Ottawa Ankle Rules Research Articles

Implementation of Clinical Decision Rules in the Emergency Department

Clinical decision rules (CDRs) are tools designed to help clinicians make bedside diagnostic and therapeutic decisions. The development of a CDR involves three stages: derivation, validation, and implementation. Several criteria need to be considered when designing and evaluating the results of an implementation trial. In this article, the authors review the results of implementation studies evaluating the effect of four CDRs: the Ottawa Ankle Rules, the Ottawa Knee Rule, the Canadian C-Spine Rule, and the Canadian CT Head Rule. Four implementation studies demonstrated that the implementation of CDRs in the emergency department (ED) safely reduced the use of radiography for ankle, knee, and cervical spine injuries. However, a recent trial failed to demonstrate an impact on computed tomography imaging rates. Well-developed and validated CDRs can be successfully implemented into practice, efficiently standardizing ED care. However, further research is needed to identify barriers to implementation in order to achieve improved uptake in the ED.

Validation of the Ottawa ankle rules in a second-level trauma center in Italy

Trauma of the foot and ankle is commonly seen in the emergency unit. Nearly all of these patients undergo radiography even though only approximately 15% have clinically significant fractures. The Ottawa ankle rules (OARs) have been designed to reduce the number of unnecessary radiographs ordered for these patients. The objective of this study was to validate the OARs in a Italian trauma center. This prospective study enrolled 248 patients with acute ankle injury from July to October 2006 in the Ospedali Riuniti emergency department. Main outcome measures were: sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios (positive and negative) of the OARs. Sensitivity of the OARs for detecting 42 ankle fractures (29 in the malleolar zone, 4 in the midfoot zone and 4 concomitant in both zones) was 100% for each of the two zones and for both zones. Specificity of the OARs for detecting fractures was 46.5% for both zones, 43.5% for the malleolar zone, and 41.0% for the midfoot zone. Implementation of the OARs had the potential for reducing radiographs by 29%. OARs are highly sensitive tools for detecting ankle and midfoot fractures. Implementation of these rules would reduce the number of radiographs and the associated costs, radiation exposure and waiting times in emergency departments.

Application of Ottawa ankle rules—How far it is justified in children with ankle injuries

Application of Ottawa ankle rules—How far it is justified in children with ankle injuries

Will a New Clinical Decision Rule Be Widely Used? The Case of the Canadian C-Spine Rule

Objectives: The reasons why some clinical decision rules (CDRs) become widely used and others do not are not well understood. The authors wanted to know the following: 1) To what extent is widespread use of a new, relatively complex CDR an attainable goal? 2) How do physician perceptions of the new CDR compare with those of a widely used rule? 3) To what extent do physician subgroups differ in likelihood to use a new rule? Methods: A survey of 399 Canadian emergency physicians was conducted using Dillman’s Tailored Design Method for postal surveys. The physicians were queried regarding the Canadian Cervical-Spine Rule (C-Spine Rule). Results were analyzed via frequency distributions, tests of association, and logistic regression. Results: Response rate was 69.2% (262/376). Most respondents (83.6%) reported having already seen the Canadian C-Spine Rule, while 63.0% reported already using it. Of those who did not currently use the rule, 74.2% reported that they would consider using it in the future despite the fact that, compared with another widely used rule (the Ottawa Ankle Rules), the C-Spine Rule was rated as less easy to learn (z = 6.68, p<0.001), remember (z = 7.37, p<0.001), and use (z = 5.90, p<0.001). Those who had never seen the rule before were older (chi2(2) = 5.10, p = 0.007) and more likely to work part-time (chi2(2) = 7.31, p = 0.026). The best predictors of whether the rule would be used was whether it had first been seen during training (odds ratio [OR], 2.62; 95% confidence interval [CI] = 1.14 to 6.04), was perceived as an efficient use of time (OR, 4.44; 95% CI = 1.12 to 16.89), and was too much trouble to apply (OR, 0.25; 95% CI = 0.08 to 0.77). Conclusions: Widespread use of a relatively complex rule is possible. Older and part-time physicians were less likely to have seen the Canadian C-Spine Rule but not less likely to use it once they had seen it. Targeting hard-to-reach subpopulations while stressing the safety and convenience of these rules is most likely to increase use of new CDRs. Comment:So, you can teach old dogs new tricks. This is evidence that if you do the research and develop an effective evidence-based decisionmaking tool, we will use it—even if it is not the way we’ve been practicing for 20 years. S. L. Werner, MD

Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head

Traumatic injuries to the ankle/foot, knee, cervical spine, and head are very commonly seen in emergency and accident departments around the world. There has been much interest in the development of clinical decision rules to help guide the investigations of these patients in a standardised and cost-effective manner. In this article we reviewed the impact of the Ottawa ankle rules, Ottawa knee rules, Canadian C-spine rule and the Canadian CT head rule. The studies conducted have confirmed that the use of well developed clinical decision rules results in less radiography, less time spent in the emergency department and does not decrease patient satisfaction or result in misdiagnosis. Emergency physicians around the world should adopt the use of clinical decision rules for ankle/foot, knee, cervical spine and minor head injuries. With relatively simple implementation strategies, care can be standardized and costs reduced while providing excellent clinical care.

Will a New Clinical Decision Rule Be Widely Used? the Case of the Canadian C‐Spine Rule

The reasons why some clinical decision rules (CDRs) become widely used and others do not are not well understood. The authors wanted to know the following: 1) To what extent is widespread use of a new, relatively complex CDR an attainable goal? 2) How do physician perceptions of the new CDR compare with those of a widely used rule? 3) To what extent do physician subgroups differ in likelihood to use a new rule? A survey of 399 Canadian emergency physicians was conducted using Dillman's Tailored Design Method for postal surveys. The physicians were queried regarding the Canadian Cervical-Spine Rule (C-Spine Rule). Results were analyzed via frequency distributions, tests of association, and logistic regression. Response rate was 69.2% (262/376). Most respondents (83.6%) reported having already seen the Canadian C-Spine Rule, while 63.0% reported already using it. Of those who did not currently use the rule, 74.2% reported that they would consider using it in the future despite the fact that, compared with another widely used rule (the Ottawa Ankle Rules), the C-Spine Rule was rated as less easy to learn (z = 6.68, p < 0.001), remember (z = 7.37, p < 0.001), and use (z = 5.90, p < 0.001). Those who had never seen the rule before were older (chi2(2) = 5.10, p = 0.007) and more likely to work part-time (chi2(2) = 7.31, p = 0.026). The best predictors of whether the rule would be used was whether it had first been seen during training (odds ratio [OR], 2.62; 95% confidence interval [CI] = 1.14 to 6.04), was perceived as an efficient use of time (OR, 4.44; 95% CI = 1.12 to 16.89), and was too much trouble to apply (OR, 0.25; 95% CI = 0.08 to 0.77). Widespread use of a relatively complex rule is possible. Older and part-time physicians were less likely to have seen the Canadian C-Spine Rule but not less likely to use it once they had seen it. Targeting hard-to-reach subpopulations while stressing the safety and convenience of these rules is most likely to increase use of new CDRs.

