CORR/A866). We could not assess one study using the MINORS criteria because this article did not include patient data [25]. What We (Think) We Know We found a variety of studies describing triage practices in the outpatient primary care or orthopaedic setting [9, 16], ED setting [1, 2, 8, 10, 12, 19, 25, 32, 34], and in the trauma center setting [5, 7]. Although we did not find any studies related specifically to triage practices in the UCC or MUCC setting, some of the triage guidelines intended for use in the ED may be adapted for use in urgent care facilities. Published triage protocols designed for use in the primary care setting were more targeted toward identifying low-acuity conditions that can be safely treated outside the ED [9, 16]. One study conducted in the primary care setting included a table listing the upper and lower limb musculoskeletal conditions that can be safely managed by a primary care provider to reduce the demand on hospital resources; however, this study focused more on specific injuries rather than symptoms that could be used to direct patients to the most appropriate care setting [9]. Another study done in the outpatient setting included a table with referral protocols for specific musculoskeletal symptoms and diagnoses separated by part of the body [16]. This study also included examples of conditions that should be immediately identified and assessed because the patient could be demonstrating signs of a potential musculoskeletal emergency, such as septic arthritis or cauda equina syndrome. However, neither of these studies provides specific protocols for distinguishing between conditions that would require ED care versus specialized urgent orthopaedic care that could be provided at an MUCC. One group from Australia provided recommendations for assessment, imaging, treatment, referrals, and follow-up for common orthopaedic conditions by assembling guidelines from systematic reviews. However, these reviews were not performed in urgent care or emergency settings [26-31]. These reviews covered foot and ankle injuries, low back pain, hand and wrist injuries, knee injuries, neck injuries, and shoulder injuries. The authors identified several symptoms that are likely to be associated with musculoskeletal emergencies such as saddle anesthesia, loss of bladder/bowel function, significant weakness, fever or malaise, unexplained deformity or swelling, nonmechanical pain, weight loss, recent infection, or history of cancer, and they emphasized the importance of thorough history-taking; however, they did not provide easy-to-follow triage protocols to identify conditions that would require immediate care to prevent loss of limb or life. ED triage protocols focus on distinguishing conditions that require immediate care from conditions that can be safely treated as an outpatient [10, 34]. Although the articles we found in our review mostly include triage guidelines for hand injuries and nontraumatic low back pain, these triage suggestions could be adapted to the UCC or MUCC setting. A multisite, retrospective study evaluated the treatment of patients with upper extremity injuries and infections and found that the use of triage guidelines may be associated with better resource use [10]. This study included a table of musculoskeletal conditions and described which ones required emergent hand surgery consultation as opposed to those that could be managed with hand surgery follow-up without emergent consultation or those that did not call for hand surgery consultation or follow-up. Hand injuries or conditions that do not require emergent hand surgery consultation could likely be treated in the UCC or MUCC setting. These include conditions that would not require specific hand surgery consultation or follow-up such as uncomplicated superficial cellulitis or abscesses; lacerations without bone, tendon, nerve, or vascular injury; sprains; contusions; mild edema; and uncomplicated removal of a superficial foreign body with no involvement of deeper structures [10]. In addition, closed metacarpal, closed phalanx, closed carpal, closed nondisplaced distal radius, closed nondisplaced distal ulna, and closed and appropriately reduced distal radius or ulna fractures could likely be managed in a UCC or MUCC setting, as the study suggests that these injuries do not require emergent consultation but do require follow-up [10]. When considering ED protocols that discuss low back pain, we found a small study that involved a consensus process and field test; the authors found that 24% of patients with musculoskeletal concerns such as low back pain, neck pain, isolated extremity pain, and generalized musculoskeletal pain can have their care safely deferred [34]. This study suggested that patients could have their care deferred for nontraumatic low back pain if they have normal vital signs and they do not have weakness, numbness, or tingling that involves both arms or both legs that started within the past 7 days, problems walking without help that are new within the past 2 weeks, back pain associated abdominal pain, urinary or fecal incontinence that started within the past 7 days, urinary retention that started in the past 7 days, or the inability to do usual work or care for themselves because of the pain [34]. Those elements could potentially be used in a triage protocol for a patient presenting with nontraumatic low back pain in the UCC or MUCC setting. An earlier study by some of the authors of the previous study [35] developed a list of standardized critical criteria, including patient criteria (age greater than 65 years, history of cancer, and lumbar spinal surgery within 1 month), that may increase the risk of a musculoskeletal emergency and critical musculoskeletal concerns that may call for immediate attention, including new neurologic symptoms (less than 1 week) in patients with low back pain or asymmetric swelling, temperature, color, or pulse of the involved extremity in a patient with an isolated extremity concern. Again, these criteria could be implemented to assess for extremity or spinal injuries that would be better suited for care in the ED setting as opposed to the UCC or MUCC setting. When considering the use of imaging in the ED, the research studies in our review demonstrated that decision rules such as the Ottawa Ankle Rules [21, 22], Ottawa Knee Rules [23, 24], and Pittsburg Decision Rule [17, 18] can be successfully implemented by triage providers. These