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

Abstract:

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.

journal_name

BMJ

authors

Bessen T,Clark R,Shakib S,Hughes G

doi

10.1136/bmj.b3056

subject

Has Abstract

pub_date

2009-08-12 00:00:00

pages

b3056

eissn

0959-8138

issn

1756-1833

journal_volume

339

pub_type

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