Validation of the Ottawa Ankle Rules in Iran: A prospective survey

BackgroundAcute ankle injuries are one of the most common reasons for presenting to emergency departments, but only a small percentage of patients – approximately 15% – have clinically significant fractures. However, these patients are almost always referred for radiography. The Ottawa Ankle Rules (OARs) have been designed to reduce the number of unnecessary radiographs ordered for these patients. The objective of this study was to validate the OARs in the Iranian population.MethodsThis prospective survey was done among 200 patients with acute ankle injury from January 2004 to April 2004 in the Akhtar Orthopedics Hospital Emergency Department. Main outcome measures of this survey were: sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios (positive and negative) of the OARs.ResultsSensitivity of the OARs for detecting 37 ankle fractures (23 in the malleolar zone and 14 in the midfoot zone) was 100% for each of the two zones, and 100% for both zones. Specificity of the OARs for detecting fractures was 40.50% for both zones, 40.50% for the malleolar zone, and 56.00% for the midfoot zone. Implementation of the OARs had the potential for reducing radiographs by 33%.ConclusionOARs are very accurate and highly sensitive tools for detecting ankle fractures. Implementation of these rules would lead to significant reduction in the number of radiographs, costs, radiation exposure and waiting times in emergency departments.

The Effect of Triage‐applied Ottawa Ankle Rules on the Length of Stay in a Canadian Urgent Care Department: A Randomized Controlled Trial

To determine whether triage nurses ordering ankle or foot radiographs according to the Ottawa Ankle Rules (OAR) before physician evaluation decreases the length of stay for patients visiting an urgent care department. From July to September 2004, a randomized controlled trial of consecutive adult patients with ankle or foot twisting injuries who arrived at an urgent care department was conducted. Patients were included if their age was 18 years or older and their injury had occurred within seven days. They were excluded if there were neurovascular deficits, limb deformities, open fractures, or nonisolated ankle or foot injuries. Patients were randomly allocated to a roentgenogram-ordering clinical pathway (intervention) or to standard departmental care (control). Those assigned to the intervention group had triage nurses applying the OAR, and those with positive OAR were sent for roentgenograms before physician evaluation. Physicians were blinded to negative OAR nurse assessments. Investigators were blinded to group allocation. The primary outcome was the total mean length of stay (TLOS). The secondary outcomes were patient satisfaction (five-point ordinal scale) and the proportion willing to return to the site for future care. Two-independent sample t-test was used to analyze the TLOS. The Kruskal-Wallis test was used to analyze satisfaction ratings differences between groups. Fisher's exact test was used to analyze the willing-to-return outcome. This study had 80% power to detect an effect size of 25 minutes. Two hundred thirty-two patients were eligible; 130 patients gave consent and were enrolled. Three patients were then excluded, three were lost to follow-up, and one left without being seen. The intervention and control groups had mean TLOS of 73.0 minutes and 79.7 minutes, respectively. There was a statistically nonsignificant time difference of -6.7 minutes (95% CI = -20.9 to 7.4) between groups. There were no differences in patient satisfaction ratings (p-value = 0.343) or WOR (3.8%; 95% CI = -3.3% to 11.0%). The use of OAR and the ordering of roentgenograms by triage nurses before physician evaluation for twisting ankle or foot injuries does not decrease the length of stay in an urgent care department.

The Effect of Triage-applied Ottawa Ankle Rules on the Length of Stay in a Canadian Urgent Care Department: A Randomized Controlled Trial

The Effect of Triage-applied Ottawa Ankle Rules on the Length of Stay in a Canadian Urgent Care Department: A Randomized Controlled Trial

Kafka, New Orleans, the OARs and the KT Boundary

The dying emperor in Kafka's tale has sent you a message of great importance, entrusted to his strongest herald. But the throne room, the palace, the city are so huge and so crowded with people that the message can never reach you. Reverse the tale and you have the problem of Knowledge Transfer (KT)--brutally illustrated by the fate of New Orleans. Important information, of unquestioned validity, soundly based in research and easy to understand, simply does not get through to practice. A recent evaluation of the Ottawa Ankle Rules makes the point all too clearly. Indeed, the KT problem is worse than Kafka's. Economically motivated people and organizations actively distort the messages--and try to trip the herald--while grossly oversimplified frameworks of understanding include no language in which the messages can be expressed. "More research" is not the answer.

