title: A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments.
abstract: OBJECTIVE
  Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably.
  
  
  METHODS
  Before and after study.
  
  
  METHODS
  Emergency departments of a tertiary teaching hospital and a community hospital in Australia.
  
  
  METHODS
  Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture.
  
  
  METHODS
  Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as "gatekeepers."
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Medical Imaging, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. Taryn.Bessen@health.sa.gov.au
authors.forename: Taryn
authors.initials: T
authors.lastname: Bessen
authors.forename: Robyn
authors.initials: R
authors.lastname: Clark
authors.forename: Sepehr
authors.initials: S
authors.lastname: Shakib
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Hughes
mesh_terms: D016512:Ankle Injuries / Q000000981:diagnostic imaging*; D002985:Clinical Protocols; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000592:standards; D006764:Hospitals, Community; D006784:Hospitals, Teaching; D006801:Humans; D008499:Medical Records; D015397:Program Evaluation; D011859:Radiography; D012017:Referral and Consultation / Q000592:standards / Q000706:statistics & numerical data; D013021:South Australia
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