Radiographer - Clinician agreement on imaging selection for extremity injuries in the emergency department – A pilot study

Introduction

The Emergency Department (ED) is a critical setting for multidisciplinary care, where medical imaging plays an essential role. Approximately 50 % of ED presentations involve imaging to support diagnosis and treatment planning. Nurse-initiated and physiotherapist-initiated X-ray requests are now common in some settings. This pilot study examines the feasibility of expanding radiographers' scope of practice by assessing their ability to determine the appropriate imaging for musculoskeletal injuries.

Methods

A retrospective audit of the ED Information System (EDIS) was conducted to identify triage notes from March 2022 to March 2023. Of 5769 musculoskeletal presentations, 90 scenarios were purposively selected across nine anatomical regions. These were embedded in an online survey distributed to 15 participants, grouped into three equal cohorts: radiographers, ED nurse practitioners, and ED consultants. Participants independently identified the most appropriate anatomical region for X-ray imaging based on the clinical scenarios. Inter-rater agreement was assessed using Fleiss' Kappa (FK).

Results

Inter-rater agreement was excellent across all cohorts, with overall FK = 0.948 (95 % CI: 0.943–0.953). Radiographers demonstrated the highest internal agreement (FK = 0.977), followed by nurse practitioners (FK = 0.932) and ED consultants (FK = 0.928). Agreement between radiographers and ED consultants was also high (FK = 0.952), supporting alignment in clinical decision-making.

Conclusion

Radiographers demonstrated strong agreement with ED consultants in determining appropriate imaging for musculoskeletal injuries, supporting the feasibility of radiographer-initiated X-ray (RIX) protocols.

Implications for practice

Structured RIX protocols could help alleviate ED workflow pressures, reduce unnecessary delays, and streamline imaging pathways for low-acuity injuries. These findings support future scope of practice reform and the development of competency-based RIX models in emergency settings.