The Bernese Ankle Rules: A Fast, Reliable Test after Low-Energy, Supination-Type Malleolar and Midfoot Trauma

Trauma of the midfoot and ankle joint are among the most commonly treated injuries in the emergency unit. The "Ottawa ankle rules" were introduced in 1992 to lower the amount of radiographs based on a standardized clinical examination. The weakness of the "rules" is the low specificity reported in several clinical studies. We introduced a new indirect stress technique to examine the ankle and the midfoot after low-energy, supination-type trauma, avoiding direct palpation of the injured region. In 354 prospectively documented patients, the Bernese ankle test produced a sensitivity of 100% and a specificity of 91%. Compared with the original Ottawa ankle rules, the number of false-positive findings could be significantly reduced, resulting in a reduction of 84% in radiographs after low-energy, supination-type trauma ankle and midfoot trauma. Further investigations have to be performed to prove whether these findings are reproducible within other clinical settings, which could result in major cost savings for the health care system.

Clinical Decision Rules "in the Real World": How a Widely Disseminated Rule Is Used in Everyday Practice

Widespread, appropriate use of clinical decision rules would result in many benefits for health care. While it is known that clinicians report using these rules, little is known about how the rules are actually used in everyday practice. To conduct a survey of emergency physicians to examine whether they use the Ottawa Ankle Rules (OAR) consistently, exclusively, and accurately. A postal survey was administered to 399 emergency physicians randomly selected from the membership list of the Canadian Association of Emergency Physicians using Dillman's tailored design method for postal surveys. Results were analyzed via frequency distributions and linear regression. Response rate was 69.7% (262 of 376 eligible respondents), of whom 99.2% were familiar with the OAR. Most physicians (89.6%) reported using the OAR always or most of the time in appropriate circumstances, while only 42.2% reported basing their decisions to order radiography primarily on the rule. Physicians reported considering non-rule factors that are not related to the presence of a fracture (e.g., swelling: 54%), and factors that add no more predictive value over and above the rule (e.g., age >55 years: 55.2%). While 82.4% reported not having reviewed the rule for months or years, only 30.9% of the respondents were able to correctly remember the components of the rule. Errors in remembering rule components were more common among part-time (beta = 0.18, p = 0.009) and older (beta = 0.18, p = 0.04) physicians, and those who do not apply the rule consistently (beta = 0.14, p = 0.04). Most physicians report using and applying the OAR consistently, but most report that the rule is not the primary determinant of their decisions. Most apply this rule without referring to memory aids, yet their memory for this simple rule is imperfect. Future work should study how different memory aid strategies might improve the accuracy of rule application and reduce the use of nonpredictive cues.

Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses

Objectives The ED is often confronted with long waiting periods. Because of the progressive shortage in general practitioners, further growth is expected in the number of patients visiting the ED without consulting a general practitioner first. These patients mainly present with minor injuries suitable for a standardized diagnostic protocol. The question was raised whether these injuries can be treated by trained ED nurses (specialized emergency nurses [SENs]). The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules (OAR) and Ottawa Foot Rules (OFR). Methods In a prospective study, all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor (house officer [HO]) randomized for first observer. Before the study, SENs were trained in applying OAR and OFR. In all patients, radiography was performed (gold standard). The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics. Furthermore, from the paired results, reproducibility was calculated using κ statistics. Results In total, 106 injuries were assessed in pairs, of which 14 were ultimately found to concern acute fractures (prevalence, 13%). The sensitivity for the SEN group was 0.93 (95% confidence interval [CI], 0.64-1.00) compared with 0.93 (95% CI, 0.64-1.00) for the HO group (no significance [ns]). The specificity of the nurses was 0.49 (95% CI, 0.38-0.60) compared with 0.39 (95% CI, 0.29-0.50) for the doctors (ns). The positive predictive value for the SEN group was 0.22 (95% CI, 0.13-0.35) compared with 0.19 (95% CI, 0.11-0.31) for the HO group (ns). The negative predictive value for the nurses was 0.98 (95% CI, 0.87-1.00) compared with 0.97 (95% CI, 0.84-1.00) for the doctors (ns). The interobserver agreement for the OAR and OFR subsets was κ = 0.38 for the lateral malleolus; κ = 0.30, medial malleolus; κ = 0.50, navicular; κ = 0.45, metatarsal V base; and κ = 0.43, weight-bearing. The overall interobserver agreement for the OAR was κ = 0.41 and κ = 0.77 for the OFR. Conclusion Specialized emergency nurses are able to assess ankle and foot injuries in an accurate manner with regard to the detection of acute fractures after a short, inexpensive course.

