The Ottawa knee rule: examining use in an academic emergency department

The Ottawa Knee Rule is a validated clinical decision rule for determining whether knee radiographs should be obtained in the setting of acute knee trauma. The objectives of this study were to assess physician knowledge of, barriers to implementation of, and compliance with the Ottawa Knee Rule in academic emergency departments (EDs), and evaluate whether patient characteristics predict guideline noncompliance.

A 10 question online survey was distributed to all attending ED physicians working at three affiliated academic EDs to assess knowledge, attitudes and self-reported practice behaviors related to the Ottawa Knee Rule. We also performed a retrospective ED record review of patients 13 years of age and older who presented with acute knee trauma to the 3 study EDs during the 2009 calendar year, and we analyzed ED records for 19 variables.

ED physicians (n = 47) correctly answered 73.2% of questions assessing knowledge of the Ottawa Knee Rule. The most commonly cited barriers to implementation were "patient expectations" and system issues, such as "orthopedics referral requirement." We retrospectively reviewed 838 records, with 260 eligible for study inclusion. The rate of Ottawa Knee Rule compliance was retrospectively determined to be 63.1%. We observed a statistically significant correlation between Ottawa Knee Rule compliance and patient age, but not gender, insurance status, or provider type, among others.

Compliance with the Ottawa Knee Rule among academic ED healthcare providers is poor, which was predicted by patient age and not other physician or patient variables. Improving compliance will require comprehensive educational and systemic interventions.