A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments

Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably.

Before and after study.

Emergency departments of a tertiary teaching hospital and a community hospital in Australia.

Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture.

Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as "gatekeepers."

Documentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P<0.001 for both). The proportion of patients undergoing radiography fell from 95.8% to 87.2% at the tertiary hospital, and from 91.4% to 78.9% at the community hospital (P<0.001 for both). The proportion of radiographs showing a fracture increased from 20.4% to 27.1% at the tertiary hospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the community hospital. The missed fracture rate increased from 0% to 2.9% at the tertiary hospital and from 0% to 1.6% at the community hospital compared with baseline (P=0.783 and P=0.747).

Assessment of case note documentation has limitations. Clinician groups seem to differ in their capacity and willingness to change their practice. A multifaceted change strategy including a problem specific radiography request form can improve the selection of patients for radiography.