decision rules could also be implemented in the UCC or MUCC setting if these facilities have the equipment to perform radiographs. Two small studies found that using the Ottawa Ankle Rules might be associated with reduced unnecessary radiographs and reduced ED transit time [1, 2]. Two retrospective studies of longitudinally maintained data found that triage providers can use the Ottawa Knee Rules appropriately [12, 32], and a further study [19] found that triage providers can successfully apply the Pittsburgh Decision Rule. In a study assessing distal limb injuries, the authors demonstrated that triage providers could assess patients and order appropriate radiographs to evaluate these injuries [8]. The triage providers ordered fewer radiographs than medical staff, and these radiographs were more likely to reveal abnormalities [8]. We found another study in which the authors developed a triage algorithm for wrist radiographs that providers could use in the ED [25], but this study did not include patient data. This algorithm was designed to assess patients for injuries that would require radiographs and includes questions that address whether the patient has a history of wrist trauma, any evidence of an open fracture or neurovascular compromise, severe wrist pain or other serious injuries, deformity or swelling of the wrist, anatomic snuff box tenderness, or distal radius or ulna tenderness [25]. These questions and this algorithm could easily be deployed in the UCC/MUCC setting if these facilities have the equipment necessary to perform radiographs. These studies highlight that triage providers can have a critical role in patient triage and can aid physicians and midlevel providers by identifying musculoskeletal injuries before assessment by an orthopaedic clinician. Two studies describing triage guidelines in the trauma center setting focused on the accuracy of transfer criteria. One group used the Hand Trauma Severity Matrix in a retrospective, institutional study to investigate associations between Medicaid expansion and the appropriateness of transfers to a quaternary referral center; they found that during the study period, Medicaid expansion was not associated with an increased probability of appropriateness as they hypothesized [5]. However, the study found that after Medicaid expansion, the appropriateness of patients who were not transferred from other institutions and either presented directly to the ED at the quaternary referral center or were triaged to the referral center from the field decreased, which may indicate that patients are presenting to the ED directly with lower-acuity injuries [5]. A small study investigating pelvic fractures found that there was no difference in trauma score between different mechanisms of injury or injury classes, which suggests that trauma score alone may not be reliable in the prehospital triage of patients with pelvic fractures [7]. Both studies suggested that although triaging patients is necessary to that they receive care, it is not effective as patients may choose to seek care at the ED for low-acuity injuries, or triage may not be specific for musculoskeletal injuries and as may not be as effective in triaging patients with musculoskeletal injuries. and In our we did not find any studies that provided guidelines on when patients should receive care in the ED as opposed to the urgent care setting for orthopaedic Although some of the triage guidelines developed for the ED could be adapted to the MUCC setting, MUCCs are an part of the care and it is critical to guidelines to that patients seek care in the ED, when of the studies we found in our review were in the the 13 studies included in our final only four were after [5, 10, the seven studies specific to imaging in the ED, only one was after [25]. Given the in orthopaedic since the these studies may no be or their may be because of in and to research is to triage guidelines for emergent and urgent musculoskeletal The most detailed triage guidelines we found were for imaging, and these guidelines can only be used after a patient to a care that has imaging which may include some UCC or MUCC [1, 2, 8, 12, 19, 25, Triage guidelines that can be used before at a care are necessary to patients are orthopaedic care in the setting. the two studies that were intended for use in the primary care setting mostly injuries that are appropriate for this setting of including questions that would help a provider between and urgent orthopaedic conditions [9, 16]. We it is to and standardized triage practices for emergent and urgent orthopaedic conditions to prevent in care that can to such as limb loss and We have a list of orthopaedic emergencies that would be for treatment at an MUCC based on our including cauda equina open or with the potential for vascular involvement or risk of injuries that a loss of and injuries with severe mechanisms of injury such as greater than trauma, or motor vehicle a patient initially presented to an MUCC of an ED with one of these the may not have the necessary resources for treatment, which could to serious including limb loss, severe or we developed triage questions that could be by a or triage provider at a UCC or MUCC when a patient to patients are to a level of care if (Table Triage questions that between musculoskeletal injuries that can be treated at an MUCC versus those that require care in the ED may MUCCs in and appropriate care for Table - urgent care triage questions that an ED visit if the is new numbness, or a fracture with a the malaise, and new that have not to or with and are or new loss of of or are pain, has the pain from for or from usual We that MUCCs will become more and that more patients will use for low-acuity injuries. Given that orthopaedic surgeons often and MUCCs, we must protocols to prevent in evaluate the potential of triage could perform studies that assess the sensitivity and of guidelines to that they can between conditions that require care in the ED versus the MUCC. In addition, studies that evaluate whether triage guidelines reduce the of patients presenting to the ED with low-acuity injuries could be Many musculoskeletal injuries can be safely treated at MUCCs, and those can provide more to orthopaedic However, we must that patients who require the level of care that can only be provided in a ED are appropriately triaged to an ED to prevent in care and

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