Attitudes of Emergency Physicians toward the Ottawa Ankle Rules

Attitudes of Emergency Physicians toward the Ottawa Ankle Rules

The Effect of Triage-applied Ottawa Ankle Rules on Length of Stay in a Canadian Urgent Care Department: A Randomized Controlled Trial

The Effect of Triage-applied Ottawa Ankle Rules on Length of Stay in a Canadian Urgent Care Department: A Randomized Controlled Trial

Clinical audit and the implementation of the Ottawa Ankle Rules

PurposeTo implement the research‐based Ottawa Ankle Rules in a district hospital and audit their impact on the number and appropriateness of X‐rays for ankle injuries in A&amp;E.Design/methodology/approachThe method used was retrospective data collection, followed by education and prospective data collection on the management of subsequent ankle injuries. The computer records of the first 150 people presenting to A&amp;E with ankle/foot injuries in one month were reviewed to determine whether the patient underwent an X‐ray, and what the results were. Every doctor working in A&amp;E was then educated using a hand‐out giving the Ottawa Ankle Rules. The management of 150 people presenting with ankle/foot injuries in the month after this intervention was assessed.FindingsThere was a reduction in the number of patients receiving X‐rays (83/150 or 55 per cent versus 128/150 or 85 per cent pre‐intervention; p&lt;&lt;0.001). There was also an increase in the proportion of X‐rays showing fractures (17/83 or 20 per cent versus 16/128 or 12.5 per cent; difference not statistically significant).Research limitations/implicationsPossible to stimulate good practice with audit.Practical implicationsImprovement in practice stimulated by a motivated trainee doctor with appropriate support. Factors contributing to success discussed.Originality/valueEncouraging example of successful audit, of interest to those interested in using clinical audit to improve care.

The Ottawa Ankle Rules and the “Buffalo” Rule, Part 2: A Practical Application

The Ottawa Ankle Rules and the “Buffalo” Rule, Part 2: A Practical Application

The Ottawa Ankle Rules and the “Buffalo” Rule, Part 1: Overview and Background

The Ottawa Ankle Rules and the “Buffalo” Rule, Part 1: Overview and Background

Ottawa Ankle Rules Work, but Are Rarely Used by EPs

Ottawa Ankle Rules Work, but Are Rarely Used by EPs

Prospective Validation of the Ottawa Ankle Rules in a Deployed Military Population

This study prospectively validated the Ottawa Ankle Rules (OAR) in patients presenting with acute ankle trauma to a deployed military clinic at Prince Sultan Air Base in Saudi Arabia. The treating physician determined whether the patient met OAR criteria. The decision to obtain radiographs was left to the discretion of the physician. All radiographs were read by a radiologist blinded to the study. Patients who were not evaluated by radiographs received follow-up in the orthopedic clinic or by telephone. Forty-five consecutive patients were enrolled over a 3-month period. Twenty-nine (64%) patients met the OAR criteria, 32 (71%) received radiographs, and 5 (11%) fractures were identified. All fractures were predicted by the OAR. The sensitivity of the OAR was 1.0 and specificity was 0.40. Negative predictive value was 1.0, positive predictive value was 0.17, likelihood ratio positive value was 1.67, and likelihood ratio negative value was 0.0. The OAR correctly predicted all ankle fractures in the military population studied.