title: Effect of triage-based use of the Ottawa foot and ankle rules on the number of orders for radiographic imaging.
abstract: BACKGROUND
  Reducing unnecessary testing lessens the cost burden of medical care, but decreasing use depends on consistently following evidence-based clinical decision rules. The Ottawa foot and ankle rules (OFARs) are validated, longstanding evidence-based guidelines to predict fractures. Frequently, radiography is automatically ordered for acute ankle injuries despite findings from OFARs suggesting no fracture.
  
  
  OBJECTIVE
  First, to determine whether implementation of protocol-driven use of the OFARs at triage would decrease the number of radiography orders and length of stay (LOS) in the emergency department. Second, to quantify the incidence of OFARs use at triage and to assess patient expectations of radiography use and patient satisfaction as rated by both patients and clinicians.
  
  
  METHODS
  In this prospective, 2-stage sequential pilot study, patients with acute ankle and foot injuries were screened in the emergency department between January 2013 and October 2013. In the first stage, clinicians (physician assistants, residents, and attending physicians) performed their usual practice habits for radiography use in the control group. For the second stage, they were educated to appropriately apply the OFARs before ordering radiography. For patients who were suspected of having a fracture at triage, nursing staff ordered radiography. For patients who were not suspected of having a fracture at triage, a clinician reassessed them using the OFARs after their triage assessment. Radiography was then ordered at the discretion of the clinician. Results gathered after training in the OFARs comprised the intervention group. After discharge, patients were surveyed regarding their expectations and satisfaction, and clinicians were surveyed on their perceptions of patient satisfaction.
  
  
  RESULTS
  A total of 131 patients were screened, 62 patients were enrolled in the study after consent was obtained, and 2 patients withdrew from the study prematurely, leaving 30 patients in each group. Fifty-eight of the 60 patients (97%) underwent radiography. Emergency department LOS decreased from 103 minutes to 96.5 minutes (P=.297) after the OFARs were applied. There was also a decrease in LOS in patients with a fracture (137 minutes vs 103 minutes [P=.112]). Radiography was expected to be ordered by 27 of 30 patients in the control group (90%) and 24 of 30 in the intervention group (80%) (P=.472). Patients were equally satisfied among the groups (54 of 60 [90%]) (with no difference between groups), and 27 of 30 (90%) vs 30 of 30 (100%) clinicians in the control and intervention groups, respectively, perceived that patients were satisfied with their treatment.
  
  
  CONCLUSIONS
  There was no statistical evidence that application of the OFARs decreases the number of imaging orders or decreases LOS. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania ashurst.john.32@gmail.com.
authors.forename: John V
authors.initials: JV
authors.lastname: Ashurst
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Thomas
authors.initials: T
authors.lastname: Nappe
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Digiambattista
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Avinash
authors.initials: A
authors.lastname: Kambhampati
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Sarfraz
authors.initials: S
authors.lastname: Alam
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Michelle
authors.initials: M
authors.lastname: Ortiz
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Paul
authors.initials: P
authors.lastname: Delpais
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Bernadette Glenn
authors.initials: BG
authors.lastname: Porter
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Anita
authors.initials: A
authors.lastname: Kurt
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Bryan G
authors.initials: BG
authors.lastname: Kane
authors.affiliation: From the departments of emergency medicine (Drs Ashurst, Nappe, Digiambattista, Kambhampati, Alam, Kane, and Greenberg, Ms Ortiz, and Mr Delpais) and emergency medicine research (Ms Porter and Dr Kurt) at Lehigh Valley Health Network in Bethlehem, Pennsylvania.
authors.forename: Marna Rayl
authors.initials: MR
authors.lastname: Greenberg
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016512:Ankle Injuries / Q000000981:diagnostic imaging*; D016022:Case-Control Studies; D002985:Clinical Protocols; D004636:Emergency Service, Hospital; D005260:Female; D018409:Foot Injuries / Q000000981:diagnostic imaging*; D050723:Fractures, Bone / Q000000981:diagnostic imaging*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D010414:Pennsylvania; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D014218:Triage / Q000379:methods*; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*; D055815:Young Adult