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

doi:10.1136/bmj.b3056

Published 12 August 2009, doi:10.1136/bmj.b3056
Cite this as: BMJ 2009;339:b3056

Practice

Quality Improvement Report

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

Taryn Bessen, NHMRC NICS-RANZCR fellow ¹, Robyn Clark, NHMRC fellow (former heart Foundation-NHMRC NICS scholar) ², Sepehr Shakib, NHMRC NICS-SA DoH fellow³, Geoffrey Hughes, director of critical care services⁴

¹ Department of Medical Imaging, Royal Adelaide Hospital, Adelaide, SA 5000, Australia, ² Sansom Institute, Faculty of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia, ³ Department of Clinical Pharmacology, Royal Adelaide Hospital, ⁴ Emergency Department, Royal Adelaide Hospital

Correspondence to: T Bessen Taryn.Bessen{at}health.sa.gov.au

Abstract

Problem Despite widespread acceptance of the Ottawa ankle rulesfor assessment of acute ankle injuries, their application variesconsiderably.

Design Before and after study.

Background and setting Emergency departments of a tertiary teachinghospital and a community hospital in Australia.

Key measures for improvement Documentation of the Ottawa anklerules, proportion of patients referred for radiography, proportionof radiographs showing a fracture.

Strategies for change Education, a problem specific radiographyrequest form, reminders, audit and feedback, and using radiographersas "gatekeepers."

Effects of change Documentation of the Ottawa ankle rules improvedfrom 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 proportionof patients undergoing radiography fell from 95.8% to 87.2%at the tertiary hospital, and from 91.4% to 78.9% at the communityhospital (P<0.001 for both). The proportion of radiographsshowing a fracture increased from 20.4% to 27.1% at the tertiaryhospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the communityhospital. The missed fracture rate increased from 0% to 2.9%at the tertiary hospital and from 0% to 1.6% at the communityhospital compared with baseline (P=0.783 and P=0.747).

Lessons learnt Assessment of case note documentation has limitations.Clinician groups seem to differ in their capacity and willingnessto change their practice. A multifaceted change strategy includinga problem specific radiography request form can improve theselection of patients for radiography.

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