Implementation of the Ottawa Ankle Rules

TLDR

The Ottawa ankle rules require further study to confirm their applicability across diverse hospital environments. The study evaluated how implementing the Ottawa ankle rules changes clinical practice. A nonrandomized controlled before‑after study compared a university emergency department that adopted the rules with a community hospital that did not, measuring radiography referral rates among 2,342 adults with acute ankle injuries. Implementation of the Ottawa ankle rules reduced ankle radiography by 28% and foot radiography by 14%, shortened ED stays, lowered costs, maintained 100 % sensitivity for fractures, and did not increase imaging over the following year.

Abstract

To assess the impact on clinical practice of implementing the Ottawa ankle rules.Nonrandomized, controlled trial with before-after and concurrent controls.Emergency departments of a university (intervention) hospital and a community (control) hospital.All 2342 adults seen with acute ankle injuries during 5-month periods before and after the intervention.The implementation of the Ottawa ankle rules by emergency department physicians.Proportions of patients referred for standard ankle and foot radiographic series.There was a relative reduction in ankle radiography by 28% at the intervention hospital but an increase by 2% at the control hospital (P < .001). Foot radiography was reduced by 14% at the intervention hospital but increased by 13% at the control hospital (P < .05). Compared with nonfracture patients who had radiography during the after period at the intervention hospital, those discharged without radiography spent less time in the emergency department (80 minutes vs 116 minutes; P < .0001), had lower estimated total medical costs for physician visits and radiography ($62 vs $173; P < .001), but did not differ in the proportion satisfied with emergency physician care (95% vs 96%) or undergoing subsequent radiography (5% vs 5%). The rules were found to have sensitivities of 1.0 (95% confidence interval [CI], 0.95 to 1.0) for detecting 74 malleolar fractures and 1.0 (95% CI, 0.82 to 1.0) for detecting 19 midfoot fractures. In the following 12 months at the intervention hospital, use of radiography did not increase.Implementation of the Ottawa ankle rules led to a decrease in use of ankle radiography, waiting times, and costs without patient dissatisfaction or missed fractures. Future studies should address the generalizability of these decision rules in a variety of hospital settings.