CCBYNC Open access
Practice Quality Improvement Report

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

BMJ 2009; 339 doi: (Published 12 August 2009) Cite this as: BMJ 2009;339:b3056
  1. Taryn Bessen, NHMRC NICS-RANZCR fellow 1,
  2. Robyn Clark, NHMRC fellow (former heart Foundation-NHMRC NICS scholar) 2,
  3. Sepehr Shakib, NHMRC NICS-SA DoH fellow3,
  4. Geoffrey Hughes, director of critical care services4
  1. 1Department of Medical Imaging, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
  2. 2Sansom Institute, Faculty of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
  3. 3Department of Clinical Pharmacology, Royal Adelaide Hospital
  4. 4Emergency Department, Royal Adelaide Hospital
  1. Correspondence to: T Bessen Taryn.Bessen{at}
  • Accepted 27 May 2009


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

Design Before and after study.

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

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

Strategies for change Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as “gatekeepers.”

Effects of change 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).

Lessons learnt 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.


  • TB is a NHMRC National Institute of Clinical Studies-Royal Australian and New Zealand College of Radiologists (NHMRC NICS-RANZCR) fellow 2006-2008. She acknowledges the important contribution of her mentors, Virginia Deegan and Judith Dwyer. We also acknowledge our “change champions,” without whose support this study would not have been possible. These include (but are not limited to) Dianne King, director, emergency department, Flinders Medical Centre; Sue Farr, acting manager emergency department, Noarlunga Health Services; and staff in both emergency departments, who we hope are now our new change champions. We also acknowledge the department of medical imaging at the Royal Adelaide Hospital, and Dr Jones and Partners Medical Imaging, Noarlunga Health Services. Special thanks to Rebecca McMahon for research assistance.

  • Funding: This work was funded by NHMRC NICS and RANZCR.

  • Contributors: TB conceived and designed the study and won the funding for the study; TB, RC, and SS analysed and interpreted data. All authors drafted and revised the article and approved the final version. GH is guarantor.

  • Competing interests: None declared.

  • Ethical approval: Ethics approval was granted from all participating centres.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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