Clinical Decision Rules and Reduction of Ankle X-Rays in Pediatric Population: An Intervention Study

Ankle injuries are common in pediatric patients and have a low incidence of fractures. This study aimed to evaluate the implementation of a protocol based on clinical decision rules to reduce the number of radiographs requested during nursing triage, thereby decreasing radiation exposure, waiting times, and health care costs.

A quasi-experimental pre- and postintervention study with nonequivalent groups was conducted. Patients aged 3 to 16 years presenting with ankle injuries to the emergency department were included. The number of radiographs requested before and after the protocol's implementation was compared. The protocol incorporated the Ottawa Ankle Rules and the Low-Risk Ankle Rule, which were applied during nursing triage and medical assessment. The absolute risk reduction, relative risk reduction, and number needed to treat were calculated, along with the emergency department length of stay and associated economic savings.

A total of 252 patients were included (preintervention: 132 and postintervention: 120). Radiograph requests decreased significantly, with an absolute risk reduction of 46.81% (95% CI, 36.59%-57.03%), a relative risk reduction of 51.93% (95% CI, 40.57%-61.12%), and a number needed to treat of 2 (95% CI, 1-2). Interobserver agreement between nursing staff and physicians was good to very good (Cohen's kappa of 0.779 for Ottawa Ankle Rules and 0.825 for Low-Risk Ankle Rule).

The implementation of clinical decision rules by nursing staff significantly reduces radiograph requests in pediatric ankle injuries without compromising safety. This strategy reduces radiation exposure, health care costs, and emergency department length of stay.